S 3214 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'RR'I'INO IRA ANC-ELE JRICgL 1'E 1'I'NO
BUILDING DIVISION APPLICATIONIPRRMIT rLumamr.-n1Erunrvu;nl' -3214
ItU I LDING rRO.IECT IIIP:NTUTICAINON
BUILDING AUDItIiSS: SAN1'1'AItY NU. APPLICATION SDBMI"ITAI.DAT[
U/sem ,4 My 4H LT 0.4 9'�i5- /- 7c}
OWNER'S NAME: I'IIQNE. CONTRACTOR'S NAAIIG LICnNO.
.Lp /VG g --D 93 � E477,0C16 s7D 2 g' SIC CONN ROLa
ARCH' .CT/ENGINEER: 1.11 NO: ADDRESS ^, �l ❑
CONTACT: PHONE: is ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BI❑DG EIAiCT PLU❑MII MPCCH
I ICLNM.D CONTRACOR S DECLARATION
:C�lc)
TY. CInIiCfRIC PERMIT. t.. FEE JOB DESCRIPTION
1 hereby ap Nm 1 am licensedorderp : f Chaplcr 9ng
wims f 9IXI0) fDivsnn3 of the Pusmv.:ane!roles.pins Cswlc an �t RBSIDENTIAI:
1+10 �0 �� PERMIT ISSUANCE ...1
woo in tall forty and e0w U 1 ❑SPDWI. ❑KITCHEN REMODEL
dUU License Clues Lica APPLIANCES-MiSIDF.NfIAL ❑ADD]TION ❑PLUMBING RE-PIPE
f—Z W Dam----y Contme .. !/•yi Fitr i
mdy -❑MULTI-UNIT ❑STRUCRIRAI.
A CHI'1-'l'S OIdCI.AIIRDON
I'ANIi1.5 - A1UUIFICATION
Z 0 m Z 1 undemmnJ my plans shall M used its public ranNn
OZ^Q � UP TG 2fx1 AhIPS ❑INTENIOR ❑CHIMNEY RF.PAIN
e14tw Licened l'ml"onal 2JI-1000AMPS IMPROVEIvIIiSWIMMING POOLS
� OWNER"BUILDER DECLARATIONOVER 1UX1AMPS ❑BATT{REMODELIREPAIR ❑DEMOLITION
I herchyaffirm that 1 am exempt Gam the Contractors Liamenr the. 1U EJlowingnaso..(Section JBJ1.5.Business and Professions Code:Any amay SIGNS aLl!QDUCALOTIIIiRIv which reynims a permit t,,moves,alter,improves demolish.or repmcturerii t t: a1 'd apphe tf Apv 'u 11 ¢trent SPECIAL CIRCIR DMISC. 01hat l 1 d,urst t II p f M1 C t l :I Lapmr l�� (Tnmmenang with Section 7")ofDivision l ofpm Buiness and Lremile)or I EMP.MG TER OR POLEINST COMMERCIAL' e
her hu Is exempt therefrom:rod the basis tar the alleged exemption.Any violation of ❑NFW BLDGIADD[HON ❑DEMOLITION
W N Scetion"111)1.5 by tiny o,lican lima permit nabjem,the ap,hi m m o evil penally of POWER DEVICES ❑TENANT ❑ °OOD SEItVICI?
[-. not more than five hundred dollars($50n). IMPROVENIEN17
tyZ� 01,its ownerif(bcproperty,or illy empinyecs with vases as their nnle cmnpnmmtinn, SWIMMING POOL ELECTRIC OTIIIi
W f..m will dnthe work,and the stowarmis tot inteneedoroffered for.ala(Sce 9044,Business
and Professns GMB The Contractors Licerse Laity does not up,ly to an mvncr of OUTLE'1:S-SWITCHES-IIXTIJµ1:S i
prPollution,
operly wltn haflds nr I T,Ibemnn,and who dove such wad;hnnselfoth
r rough
his own employees,provided that such improvements are not intended or offered tor NEW RISIDENI'[A],EIJ!C of SQ PI'.
sit,If.hatwem,the handing.,impowementissnld within one year of completion,the :Q.IT.MOOR AREA 3/SQ.1--n
iwner-holldo-will have the burdened pmvins that hu did nn(build nt improve for,overtime.).
