S 2228 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFN,RTINO BUILDING-ELECTRICAL 116181TT NO.
ICAL
BUILDING DIVISION APPLICATION/PERNIIT rINGP OJECNC TIDENTIFIC
BUILDING 1'N(»ECT IIIENTIFICATIUN' 2228
BUILDING ADDRESS: SANT MEN NO, APPIJCAI ION SUBMI'PIAL DAD;
OWN N�A�f '�JIU�Y� CUNTRACIOR'S NAMIi'. LIC NO'.
WC CONfNOI,N
ARCHRI!CI'/FNGINEER; LIC NO: ADDRESS: El
CO n CT: PHONE: BUILDING PERMIT INFO
�TZ 5'-� z/� ❑ Consultant Pees Paid by Applicant(Inilial) BLD(: 'ELECT PLUMB MI:CH
LICCNSEI)CONCRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE CJ
1 hereby affirm that I am BecnrN ander pmvi.mn.m Chapter v(comrrcneing JOB DESCRIPTION
wilhSrainrr70)()ofUiAme.3ofrheH.via—M l'mlevo.0 CMc.mmnry Inenne is RFSIDENTIAL:
F W P m full force and.Bml. PERMITISSUANCE
W- ❑SFDH'L ❑KITCHEN REMODEL
'u, U.rn.¢Chi, ue.N APPLIANCES-RESIDENTIAL. ❑,ADDUION ❑PLUMBING RI.PIPE
N d W Dole, f:lnmrnaf
ARCHITECT'S DECLARATION C1MUCFFUNIT ElSTRUCTURAL
o Imd ,
ces " myplms shall be."as'blicfearJ. PANELS
zoz MODIFICATION
pzmG'0 UP To 200 AMT'S El INTERIOR El CHIMNEY RE!AIR
u] Liccnvrl Prnfe7.iowl 2111-IINx1AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IfMk1 AMPS ❑BATH RF_MODELPREPADI ❑DEfOLRION
Y
C Q I hereby aRrm o
that 1 am exempt from rbc Comraother's Liccrw law for t
K L U following!fide..Station 7031.5,Bwincu aM I'mfex mos Coli:Any city nr euumy SIGNS ELECT RICAL E1URH"R
4!3 LL which!inures a fiction to crrLxWCL after,improve.cminooi h,or r'fecr arty slNcture _ l
l;_LLp pnorn it,...Bo reyuc thkv
ite apfln fm wchpemJtm flea slimed stmemort SI'ECIALCIRCUR/MISC.
gy��y� that he is licensed pomunm 1.he,My!sirmxof the Ctmltacmr'e Lilee,law(Chapto9
RaQ0' (enntmnwtg with Snnion 70(Xiol Division 3 ofllln Easiness and Profession,GW)o THMI'.METER OR POLE INST. COMMERCIAL:
ei.a o K that he is exempt tberefmm mM the 1vtsia for the alleged exemption.Any AnInion of ❑NEW BLDWADDRION ❑DEMOLITION
.-y Section 7131.5 by any"Brain for a permit wbj¢n the applicant to a civil peswlly of POWER DEVICES (]TENANT ❑FOOD SERVICE
orx mere Nun Five huobcd dollar.(S4MH.
CLQ 1.mrvwncrot the n'.orm Tom with we ,m tleE sale compensation, SWIMMING POOL ELECT RIC IMPROVEMENT1
will r�y ❑ thoR' ) Y emp y g Pen
F- adJONc,irm,emJlM swclurtismts Liters,Law coc,ant lIDW,o aircu ❑OTHER
13w end any wsiah holds-
Vre Cnmmcmrs Liana lee]roes ma apply m an rsvar of 011'U,IIT'S-SW'RCHES-IIkTVR'
pnryeny who,ee,oa impnrvu tnm.r,and who mktiw such antic hies]or orermmgh
hls nem oeweveyccs,pnovidcJ That wch imp i,"d is am!lot intensities]o oRcmnl for NEW RESIDENTIAL LLECI'ft
Bale.IL lrwncnllelvildethor. ler cf,r m rs uAd whol..me ycvof corn ve air he Se},FT.FLUOR ARTA LSV,F7
ter-M1uiklmr will havede Mmmkn of proving That M:Jrd ne Nrild or irnprnvc 4r pur-
wk.1.
r of Tic Property.ani excluxivcly cummerin wit linm»vl conavctam to TOTAL'
mwYm theeelnoject INV.70aW.Huxirms aril Proossions Cnkp TM Crmwrnrca U-
mLawJrxenmupplymxnawncrol'pmpmy woo Hood.ac impnsvcs tcrnm.and QTY. PLUMBING PERMIT FEE
who rnntram.fu sib projects with a montmctonx)listened W muant to the Cmmtost
1.1reel L _ PERMIT ISSUANCE - fQ
,B& 'Cfmtismawn -
AI:I'ER-DRAIN&VENT-WATCH TA) VALUATION
Doc
~� WORKER'S COMPENSATION DECLARATION BACK IIAW PRO EC'F..DEVICE
M
1 Imtbyemunp
ffirlerlwhyof P'dury meof the tblluwing 'lan(ims'.
