S 2690 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTI NO BUILDING-ELECTRICAL VHRMIINO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING—MECHANICAL S 2690
BUILDING PROJECT IDENTIFICATION
BUILUINGADDRILSS: SANITARY NO. APPLICATION SCENE'TITI.DATIi
10L165 f4 filly DK 3-9-r1
O\VNF 'S NAME: 1 PIIONE: Cf NTR.CI �AM'. ICES
10
NIC CONIAOLM
Z R:Lel LIRVI ❑
1, �ARCIIITECI'/E@GINIifiR: LIC NO: ADDRESS:
CONTACT. PHONE: BUILDING PEItM1T'INFO
/ S [:jConsull'anl Fees Paid by Applicant(Initial) RL❑DC LMc 1'LUEl ME❑CII
LICENSED CON'rRACIIOR' S DECLARA'GOON J QTY BLFCTRIC PERMIT FEE LIY/
I hemhy anon,that I am Recoiled under pmenions of Chapter 9(commencing JOB DESCRIPTION
C d'Z with Scction]1XX1)nf Uivi,inniuf me l3winco and l'mfcssiom Cala and my liccnw is RESIDENTIAL:
W O p PRRMIT ISSIJANCE
F W._ in snit IOrce and elf� _ Gp�1 S ❑SFOWL ❑KITCH17N REMODEL
aUU Liam 1`, min # 8J I APPLIANCES-RESIDENIIAI. ❑ADDITION ❑PLUMBING RE-PIPE
FZW Dom Coma. 11
H 6 a ❑MULTI-UNI ❑STRUCTURAL
Dm ItCHI iC SDIECLAHAIION pANIELS
Fz C)enZ IunJ sea myp methal sed a,publigrecorJs MODIFICATION
O Z-C UP r0 2(0 AMPS
❑EST'IiR10R ❑CIE 1M1IN1iY REPAIR
I Licensed Pon! ..tonal 2111-IIXXIAMI'S IMPROVEMENT SWIMMING POOLS
yf OWER-BUILDER DECLARATION OVI3R I'EAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C w Q I hetcb Ilion that I ant e,em t lion.the Gmtrannr.,License Law fur the
Yo P ❑OTIIIER
X36F which re requires
(Section]11315,ifu.,inms'and ve.doc ion,C'1de Any city nramnrY SIGNS ELi[CI'KICAI.
W ea.0 m which mquires a pcnnit to nmamc6 alcor,impmvc.Jcmolish,or repair any smnurc
F�'OQ frit t ... al sit remainstho;LEPEplicantf h pernat torile a signed stailmetl SPECI AL CIRCU I I IMISC. 2-5- 15
that he beemotalpursuant tthe pmvims OFth Contractor s Lnecow,Law(Chapter 9 OMM R IA
W�pO
(commencing with Seen..7000[,ofDi .sir J ofth B .bes,andPmf .'ons Code)or TFMPMCII:RORPOLF:INST.
d L C Not he k eamnpl merefnn t..,it the hast,for the ah,ged uxempuan.Any violuuon of ❑NEW BLDGIADDITION ❑DI:MOLI"DON
K W SeOion welsh famed j Y .
Www yuny applicants faro snub cors the applicanuoacivil penal, POWER UIEVICFS ❑TENANT El FOOD SERVICE
not;n me than f ve handmd collars 65(10). IMPROVEMENT
fSaO �I,usowne cfinep'o"Ey,nr my employee,'win,wage,as their sole ca,ulnmasion, SWIMMINGPO(11,BI.EC1'RIC
p. willdothe work.ondthe etrucmre isnot intended ornffered for sale(Sec.TW.Mosinee., ❑Q'IIBiK
3 m and Professions Coale:The Contractor's License Law dere,not apply to o n owner of OUTLETS-SWITCHF_S-FIXTURES
pmpeny who huild.nr improves thereon,.nal who Jere,rush work Monello,through
his own employees,provided that such improvement,art not intended m offered far NEW RESIDENT IAI.ELECTR SQ PI'.
cote"If.he.on,or he build'mgnr improvome.,moold wilhinea
ane yrof completion.she SQ.FU Il,WHARCA SISQ.Pr.
