S 0786 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
sITY OF,EUPERTINO IsEHAHNG-ELECI'RIC'AIs P15 IT NO, 0786
BUILDING DIVISION APPLICATION/PERMI"I' PLUMBINX: MECHANICAL" J
ILILDING PH(LIEct IDENTIFICATION , /
11UI1.1 LNG ADURIiSS: -��/�70- / SOI I SANIIAHY NO. AI'I'LICAI ON SUBb9 l'I'AI,De\Lott
�ll rC� 1�r ' Cvp / fa a3 to
ER;SNAME: IR
P.I/C � f91G�^�^�, ��'RACI 1��(AMIi: �� LCNO: NIC BONN Bill
RC ITEC!'/ENGI -F.R: `d-LLIICN0:4I ,Ulama?/I'J ADDRESS I.
�j �T [/�� �� ❑
CONTACT: PHONE: �[AYI� BUILDING PHRMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACI OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I brachy od!nn that I ata I cervced under provisions of Chupwr 9(ro cconci ng
MWaZ with Section 7000)nf Division 31d the Business and P4ofcsomf%Cook.andnty license IN RESIDENTIAL
[ �� v fulls nect.ndeli / /// �� 1'ERMIt'ItiSUANCIi CSFDWL OKI]CHEN REMODEL
QUU Liccns Oa Lica APPLIANCES-HESIDIN'UM, ❑ADDITION PLUMBING Ric PIPE
ZZW pate Contractor ❑MULTI-UNIT 0STRUCTURAL
` ARCIII'TEC11S DECLARATION PANELS MODIFICATION
OZti^ I understand my plansshall b;...daspublic ncaids UP TO 2B)AMPS
C INTERION CCHIMNEY REPAIR
W Licensed Professional 201-100CAMPS IMPROVEMENT SWIMMING POOLS
�at: OWNER-BUILDER DECLARAI ION 5SWIMMING
IBM) C Rs\TH REMODEUREPA1R CDEMOLI'I'ION
C=6 1 hereby a0inm thus 1 in exempt 1'nnn the Conmmtor's License Law far the COTHFIR
K,oyU fnllowing reason.Section 7031.5,Business and Professions Coda Any city'(county RICAL, ijl f/
m 3 icy whim rey'ina a peronu m annswrt mmr,intprave,aemnnan,nr nrvdr any swanire
F'�0< prior to its issuance,also requires the applicant for such permit file a signedstalement NI'1'/A115C.
r�}J that heis licenud normal oil the pmvisiens I he Commret,License Law IChapter9 COMMERCIAL;
C y.Q� (commencing with gen ion 7")of Division 3lathe Business and Professions Code)or R OR POLE 1'.
y p,o W that he is exempt tberefnrm and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DIiMOLI'1'ION
WMm Seainn703 L5 by any applicant for a permit mbjeco the applicant a Civil penalty of ICES ❑'1'F.NANT CFOOD SERVICE
nm marc than five hundreJ Jolles(85(X1). IMPROVEMENT
f=� C h as owner of the Iom, R onny employees with wages as their soli,connersati'n, POOL ELECTRIC COTHER
z will do the work.and the structure is not intended orufIDtedfe—le(See 70ti Business DIfI LETS-SWITCHES-FI%'1'URIS V
W 3 m and Pmfesions Codd The Contfamoe's License Law tows ntu apply m ret owner of
property who builds or improves themon.and who does such work himself or through NEW RESIDENTIAL IiLECI'R SQ FT.
his own employees, m
Provided that such Improvements arc not intended or offend for SQ.IT.FLUOR AREA 5/SQ.FC
sale.If,however,the building'(impmvemcm is sold within one year of completion,the
tmarnhuilder will have the burden of proving that he did not build or improve for pur-
pose of alal� '1'OTA L:
❑ I,as onvhe,of the propriety,am exclusively contracting with licensed contract.,m
nwetthroe Project(See.9610,Bminrss and Profcooians Cost:)The Comraemis hi- NC�R3n/
c seLaw does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PFRMIT FEE ] R!�
who contracts far such projects with o coatomtor(s)licensed pursuant m the Cornet r s — �
License Law. B&P C for miss reason PERMIT ISSUANCE YtJ
I am cocuri t ander Sec.
