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S 2258 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPBR'1'INO BUILDING-ELECT RICA[. FE Tr No. ISUB,DING DIVISu>N APPLICA'I'ION/I'ERMIT rhumnwc-Mecu,wlCAl. 2258 BUILDING PROJF.C'iIDEN'1'IF'cNrION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATI Z�( V�WJ{'ER'S AMC: PHONE?. 4.3 CONTRACT /L P 'OR'S NAME {SLF IICNO' 40 1JL4A1J 129 NIC CONTROL a ARCHITECI'IIENG NEER: LIC NO: ADDRESS �a ❑ 71W MAT 1 f1Y CONTACT: PHONE: BUILDING PERMIT INFO K - r2q .aD [_ Consullan[Fecs Pail by Applicant(Initial) BLDG ELO PWMI ME❑CI{ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I herchy arhrttt Mta I am E,.rwed node,groxiah..o of Chapter 9 aorrnnendtta JOB DESCRIPTION O fez WOO with Secrion90(XbofDivisino3ofthe B.slne5smdPmR,,ions C,de,andmy licePERMIT ISSUANCE license is RESIDENTIAL- ad- ESIDENTIAL:ad_ in full force uncle fpr /' ❑SFDWI. [I KITCHEN RF,M(1DF,1. 4VU Dttt j�'_%��� AI'PLIANCPS-RILSIDIiN'I'IAI. ❑ADDITION [:1 PLUMBING Rif aro a i Dme , 'IfN PANELS ❑MUITI-0NIT ❑5'IRUCTURALARCHI DiCI'S DECIARn Z O h Z I undemmrJ my plans ehull he usnl as public eve nrit, MODIFICATION Oil FO O [I INTERIOR EICHIMNH MINGPOLL �4LW Licenced llnR„ionW 201-1XNIAMPS IMPROVEMENT C]SWIMMING POOLS 6 1'q OWNER BUILDER DECLARATION OVER I(tIN1Ah1Pl C1 BATH REMODpIJRIiPA1R ❑pIEA101,I ON C{{y�U 1 hereby offee that 1 am exempt from the Contractor's Code. License Law for themy A.r� I 1 i n r.L f_ �tD followwhich loo ire%a (,veal tocH mutt.alter.ines, pr ve,demolish, or Any city orruclum $IGN$FLIiCTRICAL ❑q'rHCR LL/ A F'IGI� C1. m 3 O y wmm�mgnim.a Ihnnn u.r.nstmrt.ober.improve,demaE,h,ar repair any,rmrwm /` I�fBw'_ 40 W 'm its iomm,e.aI,are - oma ,lormsh Imfleaei nlstwentenl �..Nd prior N.c, mors. rattni ,a SPECIAL CIRCIII'I/MISC. that Menis cing with Me of Di.ionn3 oftfthe Comracmrs Licenw Woo Chapmr9 �y'q0 (unnmenrina withSmrion llMNH ofDivision of the Business.endou.Art,n,Gdcpo TI?MP.MGfER OR PULP CO MERCIAI: d Xo C that be is cxempl thereinim and Me basic tins the alloyed cxongnlon.AnY violation of ❑NEW BLDG/ADDITION ❑DEMOLITION �-w Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES H [I TENANT Ell OOD SERVICE nm ntore than five hundred dollen(S51MB. ^Z>- OTHERVEh11ENT SQ ❑ Lasowner k.Mopmpcay,nr nryarimenemployees with wages l for Mei(Sec.comemaien. SWIMMING POW L T QFC will 11 the work,and the sat Coulturn,,ala-Linen,c Lal Joe, llappey o an, walle.v ❑OTHER 3m and Eby no Crelorimu Coomaants L imn.e Lnwssucnutrk hi saoownerof oil'rLETS-SWI'I'CfIES-FI his o ,,,,,by who builds or t a thereon,andfo who duos such wnrk himself or through his own angios the InAdoprovided that such i em ,old ate nal intended or,Meted Iia NEW RESIDENTIAL ELIiCfR irf, rale If.howcvcr.lhu huilrliny nr inrprovurnem is sold within one Yuar of compluriun,Me SQ.IT.FLOOR AREA $ISQ.IT. owner builder will have the burden of proving that he did not build or imgmve torpor. ne'r orpur- ne'r afs:de.). E3 I,as owner of the progeny,am exclusively contracting with licensed contractors it) TOTAL: ,mmuct the project(Seo VHJy,Bmines,trod Profession,Gde,')The Commmnh Li- ,<Lawdoe,uan a,gly m en u,m,of progeny who, dl,orlmpror,Meront,and QTY. PLUMBING PERMIT FEF. whoenmmetx for such project,with a mmnractoaO Iicenmd pursua.0o the Commam's Lice oc Law. PERMIT ISSUANCE? ❑ Iarnexmnptcander Sec. .B&PC1orlhixrcaum Own" [late ALTER-DRAIN&VENT-WATER TPA) VALUATION Wm code,S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /- L J_ L 4 Ihemhy allirm under pemdq'oflm',jury