❑ I have marl will near...n Ccnifc.of Cn., ,,xclf-i come mr WoAcrs Compcm DRAINS-FLUOR.ROOF,AREA.C'OND, StT(IRIESTYPE CONSTRUCTUN
xatkn.as pruvideml for by Section 37M of the Labmx Cad,forto Icrfmrmarce of the `u1
wok for which thin permit is is.wcd FIXTURES-PFFI TRAP
O I have mal will naimuin Wokm''s Cnmlansatiun In...r,as national by Scctian
37M.fthe lalav Code,Inclose Ismoc urce ofthe work fo ich tkrpemit is iocaml. t GAS-IA.SYSTEM(INC.4 OUTLETS l r�NUstl' APN
My WmLer's Compeoxmion humvice cetim W Policy number mc: 1 j1 .p74kiN
Cm riser: Policy No.. GAS-IA -0
SYSTEMVHR 3(PA)
CEIG IFICATE UP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GkEASEIINDUSTRL WASTE INTERCEPTOR
BUIhDING OR SIGN LIPS
1'ILir.usrimn and my he cmrnpMcA ifth<Prn)il ie fnrnre huMNJ dnikn(511101
ma less.)
GREASETRAP
Icenythat in the PHomuree ofJe whichtupermit ixissued,
rdl
PLANTS
ren cmMnY aunycmon in any manner w m mo bimmosrc wban woe Workcr,'CmrTPSEWER-SANITARY-STORM EA. 0 IT
� GY II!E
zz .tion Lows of Cali I nmia Dale WA117K H C<IP R WN EN'171FLECIR
O APPlicam GRADING FIC
y
NOTICE TO APPLICANT:IL after making tis Centif te of Ex.mlNimm,yme sMnkl WATER SYSIEM/IREATING
bu'ome suhlect m eche Wn,rd's Cospemmion pmovisimmn of the lahm Cole,yna rosea, SOU-SITE
iy+ tach with cmnply w'aM1 xmh lxuvi s Les or lL l a anorth shall be danced mvnked. WA'I'HR SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEIN RESIDENTIAL NAB. SQ.FE PAID
U O Iherchy affirm tion lhere is a cmearaclum koding agency,Bole aero mzrce of U e RaciptN
In,work lar which this moil is issued(,4e,,3097,Ci,C.1
0 is mu crs Name TUTAfL
O !U Demukh AdJmss T l'AL:
I amity than I Iwvc mal this alvate line and stale tlal the uMrvu information is BUILDING HILI
r% noxa.I agree to cmnply with all city mmJ.nunly commoen ail vane Iowa relating to QTY. MECHANICAL PERMIT FF.13
V Z building cmcumnimr.ad lmcmby aubvtim mepr.renaliv.n of this city to enter ulam the SEISMIC IEE
abuse mentioned pngeny for inspection puapor<s. PERMIT ISSUANCE. -
(Wdug¢c(owrw. l T Mes t
' o nrn
mJehyanJnnlCity of Cupcnnuim aµiELLCIWCII31?
Iialsim ,judgmer.conn and e.spenws which may in any way accrve agaim.,said City ALTER OR ADD TO MECH.
in mmwyence of the grunting iftisprnni. PLUM1IHING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'('11)10t)(11CF10)
r RCI: 11 /1 MF,CEIANICAI.FEE
9`�S AIR HANDLING UNR(OVER HGAMCFM) CON.SIOC-ION TAX
Sigrmmrc of ApplicunVCnmmm�x C.- Dfwc EXHAUSTHOOD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tteapplknnl or future baildinymcupant stare,or tholle hmaNuun maicnal HEATING END(To I00,000 BTU)
as defined by rhe Cup,rom Municipal Cue,Chapter 9.14 and the I ealh aM SaMy
CoJe.Section 255321aT! HHA'I'INC,UNIT(OVER IIA1,000 B'I'U)
Olc, ON. VENTILATION I'AN(SINGLE RESID) PAID
e I}tc RccciplN
Will tlro aircammrcane.roam!-budding by the ay Aalnipn¢noit,,M ,c.M ROILHR-COMP(3HPOR I0O.0011HTU)
ice hmaJmx air rnnumimrmsr u J.HwI by Je Hey A.Air Qmrmliry MawgcmrcN O
Dison". T
❑Vu 0N BOILER-COMP(OVER IIp,g10BTU) '
I have rmJ the havarmmfaoafialb grtmrnnkCtupter 445 of olCr AIRCONDIDONER
ISSUANCE DATE
foroor Health A Soley Coals_mions 214)5,25533 ata1255U I uaxlmW lJot if the NEW RESIDENTIAL MECH SU.IT. Z1
In1ldir,icsnot current,lwvca nmanl.I hal it emy msptrasihilov,,coli fy lk anvpam /j JdCIJ�
of Ile rcyaitcnems which.11S met Prom a,i.es.m{a Ccn Biome of fkNpancy.
Uwrcn»anmamnlagmt Data TOTAL. ISSUED BY
OFFICE �F �