S 1724 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTI NO BUILDING-I'ILEC'I RIL-AL P1;glI NO. I �� �
BUILDING DIVISION a 1PPIACA-I'ION/PERNII'P PLUMBING-MECHANICAL l`7 1
BUILDING PROJECT'IDEN'I'IF'ICATIOn'
IiUI1,IlINGAIIIlRESS: SANITARY No. APPLICATION lUI{NII'I'Ah.,1I
/p83g
71PI'1"N
(lN'N1jR' NA. E \ S/C: -OR'1'I A: .'S ryAMli:�s I.IC NO'.LC NIC CUKIROLp
AHCHIILCf/ENGINEER: . O: ADUIILSS /- ❑CON'I'ACI': Consultant Fees Paid by Applicant(Initial) BLDG BIJII'DINCG PERv1f NNPUMFCI1,`
uCINSE'Dc0 ACIUKSDIC1ARAliON QTY ELECTRIC PERMIT FEE JOE DESCRIPTION
1 hereby'thrm that1 I' :d J p ' s ofCh Chapter)(ummenemg
DIYZ IIS t 7000)of 11 9Id Ho. and I o.0 Iny licrt.C. RESIDENTIAI.:
Wpm sum PEI(MI'F ISSUANC11
FW nholl Ile" '�� ❑SFDWh ❑KIICIII:N It V,NODI:h
Q V U Lia 1 o p Ir AAPPLIANCES RLSIDIEN I'IAh ❑ADDITION [I PLUMBING Rh 1'IPIi
FZW Uulc Convuu+r
hQy ❑MULTI-UNIT ❑STRUCIURAI.
N AHCIII'I IECFS D[CLA AT ON PANEiL$
F''7 I understand my plans%hall he used as public oneuri MODIFICATION
OZ-'0 UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
[-t?F•W Liccmed Professional 201-INMAMPS IMPROVEN[law E3SWIMMING POOLS
OWNER-RU1LDER DECLARATION OVER 10MN1AMPS O BATH REMOUEIJREPAIR ❑DESIOLHION
C C Q 1 hereby afhuo that I am exempt from the Connector's hicenx Law for the
XO a O following reason.(Section 7031.5.Bach...and Prnfrowns Cde:Any c'ny or county SIGNS ELECTRICAL OTHP'k��
W3LLh %i h 1 fe II t t II p I .I p > occmc
A) 0610
Wn pro I t 'l. tl ,pl II . -0p It II 6 J.ticrnnl SPECIAL CIRCUIT/MISC,
f�Iy„ da,h I :Jp It II 1' III Contractor, I' (Cl"ac,9 -
W COMMERCIAL
Wap0 lam y id,S I 700(0 tDim J fth B ' II I :.' Code) 'PIMP MI;I ER OR POLI:INS I'.
a a eC that he is exempt therattne a u1 the far s for the alleged esc opt on.Any v aladon of ❑NEW IILDG/ADUII'ION ❑IIIIMOLITION
�My Section 7031.5 by any applicant fora permit subject,meupplileal bra civil penaltyof POWER DEVICES OTENANT El FOOD SERVICELSn
not more than Five hundred Jollan($54)(B.0ry. EMPROVGMEN'P
❑
1.it,owner of the prnpcny.or myemployee with%ages as their wile eumplawago r SWIMMING POOL EL 'ERIC
will do the work,and the structure is not intended or offered ferule(SccJtHJ,Business C]OTHER
~� n my cr UfTI''LIT$-SWI LS-II%"I'UHI3
63m andl 1 Calc IhcC Contractor's r'nl La )ten I pplyt a al
propertywhob ld%o p d J h does stch work houselfre through
his 1 provided that: 'b i t% not' I J J r offered lot NEW RESIDE 1. TI'R SQ FT
p Ymca,p p $Q.PI'.FLOOR AREA SISQ.PI'.
,,,,ai If Fin rime ler, hngnaller t cnl is err he did n t hauldrrd.prove for the
on,
,,,,air will have the Fnmdar nl'pm proving that hedid not hn11J or inmprn'c for pn-
pmcuteulcJ. v TOTAL
'-011lr of ns owner of the propcny,sun exclusively cunlrmtlng wiN IlccnncJ cnnvnnnrs I,)mFmcl We project(Seca 7(H4,Business and Pro@.'ions Cade:)The Carmelor's Li-
cerise Law does not apply toanowner ofproperty who builJ.or iniprvc%thereon,and QTY. PLUM 2iRMIT PETE
who contracts for such projoets with a ormracort i hearse)pursuant o the ConrmnoLc
I.icmn,e La, PERMIT ISSUANCE
1 um exempt under Sec. .B&1'C far this recount
AUTFIR-DRAIN&VIN1-WATEllA VALUATION
Owner Date ✓w ^ O
WOHKCH'S G(1MPIiNgAI'IQN DI?CLAHAII(lN BACKS W E'RGHTC'1'.DEVICH \\J
1 hereby atfinn nock,penalty nl'perjury one mf Ibc li llowing dedaral
Ihave and will mmntainaCenjol,atcol Cnnum wedt-inxum'c lin Wndur'a Cumpcn- DRAINS-6 .ROOF.AREA,COND' TORICS 'I'VPE C(lNS'I'NIJC'IIUN
tion,us provided far by Swtinn 3900of the Labor Code,for rbc Ieefommnec of the
lirt which tris pro n issued 19XTURIS-P. 1"HAY
IyCI have and will.min lir Worker,Compensation Insurance,as required by Section
3700 of the Labor Cade,for the l'rdaurniance of the work for which this permit is issued GAS-E3A.SYSTEA INC.JOITTLIR'S OCC.GROUP APN
My Wude( Cy a �' n ance )Policy u ye GAS-EASYSTEMO ;R4(EA)
Cutler. r Policy Nil
C fIFICA I li%EMPTION PROM WORKERS GRIiASi%WUUSTRL WAS 'INTIiRCEI'TOR
COMPENSATION INSURANCE BUILDING DIVISION ITF,S
ffhoweliomrwl sol he aa...plaud if lheperindr,0r one hundred dollars IS 11(1 ORL.A SE'I RAP
I'LANCE{ECK FEE
ca,.)
