S 0387APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATIONIPERMIT
'a b/ems view
❑ CBnmltant Feet Pald by Applicant (Initial)
LICENSED CONTRACIDR'S DECLARATION QTY
1 herthy aRrm dram I ner licerocd under prrabo mu of Ctuptcc 9lmmmennng
�pZO with Seclion7000)offukixiuoJofllr Butiaei:wl Protiressm de �mYlicmxe ix
l-,. in full lune unJ cf V/�/•
a U�) Linen -e Cl. Lic.N
H Z a eine Cwdnctm
AHCI{ITECI'S DECIARA ION
~ r Z I ardervoM mY me dull be ucen ax public nrtaJe
OZ—z
Q y t..W.1 Licensed Proraeumul
OWNER -BUILDER DECIARAHON
pp,, tY W Q I thereby affirm thin 1 am eaemp from the Carlini Liccnw ifor dbo
X a Ug. rMlowing ammo. (Section ]03LU Brnaess and Professions Cork: Any city m aumY
RJ 311. Nwhich "or,,, a Pit m a ro ual..he,, improve, xmolixh In rc7uir my sdrvcma
F-�OQ J pxiefaitsixaaaruz,nlorecluirs, thcapplic,am forwch same mElea,igrcJ xdadcnhenl
E y�Y Inv the i"B"a'
moral pursuant to rte"a"i,ian, ofd"Crmaact«nLicemelsw(Cteptm9
apo (cornmetwing with S¢lion]IMIO)n[UivisionJoflhe llu:'urn urW Rofcsxiw CldJeha
L CC that he ie exempt therefrom anal dte Fame for Inc allege) ceumpti.. Any tialminn of
MNSeamon 70313 by myeppliemt for v permit whjem,dlheuplt1k.mn a col peraRy of
not mme down five hunal crui (1501
I ~^Q❑I,a,owws oflhe propcnXor myc inumas witM1wngc.axale(Se cora. Racine,
I fF0
will Prthewmk. Co the he Carriewr"Licarect, ioffobrc,l.,..ale fScc. ](N-r.Hucire.a
13 owl ,ny who) code: Tldc C., limb L ,1 w � Jm nm apply n an wart of
he,pc a who builds m hnprovme r rich;, heal who mss x.h wrak him¢Ifw IMugh
nic awn owayar.eattimithe
pr olamp dont conn imlr is abldx ort wx imcnlN w nBnral Em
IL braver will h building ar er of prnhenl is W d within roe yens of mmpininn, the
i
owner builder will nave the dafkn of proving Nin he did .t build a impmrc (« Pao
"' el"al
1, u owner of the hnperly, nm exdu,i'ly crmvuting with liaexed C.imclra9 m
conuruct me prejat (Sec. 7011, Hurim, wl Pmfexa'ions Coco That Crompacla's Li
,an. Law dose, no. apply from owner of pnrptmy who huilds rr inflates mention , anal Qrl
win connects for catch proJmrc with a eomraanrlx) Bcenud Pmwnnl m ddc CanmCmr'n
loan. Law.
I am exempt mato Sm. . B & P C for thB ar.
Due
WORKER'S COMPENSATION DECLARATION
I ha by infirm ureter pevlry of perjury me of 0e fallowing lkclamtLxu:
❑ I have and» ill meimeio a Cmificam of Cooscnnn rel Gloom Oa Wmkara Compcm
aatie n, to pruviJdl fm by Sealion 3700 aT Ife Lthor lUcco he the pert«nurce of a-
far which Thi, pcnnil is In.ucd.
w 1 M1erc eml will maintain Wmkch Cumpcmvfiort Inwmna, as rryuirtJ hY SnYen
J]W of the lab G.k, far Rhe erfo Mlle »art for which thi, Ixmnlnivwl.
My WMc' c I c ltd Pnliry
Curler' n Pniky Nn.:��
CERTIFIC COMPENSATION
INSURANCE WORKERS
COMPENSATION INSURANCE
(Thin xmion ntnl wN M complcllvl Iflnc lwrmil is for me huwlrtd IW lav (SIM)
mlca)
I canny areat in the perfanwncc ddr wco fur which this pemtit in;awed.I shall
employ any parwat in any nava , a v m M1ecoure wrjeca lu the Warier; Cunapm-
Z cation Law, of ColiGmin. Date
Q Applicant I
fn NOTICE TO APPLICANT: If, atter nuking this Cenif are of Exemption, ytv rMwW
a; hemrrc,uhicet m the Workers Compem armor pnrvioweet of the Whor Gide. y. must
17-1 founwith comply with wch provisions m flax permit xhall he damcd revoked.
