99120001 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O�
CITY DI CUPEGDIVISION PLUMBING-MECHANICAL BUILDING-ELECTRICALPERM O.
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION `
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
- NIC CONTROL#
OWN 'S N;MI� / RACIQ�{V- / . C NO.
HITECTMNGINEER: 1/+GC1v� LIC NO: ADDRESS: 'O`fny` /`+i-S�'r1[INe ❑
CONTACT PHONE: BUILDING PERMIT INFO
- - ❑ Consultant F¢¢5 Paid by Applicant(Initial) BLDGELECT PLUMB MECH
El El 2' ❑
LICENSED CONTRAC UOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm that I and licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
pWaz with Sedion]000)df Dimsi Sof Bmsidese and Prdfesslnne Cod nA ylicense is
1—i w_ in full force. p�� PERMITISSUANCF. RESIDENTIAL:
F FAM
Z ❑SFDWL D KITCHEN REMODEL
' Uz U ucddse Lie.#
ti64 Dam Contractor APPLIANCES-RESIDENTIAL [I ADDITION L1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O,in zr I understand my plans shall be used as public records MODIFICATION
_24- UP T0200 AMPS El INTERIOR L]CHIMNEY REPAIR
b-4 W Licensed Professional 201-1022AMPS IMPROVEMENT
y „"aj OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
C Q - 1 hereby affirm Thar 1 am exempt from the Compacvor'a License Law for the OVER Iq0 AMPS ❑BATH REMODEUREPAIR D DEMOLITION
ryryryy
0'U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELELTRICAL ❑OTHER _
FC E' which requires a permit m constma,alter,improve,demnl'rsh,or repair any swemre n �1
priorm he lssuance,aLvo requires the applicant for such pumind file asignetl s0lement SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the provisions ofthe Contractors License Law(Ch.peor9
i�� (commencing with Section 7")of Diviona 3 ofthe Businessand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
6 y m qv
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
loci m Section 7031.5 hear,applicant fill.permit subjects the applicant to.civil penally of POWER DEVICES []TENANT ❑FOODSERVICE
.H. i+ nal mom than five hundred dollars($500). TENANTP.MF.NT
Q ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is nm imended oroffercd for sale(Sce.7044,Business D OTHER
and Pnd'essions Cade:The Contractor's License Law does not apply to an owner of OUTLETS.—SWITCHES—FIXTURES'
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements union,intended or offered for NEW RESIDENTIAL ELECTR 5
sale.If.however,the building or improvement is sold within one yearofcompletion,the My FT,FLOOR AREA $/S@PE
owner-boilder will have the burden of proving that he did not build or improve for fat,
poseof saleJ,
D 1,as owner of the property,am exclusively contracting with licensed contractors to 'i UTO AL:
construct the project(Sec.7044,Business and Professions Cede:)."w Contrai Li-
me Law does not apply to an owner of property who builds or improves thercnn,uad QTY. PLU&RIr
who contracts for such projects with a contractors)licensed poomam to the Contractors
License Law. PERMITI S ANC
D lara"emptunder5ec. ,B&PCforthisreaaon
Owner DateALTER— VENT—W R ) InO VALUATION
WORKER'S COMPENSATION DECLARATION BACIC
1 hereby affirm made,penalty of perjury one of the following doolralitur
r7vrf u—
[] ,-Pon-
IIRAI ND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the L ilwr Code,for the perfmmanw of the -
-
weakforwhichthispermitisissued. FIXTU ES—PER TRAP
D I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the W,Cale,Lathe pmf......eofthewmkforwhtc th tis issued. GAS—EA.SYSTEM-I INC,4 OUTLETS OCC GROFF 7S N
CMI
Wnrke anal ton :ur: currier and Policy �
Carrier: Policy/�{N`oyt''.'P�`T`��^�" �tt GAS—EA.SYSTEM-OVER4(EA).
CERTIFICATE
COMPENSATION INN`JURANCE GREASE/INDOSTRL WASTE INTERCEPTOR
(This second need not he completed Hurt peanno is I...chondreddollarx(EIDE - BUILDING DIVISION FEES _
in less.) GREASETRAP - ,
PLANCHECK FEE
I certify that a.promer in parany manner room as
subjectch to perthe W rkis es'Comprall SEWER—SANITARY—STORM EA.200 PF.
not employ any person in any manner so m to become subject to the Workers'Cnmpen- _ ENERGY FEE
O Z ,cation Laws of California.Date WATER HEATER WNENT/ELECTR
z O Applicant ( GRADING FEE
rs NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS TEMaREATING
abecame abjeat to the Workers Cempedsmion provisions of the Labor Code,you must _ SOILS FEE
4SI forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V 0 I h
erebywhich thi thermic i issuedsuucti3 lending agency for the performance of Date Receipt#
Lhe eader,for which this permit is tanned(Seo.3097,Cie CJ
Q Lender's Name T AL:
Lenders Address - TOTAL:
1 certify that I have read this application and state that the above information is 11 BtjILD�'PHE L
Lth correct,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT F f '
U 2 building cmromption.and hereby authorize representatives of this city to enter upon the IC FE
above-me tinned property fur inspection pmpeses. PERMIT ISSUANCE 1999
(We)agree to sav indemnify and keep harmless the City of Cuperlinn against ELECTRIC PEG
liabilities.judgments,c. andespicsesedish ylnanywayaccrueagainslsvid City ALTER OR ADO TO MECH. - PLUMBING FEE
in consequence of th nongofthis ,mit. �/
APPLICANT'ON ' STANDS W COMPLY WITH At/NO -POINT AIR HANDLING UNIT(TO 10,f00CFM) BY—GU. 'IONS. iNEQtjQNICAL--FEE
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX '
Sig reef ApplicanUCenvacmr Dme EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eoenpant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Coconino,Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes LIN. -
VENTILATION PAN(SINGLE RGSID) PAID
Dam Receipt#
Will the air comm or future building bythe D nae equipment or devices which BOILER—COMP(3HPOR 100,000 BTU)
emit horrendous air cdmeminants as defined by the Bay Area Air Quality Management
Distinct? 11
❑Yes Otho BOILER—COMP(OVHR 100,00)BTU) -
AIR CONDITIONER
I have read the� rdnua materials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
Tocol.Health&Sit y ode,Sections 25 95,25533 and 255344un.
hat if the NEW RESIDENTIAL MECH. SQ.FT.
building not ad c ennn I it ISM,responsibiloccupant
f the t I ill whichmm lar to Issuance of a Cgp�y�r or authorized gent TOTAL: ISSUED BY:
OFFICE