AIJ ER-DRAIN.h VENT-WATER 1EA) n VN.UAI' N
Owner Date V
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(YfIiC'I'.DIiV ICI? V
I hereby affirm under Penalty of perjury one of the following declarations:
I have and wil l maintain o Cenilicam of Conwnuo wk-insure for Workcr'v Gmnpem DRAINS-FLOOR.ROOF,AREA,CON D. STORIES TYPE CONSTRUGTIOD
tion,as provided for by Section 37M of the Labor Coda for the Nrfonnonce of the
w vk fell which Ibis permit is illowd FIXTURES-YIiR TRAY
1 bass and will maintain Worker's Compensation Insurance,as required by Section GAS-EA.SYSTEM-1 INC.4 OUT OCC.GROUP APN
39 he[..bar Gude,for the pedlamonmoflhe week for which this permit is issued.
My Worker't�,Ir cion Insurance cater ,aniya ieyfu"n�T/�Y GAS-FA.SYS'1 EM.OVER J IEA)
Omier: Policy Nn:/TNT/ 7 6
CERI'IIlCAT,017 ICXEM PDON FROM WORKERS' GREASUINDUS1 RL WAS H?I N I'ERCEIt]OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thoves:tiofmcdont mcsnnplctv,d,hc Pennh is lmone hOldeddollnry($1a)) GREASE'I'RAI' PLANCHECK ITH
or les.)
Loy any
Person
acyl imioncrof s tworkiia which this Permitser,% on,selll SCWIiR-SANI'1'ARV-STORM EA.21X1ET ENERGY PIE:
not emptor any perssm in any manner m as to became nuhjem nr the Workers'Cninloery
Z satinet Lnws of California.Holm WATER HEATER W/VENT/IiLECI'R GRADING Bili
ZApplicant t
= NOTICE:TO APPLICANT:If,after making this Ctenifcam of Esunptinn.You should WATER SYSTENETIREATING SOILS FEE
F licence subject uo the Worker's C'mpcmution pmvisiens'It'thte Lulea Cale.yon must
�s forthwith comply with.such provisions or this potmiuhelf be deemed revoked. WATER SERVICE
0 PAID
CONSTRUCTION LENDING AGENCY NEW RI5IUCNTIAL PLAI6 50.19'' Date Recripta
UC Ihereby afirin that iso contraction lending agensy for the perfonnanaof
W the work for whichthis Permit is issued(Set.309.Civ.C.) IGI'AL:
O FHsi tier's Name TOTAL:
UU Isndds Address BUILDING FEE
6. I acetify that I have read this application and state Nat the absolve inhsrmaion is
IA rrrect.I agree to comply wfill al l cityase evantymdloomes and slate laws rebuhtsm QTY. MIiCHANICAL PERMIT FEF, SEISMIC FEE
U Z building construction,ondhcrebyauthoriee representatives'fmiseity p
toente,undl,
above-mentioned potent,for inspection Parp'sec PERMIT ISSUANCE ELECTRIC FEE
i (We)agree m save,indemnify and keep harmless the City of Copernicus against
liabilities.iudgmmiaas,costs and eapenm,whichmay in any way restate against.said City AEIER OR A DD TO MSCI I, PLUMBING FEE
in con"trenae of the granting of this porrul. _
APPLICANT UND17RSlANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('I'O 10,000 CFM) MECHANICAL FEE IS-d
SOURCE.REGULATIONS,
AIH HANDLING UNIT(OVER I0,01A CFM) CONS'TRUCI'ION'PX
Sdgnamrc of AlTheinclContmnnr Dat, EXHAUST HOOD(W/DUCTI HOUSING kuI oA'TTON FEE
HAZARDOUS MAI TRIALS DISCLOSURE
wilthe opplicam"future bnildingoucupam oomor handle bromine,material I HEATING UNI I'('H)1(pas BT Of
as dcfned by the Ctprctinn Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVHR TIM)IXMI BTU)
Code.Section 25532(-)?
�Yr, F1 No VENT ELATION FAN(SINGLE RESID) PAID
Date Receipt
Will the applicant or future building:ecupam use equipment or devices which BOILER-COMP OHP OR 100.000 B N)
it h...rdos air emmminams-s defined by the tiny Amo Air Qnality Mnnagrmteat TOTAL:
coin? BOILER-COMP(OVER 100.1X%)BTU)
❑Yes ❑No
AIR C(INDI'1'IONBB ISSUANCE PATH
I have and the ha.a, mato::,,mpmaoca s unde,Charlotte,6 95 of the Cali-
forms Health k Safety Gde.Sections 25505.25533 and 2553J.1 understand that it the NEW RESIDENT[At,MECH. SQ.TT
building docs in currently have a tenant,that it is my responsibility to nitrify eaecryant
t r sx:T6wh"m "w"t l9p5iF u b cc of- ' ilicateol' '[ucar
Owner elraaa : .reit agent ((,'�`// Dut TOTAL: ISSIIIiD BY,
OFFICE