27654PLICANT TO FILL IN INFORMATION WITHIN RED LINES -
TY OF CUPEINO
O APPLICATION /PERMIT
BUILDING DIVISION
1 ip ;4e-
J' '110%] IV& — rf
Is
ANCIII ECI' /fiNGINeER: LICNO:
CONTACT; 1+` ] r� f PHONE: /YV
and+
"ZOO /4,4,L,
LICENSED CONTRACTOR'S DECLARATION
Metz, I onchy nfOmr lost 1 all, licersOd under provisions of Choprr,9 (commencing with
µI00 Section 7000)of Division 3 of the Business and Professions Cdgand my license is in
Fet U('' full force an I effec t
a Z�µf License Class _ Li<.k— -
vl-i?y Date
ARCIITGEoC'I'S D ICARA'I'ION
000=Z M � F
Y. Sew
lunden' InndmyPlansxM1UllbcusdespuMicrccnrds.
Licensed Professional
0�
yy k!u OWNER-BUILDER
from uxj3 ts.F'- 1 hereby vffi,m that 1 am exempt Gom the Contractor's License Law for the
O`� follnw:ng ra:smn(Sccenn 91111,5, Bumnese luW PmfaselmnsfaJm: Any city nr county
f' T 6, which requires u permit to construct. alter, improve, demolish, or re pair any .Co.. m
et poor its issuvnce, vim requires the applicant for such permit mfile a signed smument
µ)j00thatbn is l icanwd formal m tirepro,ounasnflhe Contractor'. License Law (Chapter
0 uxa4,, �' 9bnmmencing with Section 7") of Division 3 of the Business and Pmfcssinns Code)
ly_sy or that he is exempt herefrom and the basis for the alleged exemption, Any violation Of
S Q Soon.. 7031.5 by any appueam for n (S5 permit subjects the applicant ro a emu Penally of
five hundred dollars W).
WFm not mom Nan ❑
I,aso wnero fthepmpry,ormyemployceswihwagesas theirsolecompnsmi
willdothewnrk, and the stuclore is nut intended or.l'.'od for
sale (Set, ]04 ness
Told Professions Code: The Commurrs License not apply to an mvol
ProPCny who holdso, imnmvn thereon. cad whod eaumM1 wo.tr M1l.n..v.........._ I r.:..
buile.). derwill IT Che burden ofprov in, he, he did n 1 build nr improve for purpose r.
sal
❑ Las owner offe plopeny, sm exclusively worm ingwilh 'tensed e a
mmnaWCl the proi (Sec. 7044, Business and Profe ions Co p T .,it, ter
License Lawdoesnmapplymano wnerofpmpe,ry who iidsmr hereo and
who Contracts for such projects wish a commit, r(s)Inert pursue veConl
Licenuc Law. c r
❑ 1 am exempt under Sec. B & P f r this reason
Owner D, e
•WORKhIAN COMPI3NSA'f10N DECIARA ON
❑ crs'C unsatlhullbuvoaeenifcmif,Mco then l (Seca ccnifent
covers s'COmpensatimn lnsumnceorucenifid copy thermf(Sec.3B a b act
Quern n11 employee's 1t� th' '
Policy d _Srt� i i`� LIZ :—:;V1 4
Company -s �_
10 Cerified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Has action need not be Complacd if the pmod is far. hundreddollen (SI W )
or Inca.)
1 Certify 'but in the performance of the work for which this perntil is iswd, l shall
not employ any person in Troy manner so as to become subject m the Work,,,
Iz COmpcnsaunn Lowe of Califnmiu. Dam
Applicant
7 0 NOTICE TO APPLICANT: If ufur, making this Cenifcme of Exemption, you should
V] become subjemm the Worker's Compensation provisions oldie Lebo, Code, you must
Xti fonhwith comply with such pmvisiom onhis pemdl shell be deemd rtvokd.
yQ CONSTRUCTION LENDING AGENCY
D Z I hereby affirm that them is a construction lending agency for the performance of
J O the work for which this permit is issued (Sec. 3097, Gtr. C.)
,mot Lender's Name
U Fina sAddress
r W 1 unity Thal l love read this application and state that that above information Is
Q. come[. I agree In comply with all city and county oNinances and sole laws relonal
In building construction, and hereby airdrome representatives of this city to enter upon the
"Z ounce - Inaaionnl property for insNnrin i purni
(We) egret to save, indemnify and keep Lamest the City of Cofferdam against
1 iabili tiev,judgmcnts, toms and expenses which may balmy way reeme aguinst lead City
in consequence ofthe granting of this Penn 313.81
Ugnatum APpll 1/Contmetnr O Date
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicam mfllum building oecupunumm orhmndieh oromfous nounnal
as derl d by the Cuperiam Municipal Cde, Chapter 9.12, Told the I leach and Safety
Code, Section 25532(x)'1
❑ Yes ❑ No
Will the applicant or future building Occupant use equipment ordevices which emit
. hazardous air contaminants as Jefind by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have rend the hmardous mauriuls requirements under Chapter 6.95 of he
California Hwhh & Safmy Cde, Sections 25505.25533 and 25534. I undmatu rd that
if the building does not currently have a tenant, that it is my esponsibility to ncity the
cupant of the requirements which must be nut Poor to issuance of a Certili,se of
Occupancy, 9-" w w n 1 .1
SALL POINT PEN ONLY
CA,
FLECPRIC PERMIT
PERMITISSUANCE
API', oNCES - RESIDENTIAL
LID
SIGNS ELECIR ,
SPECIALCIRCUIT
TEMP. MF.'I ER OR
MW17R DEVICES
NEW RVDkMAI. CLEM _ =SQ. FT.
TOTAL.:
ODRAIN EPERmrr EA
, DEVICE
DRAINS - FLOOR,
FIXTURE S - PER 110
GAS - EA. SYSTEM -I
GAS - EA. SYSTEM -C
GREASIVINDUS3RL
GREASE TRAP
SEWER - SANITARY
WATER HEAT
WATER SYS'I' nRI
20(IFT,
SQ. FT,
I'OTAI-:
MECHANICAL- PERMIT
PERMIT ISSUANCH
ALT12R OR ADD TO MECII,
AIR IIAV1W.B 0 Efia M)
AIR HANDLING ( VERI0,1M_CFM)
EXHAUU ) HEATIN00,00 B'D1) HFATIN1W, B VENTIL ING . ID)
8011,1311 - COME(311P IIIO,WB 1TU)
BOILER - COMP OVER 100,0000
NEW RESIDENTIAL MECII. SQ. FT.
TOTAL:
FEE.
276
u
HL.DGG II
� ELECT PLUMB MEC
/d" ❑ ❑ ❑
i DESCItIPII'ION
Ne L4Lf.
IX� O �Os. dD
STOIC II:S TYI
z
OCC. GROUP
FEE FLOo3DZONE
FEE SUMMARY
O SID F.
SANITARY Y_-
RECEIY M
_. SCIIOOL TAX v
PLANCHECK FEE.
GRADING FEE.
SOILS FEE
ENERGY FEE
PAID
Date - ReceiptM
BUILDING FEE
S131SM /C FEE
ELECTRIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
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MgR�p