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