S 2487— APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY-.OF CUPEWFINO BUD .Dmc - ELECER
BUILDING DIVISION APPLICATION/PERMIT rLUhunN'r. -MRCwu
IfI111.DIN1: PROJECT IDEN'
BUILDING ADDRESS:
IQOZ$5(�V�NSGi���K Butyl?
CON'I'ACI':
z =8z
1/ �of l Z ❑ Consultant Fees Paid by Applicant (Initial)
7 f� �n
1 hereby affirm Ih:n l am licensed under provisions Of Chapter 9 (commencing
0O with S,,ian91Xlgof Divisio i3oflhe Bluinusund Prnfcs) sC e:md + nx is
1 z (�r in full force laid clTea.
aUV License hic.M
NQ6 Dale�}�( -) — Conlfaclor
{Y �� ARCHITECTS DILCLA Al '1
Z O N Z unJCr<'.anJ my plans shall fw reed as public records
oz-
al Lncnwd Pool- real
.aQ+Y�j OWNER- IdUl1.DER DECLARATION
C Q I hereby union that l am exempt from the Cnntmcmrs License Law for the
XO a U built -in, noon. (Section 9113 L5. Business and ProRssions Code: Any city or county
413 LL j- which requires a Permit to construct, alter, improve, demolish, nr repair any stmmurc
0�' p rio....o o euonm,ula+requircatheupplienntlm such pennllmElcusigneA - el :nenlm+o
anal he is licmued fit ouunl It the pinli :moon be Cm I..crests Liacnse Low (Chupter9
cal (commencing with Section 7000) al Division J of the Business and YnnJsaions Gdcl or
6 6x e C that he is exempt merefmm and the basis for the alcVd exemption. Any violation of
Wpm Section 71131.5 by any applicant for a Naar subjects the applicant to a civil penalyof
{. not more hun five hnndoed dollars ($500).
CSQ ❑ Lo the work. and poor -Oc,of is not intended wio+wagasnx lh,(Sec. COanlemotion.
F• willdothewurA. mAnc� almemrclpnotlmm�Jcd und(crcJ for sal appcc.9Mn,rsser If
6 3 m and Professions Codo:'The Contmcmes License Law does nut apply m an Brener of
pmpeny w'ne builds or imprsvm thereon, and who does such work himself or throu,h
his own coil xs, provided that such iarpmvemems are not intended or limited for
role. III hhowcsca the hoilJingor mprovc ent is sold within one year of umpluGan, the
r. Idcr will have 'he burden of Pnrving that nc did -1111
Woad nr iaagm+sv rot nor.
prise of I sale,.
❑ 1, m to met of the See, 7 Business mnteaciin wins l)ce e l ttmtmcmtx m
construct the es not (Sec. 9f1Y1. Business and ay Professions ui Code:) the CPanrenair n
cruse Law Jews not apply ic an owner of propory who licensed or mor to hs Cotton, and QTY,
w1�o onuuels fm Buell pn J[CtM wnh ueunvaemr (s) lian,mA puauannnthe Commanfs
Circus, low.
❑ 1 an, esmnp' under Ste. . B & 1' C for this reason
Owner Date
ID :n C(IMPIiNSA1'ION DIiCIARATION
I hereby uID:n under pcnaly of smimy one of the holowmg declaim as
I have and will maintain a Cenilic:nc of Consent it) insure for Workers C'oapcn-
vno.. us provided for by Section 3710 Of the Lahr Code. for he perfanonce of the
work for which This pennil is issued.
El 1 have and will maintain Workers Conawnsa'ion Insurance, as required by Section
191X1 of the I,atart Cute, Ins IM1r perlimnance of the work lire whin IM1is lermit is isxncA.
My Worker's t +�rnsa�' a rtiar nnJ Policy n 0
Currier: Policy No.:
' CENT119GS'1'E OP F: %IiMIT10N FROM W(
COMPBNSATI IJ o +�
1'I'nis sccbnn ncnl not to cmnplmcd al wi sbllns $IIXB
a less.,
1 <rnmy tom i1` nor Pedi+rn+ana nnbe work Ins -men Jd> prnnb is irsned.l rear
an cn+piny any person in any runner sn xs m hcome sunjem w the Wnrkcrs Ctmpen-
C) Z cation laws of Callfnmla. Date
O AppOeam
NOT ICB'10 APPLICANT: If, one, Taking his Conif icmc n(Exmnptu +n, run should
Nx becon+e subject u+Int Wtnkcrs Compenxaum+pn....ions of me IahaCale. you nms'
loniorth cnali svim such ponsim is or this pem+it Beau lie created revoked.
asO CONSPRUCOON LENDING AGENCY
hereby affnn that here is a constriction lending agency for the lerfmm arc of
P thcwokiorwnicnthtspunnil is mu,l(Se, 3097. Co. C.)
p U Lcndcr's Nome
>" U] Lender's Address
0. 1 verify that 1 have read his application and state Char the abuse information is
FH coI I agree to comply with all city and county onlimences and state laws tearing h+ QTY
U Z handing cnnsnuction, unit hereby amnai ereprcacnmrive,'If'his oily in enter upon the
aKoe.na7vlomd pmpcny Br inNeelian pnqunes.