owner-builder will have the burden Of proving shut he did oat build or impmvc far m,-
puttnfsalc) TO O
O 1,as Owner OF;he property,oto exclusively eomracsing with licensed contraclo,at
mores,the pmleet(Sec.70,FL Bmine,,and Prnfes,inns Code:)[he Contrai I.i-
o tt Law docs not apply a,anowner of property x'ho builds or improves shetron.and QTY. PLUMBING PERMIT FEE
wltn ennmtnon,uch pn,w,n,winta commdmy,)licensed mraam in he contractor's
Licenm Law. PERIOD ISSUANCE
❑ I am exempt under see. .B K P C for this reason
ALL HR-DRAIN h VF,;YI-WX117R(EA) VA LOAF ION
. Owner Dam
WORK HRS COMPENSATION DECLARATION BACK R1)W PROTECT.DEVICE
1 herebyaffirmmai ander Cenahy al perjury one of the rots hollowing r doccWorkersans
�Iheve and parvidl for
ineCenifcam of the Labor
xlGimurce Worker's Comfthe DRAINS-FLOOR.ROOI'.ARI?A,,.OND. s :S TYPE;CONSBl1C'IION
,,tion,ax pmvidM ibr by Section 7700 of the LoMn Cede,for the conformance of the
work for which this pcmtit n i....J, Ill X GRES-VERT RAP
L`H'� and will maintain Workers Campsmasion Insurance,a,required by Senior
3]t0ofthe Labor Cock,hoorm(e prihnnvnceofine work for which mit permit i o,md. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
Cam rrkilah P/- gak o,come,and
PoliPolicy iccy nump�,a77,7 GAS-I EA.SYSTEM.OVER 4(EA)
�7CYIIiRIII'IFIICAATTEl.QIII']F,XEMPITON FROM WORKERS' GREAS191NDUS'IRL "I'E IN'I'li OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Him-,tion nredrottecomplemd fthe pnmitufnrane hundroddollin SI(M) GREASIi TKAP
Or Imes.) PLANCBECK MICE
Icertify that inthe ambarr uncenf the work lin which this lmrmit is issued.Ismail SEWER-SANITAR .I)R .''1X1
not employ any penon in any manner w a,to become mbjeet to the PStrken'Compen- 'P ENERGY FEE
Z e'u ion i,uws OI Culilitmia.Uwe WYE EK HEATER W/ 17kr/EL N' GRADING FIT;
Z Applicant
N(OICE'IOAPI'I.ICAN"1':If.after making this Certificate of Exemption,on,should WATER SYSTLMG`R!ATING
,. SOILS IgiE
f"I , Mcnntc nuam,m,hc\VnrkcR Cungtamnm i, pmm,Ione OF the IAbar Gxlc,You us,
forthwith comply with such provixinm onhi,permis,hall he JectneJ revnkeJ. Its WATER SIENVICIi Y
O Q PAID
� z CONS"fRUCUONLENDINGngAGENCY NLW RESIDENTIAL PLMIt, SQ.lel'. Uc kecuiptN
U0 ,
Ihcrcby affirm that there is acnnnrvdion lending agency for performance of
C1+ ;c work Ibrwluem mit Ee, it is w,,d(Sce.3M7.Civ.C.)
TOTAL.C) lender',Name TOTAL:
L) Lender',Add ,,
I certify mm I hove read,his applinnion nnJ nme ma me above inunction is BUILDING FEE
F V) corse'.I agree to comply with all city and county ordinance,and state law.relating to QTY. MECHANICAL PERMIT FEE SEISMIC I'EE
V Z buildingemt,trou,ni.and nacbyvushorim repm,entative,ofthis city menmrupt the
ulvrvomcnllanrd property lin ,,patio,pnrptvc,. PERMIT'ISSUANCE RLIEC'I'RIC PEE
(We)agree to Save.indemnify and keep taintless the City of Cufci ino agairta
iahilisic,,judgments cosh and esfen,es which may in any way accede agai fill%aid City ALTER OR AUDTO MIiCI I. PLUMBING hili
it,
If permit.
AI'I'1 A 'r U! )ER9'1 \DS SAND WILL COMPLY W EI It ALL NON-POINT
AIR HANDLING UNITOO 11.10X1 CFM) MHCIIANICM,IEE
amv 'nc k'
-��1 AIN HANDLING IJNiI'(OVER It1,t1IX1 CI=M) p)NS'I'HUCfION'I'A%
numrcAppliclKunUCantracnx Dmc r:%fiAUST HOOD IWIDULTI
SlgHOUSINGMI'GGATIONFEE
HAZARDOUS MAIER1ALS DISCL OSURIi
Will she applicamorfuture buildingoccupant slurs orhandlc hamordau,matemil HCATINGUNIT R0110,000BIU)
;is doh of by dm Cape0ion Municipal Ced,,Chapter 0.12,and the Heath and Safety
Cale.Section 25532m)'t GHATING UNI"P(OVER I0PDX)B'FU) f'I
- cx flAo / vpEcTILAYION FAN(SINGLE BESIDE PAID Date Receipt LI/
Will the applicant or future building occapint me equipment or Jevlecs which BOILER-CONY(3HP OR IIX),IMXI Bl'U) V
suis hvnNour air ennlantinana a,refundn by she Buy Arca Air Quality Management T AI:
Di,lricl'7 - /
❑OILER-COMP(OVER 100,SEDBTU)
Yes
I have read she hamohn,ntatermE requmncn(,under Chapter 1.95 of the Cal l- AIR CONDITIONER ISSUANCE DATE
Ionia Health 1&ty Cede,Section 25505.25533 and 255.A.I undentaml that it the NEW RESIDENT AL MECH. SQ.IT.
hulldingdoe 1 h:evc m ns,,hu,it is lay resfonsihllilymnaifccum
ythcafa
Of the re4 m. It w t cs m m is,anva.fa Cenifcam of Occ`para,
Owner
Jager
3 )am rarAl.: ISSUED Bv��
OFFICE