D
z CONSTRUCTION eelsaoucaim lNGAGENCY
U01herebych mi IMIlureieaamnmc.im7.tding.) fordo {er(omdarccof
the wok fa which this pCmlil is i.utrd (Sax. 309]. caw. c.)
Ucr's LcndNor
} Ismkr'Adl
I carnally
f.. thin I have rind this ty and v.m arc rove thin the statute melows refe0tm to
U,taIZ thmeet.Iaura+:lacomply with all city and roomymcele,rsvtd sive V»s refining to QTry.
Uz' mtildingcimamchaa.and forchyuuttrnrcmpmsnwfivc ofIllscit, mcntmupon Nc
above-memiorrJ prapabyeaw far omeat. PaHxaca.
(Wju agree to core, malexpenes keep haryinmtheySc MCupcnirosolo
Cityhal judgnrms, awls enJ cxpcmca which dory in troy way rceme agtdrdv sold City `
in mnscqucnce of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signvure 017APPlicad/Cmvanm Date
HAZARDOUS MATERIALS DISCLOSURE
W51Uhe i,therm or fuwm building ocapam emre err homlk hmeadou, material
a, dcfired by the Caisson. Municipal Cork, Chvptcr 9.12, round the Hea11A conal Swely
Coea' Secfim 255321x)'
❑ Yes
Will 0he uppluarm or fuu. huiknnu acullnv use eximiti em or dcvka which
toil horarmas air committable as Jdioed by the Buy Arca Air Quality Marmgcmcnl
I i,o
E]Yn oPINu
I have rod the hvmlderm, extends rtquireohenp rondo Chinni, fi 95 of (ra: Calr-
fanda Realm & y Cruise, Seetiradx 25505, 25533 rest 25531. I mntsetwo dhow if the
building rows n0y/f)ve n mow. ILL it i, my rexftuncto to ym einem
afne 'Wh'tyRg/ilop heme, nor la i'mml fJ a CCnl 7�ua .tyyvag
ELECTRIC PERMIT
PI ityin ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMT'S
2II-1 WO AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURM
NEW RESIDENTIAL EIF.CIR
PLUMBING
PP.RMTr ISSUANCE
SQ IT
ALTER DRAIN &V'fT-W/4 ( )
BACK ROW PROI'E ' 'ICE
DRAINS - II,WR. ROOEA D.
FIXITRLS - PER TRAP
GAS - EA. SYSTEM -I INC. J OUTLETS
GAS -EA. SYSTEM -OVER n (BA)
GREASEIINDUSTRLWASTEINTli CEPTOR
GREASRTRAP
SEWER - SANITARY - STORM EA, 200 FT.
WATER HEATER WNENTIELECIR
WATER SYST11NMEATING
WATER SERVICE
NEW RESIDIENT'IAL PLMB. SQ. FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO 10.000 CIM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (WIDUC )
HEATING UNIT (TO 100,00() RTU)
HEATING UNIT (OVER 1001100 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 1 COC BTU)
BOILER -COMP (OVER Known own BTU)
AIRCONDTTONER
NEW RESIDENTIAL MECH. SQ. II'
FE—
EE SEP 3 0 1997
19—
BUILDING
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BUILDING DIVISION PEES
PLANCHECK FEE
-9q-17
ENERGY FEE
NM,
❑
GRADING FEE
CONTROL N
i
BUILDING PERMIT INFO
/
BLDG ELE PLUMB MBC
❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL;
O SFUWL OKFIZEENREMODEI,
OADDITION OPLUMBING RE -PIPE
O MULTIUNITO STRUCTURAL
MODIFICATION
O INTERIOR OCHIMNEY REPAIR
IMPROVEMENT O,S'WIMMINGPOOLS
O BATH REMODEIIREPAIR El DEMOLITION
❑ OITIFR
n
COMMERCIAL:
O NEW RLDG/ADDITION El DEMOLITION
OTENANT El FOOD SERVICE
IMPROVEMFIST
❑ 011 EER
FE—
EE SEP 3 0 1997
19—
BUILDING
--
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS IEE
PAID
/
Uma R,xeimM
BUILDING IFI.
FEE SEISMIC FEE
V ELECTRIC IEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION Iti
PAID
Dvu Receipt 0
TOTAL
! ISSUANCE DATE
9 7
ISSUED BY:��o se'' A
OFFICE 1'