(We) v nee Io sae, indemnify and keep homeless the Gay of Cupearno against
Iiabili'ics,juJgmcith. c. I vvd cxpenms which may in any way accrue aguina said Ciry
in rtnsg.T, Of Ill?:sm n, of this permit,
nppt n' IW S'T'ANDS AND WILL COMPLY WITH ALI. NON - POINT'
I IA]ARDO1IS MATERIALS DISCLOSURE
W hheri,herm nr future building nccupant sore or handle haeanlnts material
as Jul in Fy the Copenlnn Mnnicipul Cmlc, Ch"Ins' 9.12, and the Ilcullh lad S,dely
Cmic Section 25132m)?
❑Yes El No
Will the applicant or future building occupant o k equipment or devices which
Tl nueunlous nit couI;oo Ono as dsfn,d by the ]toy Area Art Quality Moomprount
Yes ❑ Nn
yl can 9Jc'wne l 2t, 5LI5e. 1w r1c5 yIt 2is 5 5n3ay 3 anunwa J p an2ntm5l5ieh3r i3li ly 1 tunderstand e t hwnm ec uit p nurinie -
t
Prior hllssiance of a C'mileme Or lccnpamcy.
ELECTRIC PERMIT
PERMl'I ISSUANCE
APPLIANCES - RESIDENT-1 Ad.
PANEI -S
UPT021XIAMPS
SIGNS Ins
SPECIAL.
SWIMMIY' 1`001 11 I- "RIC
OUT LBI;S-SS "S- FIXTURES
NEW RESIDENTIAL E. .R SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTI7R - DRAIN M V EISF- WATF,R EAT
BACK FLOW PROI'HCE DEVICE
DRAINS - FLOOR, ROOP. AREA, COND.
FIXTURES -PER TRAP
GAS - IiA. SYSTEM -I INC, r OUT 'LEIS
GAS - IiA. SYSTEM OVER n (EAI
GREASUINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY- S'IORM IiA, 20(1 FE
M /E
W VF LIiCTR
WATER BEATER /
WATER SYS'IENItI REAL LNG
WATER SERVICE
NEW RESIDENTIAL PLMD. SQ, FE
MECHANICAL PERMIT'
FEE
PPRMI'f ISSUANCE
ALTER ORADDTO MF;CIL a
AIR HANDLING UNIT' (TO I0.IXX1 CFM )
AIR I IANOLRa; UNIT' (OVER 111,81X) CFM)
E%HAUS'I Thai OVIDUCT)
HEATING UNIT (TO IIX) IXXI BTU)
IIEA'I'ING UNIT [UVIiR IIXLfXX11Ifif)
VENTILATION FAN (SINGLE. DUMB)
BOILER - COMP (31IP OR 1011dXX1 iil'U)
HGILER -COMP (OVER I IXI,II00 B I'U)
AIR CONDITIONER s f
j NEW RESIDENTIAL MECH. SQ FT.
OFFICE
-Z -3 -9
M'
HLD(l
JOB DFSCRIPI ION
RESIDENTIAL,
❑SFIIWL
❑ KITCIICN REMODEI,
❑ADDITION
❑ PLUMBING R°LPIPH
XMULTI -UNIT
❑STRUCI URAL
MODIFICATION
[I INTERIOR
EICHIMNHY PP IH
IMPROVCMIiNT+
QSWIIMMI' P
(lLS
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El IH 10111'1
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POUNUATONN®R9ALD'S
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UFPR GROUND
NOTE: ". ALL GRADMO :AND DRAINAGE
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- SHALL. BG INSTALLED TO COMPLY WITH •
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-
-777.7218MONDAY TOFRIDAY 34 HOURS BE-
E6CIRICAL
PORE REQUIRED INSPECTION. SOB ADDRESS
'''
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PERMIT M ARE NEEDED WHEN PHONING.
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: - ATTENTION CONTRACTORS:
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NOPERSON(S)SHALL PERFORMWORK ON
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...
THIS JOB. SITE WITHOUT'BRING IN COM-
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-
'FRAMINOVENTS ., -
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..
INSURANCE REQUIRAMENTS:.:
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.- DATE
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:.
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