"eddy thal in perlbrmnnecnfthe work forwhich do,arnat it sued,Lc -SANI'e _SIO I MI FT.
not employ unY pcnam In any tnannce a a,m hcaume anhjcd to he Worker,Can HNERGV IB2E Q
Z ,talon lasv.c of California.Date ' TER ' HN I'd R GRADING PER
ZO Applicant
IA NOTICE TO APPLICANT:IL Mier making this CetiBcae of E?xemplro.,you sho WATER SYS VTR IN SOUS FEE
E••' bec nue subject m the Workels Compensation provision.of the Wbar Code,you sur
rnnhwithcnmplywith... provisions nr thio peemit,hall he JcemeJ evoked. 'ER, ER C.
Q CONSI'RUC['[ON LENDING AGENCY NIiW RESIDENTIAL PLMIi. SQ Er. PAID
`Uz Ihcrchy nffinn thm them ieuentaurenion lending agars..fonhcpcdimnancc f Dwc Rccetplk
the work for which this pcnnil le l6wmcJ[$.c.JII'q.CIv.CJ TOTAL:
O U Lcndce,Name T(l'fAl.:
N Lendc-Addre,, BUILI
0. 1 certify that I have read this application and storinformation e Thal the above infoation is
f^' N corse lagive mermply with all city and county oblinanem and state laws relining m UI-Y. MECHANICAL PERMIT FEE: SEI 1 - P
U Z building construction.and hereby authrnive repcumatives of this city to enter upon the
aLrve-mmndaned pml'etr oar inspmmhrn porpoises, PERMIT ISSUANCE:. E L 'nn:
(Wm)agree to suer,indemnify and keep harmins the City of Cuperrim against
liabdoics,judgmems,ann and expenses which may in any way accrue against said City AI, iRORADDTOMIECIL PLUM NO F1i1i
in is.....mace of the gramill of thin pcnnil.
A I'I'LICAN'1UNDEHSIANIlS AND WILL COM PON 001'111 ALL NUN-POINT AIRM,VDLINGUNII'1'UI I0,0o0CFMI ME NICA.lgili
SOIJIICC RE(IULN'IONS.
AIRIIANI INC.UNI'I'(OVER 10,06 CPM) CONS'I'R "1'ION'TAX
Signature of Applcanl/Cmnlnur Dalc IiXIIAUS'FH I W/DUCfI HOUSING MITIGATION PER
HAZARDOUS MAI HR1ALS DISCLOSURE?
Will the applicant or future huilding occupant more or handle hararrious material PRATING UNIT IT IIN).0(X I'lll
as dcflnal by the Capetian Municipal Code.Chapter 9.11 and the He rlth and Safety
Cock,Sermon 25532(.)^ IIIiATWG UNIT(QVER *,(XX)BTU) .
E)ye, 0 N VENTILATION FAN(SINGLE ESID) PAID
Doc RcttiplA
landWill the applicant...future building occnpanl use mympment at dcvicee which BOILP.R-COMP(1HPOR W,IAO Ip
mil haenrdudx air mnmminantn ux)dined by the Bay Area Air Quality Management -I UTA.,:
Di incl? H011,1IIi-COMP(OVER I001"6BI'U)
❑Yes E3 No
H have real the hamrdous materials requfaentenn under Chnper(e95of the Cali- AIH CONDITIONER / ISSUANCE PATH
h+mia Hcnllh K Safety Codc.Sminn,255115.8531 and 2551).I.nJenlarN alma if the NEW RESIDENTIAL.MIECI I. SQ,ET. 6 r / 2- _9
building clues not currently have a tans I.Ihm a is my msrym ddlity m notifye oc
thmpanl I 7
u requimtrcnn hicl twO or +mor insd&c,m.Ccti 'amaf Ocy,
4408 arOwncrc lhorizcd agent Ila¢ TOTAL: ISSUEDBY:
OFFICE