one of the(ollnwrna Jeclamriun,: (�. a J 7 ❑ I ltavveadwill rnamwrnn Ccnilicama'Gm,rnimsclfinwml'or Wnrkcr's Cnmpcm DRAINS-FLOOR,ROOF.AREA.COND, STORIES TYPE CONSTRUCTION sari..,as provided for by lection 3700t of the Lata Code,for the performance of the work for which this permit i,ie,ad, FIXTURES-PERT RAI' \0[�1 hate and will maintain Worker's Cnmgcusaiun Insurance,as required by Section 3IIXl ufrhe Labor Code.kenbepifmmana of the work for which this lcam,is i,�cucd GAS-EA.SYSTHM-I INC. OUTIHIS OCC GROUP AVN My WorkefT'c Io r and Policy rJy h:k�y�,� Comer: � �j o`k�r+rbc Policy Na:�1'lJ Aane(W GAS-EA.SYSTIEM-0VER 4IRA) CHR'1'IIICATE 017 IEXFMIMON FROM WORKERS' COMPENSATION INSURANCE GRIEASEIINDUS'I RL WASTE IN'I'F.RCIEI'TOR BUILDING DIVISION FEES (This wrorinn heal not becontpleteJ if inc pcm:it is forone hundred dollen(51 W) GREASE'I'RAP or Iuns) PLANCHIiCK FIFE I crafty that in he l+Lramu.ce.f1he work farwhich,hi,,per mit is issued.lethal) SEWER-SANITARY-STORM EA.200 FT. nor employ any person m any manner sat o,,,Iec:nne,abject rat he Workers'Cn nau ENERGY ITE ZZ ,orlon Laws of Caldernia.treat WATER HCATER WNHNT/ELECTR Applicant ), 60 GRADING IEE N-r NCH ICE 10 APPLICAN'C If,aper making thin Ceniticatc of Excmgtion,you-,hoWd WA'I'1?R SYS'IEMG REA'I'ING a > Mcome subject to the Workars Compensation provisions of the labor Coda you must SOILS FETE mahwirh comply with such provi,inmorthis pennitshall IN Jecntedrtvoked. WATER SERVICE Q 5z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB, PAID V 0 1bereby affirm that there is a conswetion lendiagagencY for the perfommuce of D' Recti Pla the wnrk lit which MI,permit is iscaed(Sec.3097.Civ.C.) 0 I"' L.ended Name TOTAL: Fy 1 reality that I have read this application and slam that the above inronnmion is ftU11.U1N J'E; h coned.l agree to comply with all city and county adman¢,and ,are law,rchaiay o Q' E NIC I PER FEE L.Jz bmidiogctm,loadin i.and hereby authorise rc,nr,cait e,offink,ity to enter upon the SEISM P' above-mentioned prepeny for inagmdon guHnscs. PERMIT ISSUn (We)"art,to nave.indenmily and keep human—the City of Culicriino against - ELF RI CF Iishiliries.ludga osis and expenses which maymany uayaccmeayaaxl,md City fll7/6 n,equence ofyr .f ihi,proofs. ACIER OR ADD TO M1tECI{ PLO :FETE Al "CAN"I 1' 1P A DS AN MPLY WI'1'il ALL NON"POINT AIR HANDLING UNIT(101,10 C 1 SODIC U L rv,' B hfECH ICAL FEE ETI)VIT.14(NNI ,ITA) CONST IC'TION'I'AX SI nammof App icaKHAUSTHOOD(W/DU(F) HAZARDOUS MATERIALS DISCLOSURE HOUSING TIGA'IION PEE Will the applicant or future building occupant store or handle hasallous material HEATING UNIT('rO IWJNX)BTU) as delinW by the Catoctin-Municipal Code Chapter 9.12,and the Hcahh and Safety Code.Scedoo 25592(.)? 1 HEATING UNIT(OVER IW.W)BTU) E]Yes El No PAID VENTILATION PAN(SINGLE RCSIU) Dare Receipia Will the applicant or rets a dehirfined by the my A a.eacai it.ranDa or Jeviceu which J emit ha'ruMous air contaminants a,defined by the liay rtrca Air Quality Manogemmm ROILIER-C.VMP OHP OR 100.000 BTU) /. ❑Yes ❑Na BOILER-COMP(OVER 100.000 BTU) l / I have read the hamrdaua materials nmu yuircenunder Chapter AAIR CONDI'I'IONFR 05 of the Cali- ISSUANCE DATE forma Heath&Safety Cute,Sections M505,25533 and 25.5.U.1 undceeand that trifle NEW RESIDIENTIAL MECH. SQ.FE building docs not curoady Lure n rmmnl,than it o my req,onsibilhy m....tily the oceugunt of the regcaimmmat,which roust he mer prem t...cannot of a Certificate of Occupancy. Owneror authoried.,cut Dam TOTAL ISSUED BY: OFFICE