0 I,as owner of Ihn pmpeny,am exclusively contracting with licensed ctmo.cton to
construct the project ,1
(Sec.90 ,Business had P..I..inns Cede:)'I'he Comme ar's Li- r
ase Lawdnannt applyhaanownerof property who bundmrmatrate,thereon,and Q'rl'• PLUMBING PERMIT FEE
who err aed f�rs wh prnlvt'ts with a cmtrnanda)limnsed,unuatn in the Cmnractnrs
Limen Law. PERMITISSUANCE
1 am exempt under Sec. .B&P C for this reason
AI:TER-DRAIN is VENT-WAI'IN(EA) VAL(In'1'ION
Owner Dale
WORKER'SCObIPEN,iDECLARATION HACK PLOW PNOfF.CI'.DEVICE
1 hereby nllirm mrn,to under penalty of jury one of me Billowing declnnilinns:
IM1ave and will tnaimuin aCenificae ill Consennn self-invert for Worker's Compen- DRAINS-FLOOR,ROOM ARBA,GOND. $TORIES 'I'YI'F.CONSTRUCTION
swoon,..which
i for by Semon 3](p ill the LuMm Cotte,fur the perfnnnance of the
work fnr wniob will
ai nh Is Issuer FIXTUIt ES-PEIi'I'RAI'
❑I have and will ude,fan Worker's Compensation Insurance, h required by Section
1]1X1 of the Labor Code,tiro the per6rmance of[lie work for which dos permit is issued. CAS-EA.SYSTIiM-1 INC.40IJTLETS OCC.GROUP MIN '
My Worker's Compensation hermncecurler nd Policyhummer um:
C.mec Policy No.: GAS-E,N.SYS"1'li V;
CERTIFICATE HIT EXEMPTION FROM WORKERS (1NIiA$IJINDUS' AS'I'F.I RRC iI'1011
COMPENSATION INSURANCEIIOILIIING DIV ISION PIJ;S
(This section need nm bemmplenW ifthe lwnnn is farnne hunJreddollws!31(X11
GREASE[RAP
nt Icsx) PLANCIII!CK II!F'
I Terrify(balm the performance of the work fnrwhich lhispermit is issued,I shall SI1WEV'-SAN BY- ( f.
nemploy any person in any manner so as to became subject to the Workers'Compen- 1'..NENGY FEE
z sntlon Laws of Calif,"'. me WATER 111!AT!R WIVEvUX-.I,1!Cflt
zO nppueat - GRADING FEE
NOTICE.f0 APPLICANT`.If,after moking( i erriftare n[Exemption,You shontid WATER SYS FbYHNG SOILS FEE
become subject ln(M1e Wmko2s Cnmpensulim anviuiensnl'the Labor Code,y m aluet
W local,11h romply with such prromeas or his penin shall bedeenmJ revoked. WA'T'ER SERVR`
Q
7 z CONSTRUCTION LENDINGAGENCY N17 RIiSIDEN'I'IAI.I'hMB. $Q.P PAID DULL e ipta
UC I hereby affirm that hem is a construction leading.gency ham,perfncra,e of
'ho work to which this permit is issued(Sty.1097,Civ.C.)
wFOlender's Name TOIAI"
U '
CLI Leadims,Address TOTAL:
I certify Ihn!I hove we This npplivatlnread auto that the above information is BUILDING FEE
.F. V0.i mreaJ agreemcnmply vim all city and count'oNinsnecs and stem laws relating to QTY. MITCHAM CAL PERM IT FBI'
C.1 7 building consorwrin4 and hereby authorize representatives of this city m Tom,aper the
SEISMIC FEE
�i above-menllnreal pmlwrty fin'...."ime pngv:m.n. PERMTI'ISSUANCE -70
(Wed agree to sauce,indemnify and keep harmless the City of Corinna against 1?LBCI'I1IC FEE
liabilities,judgments,costs and ex wnus which may in any way.ccmc against said City AI:1'ER OR ADO TO MECH.
NW
nseyucnceol the ming Ih pe tit. PLUMBING FVV
APPLICANT ON TAN S At D ILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO III,(NXI CPM)
SOURCE IKGPJC )NS. MECIIANICAI,ITF.
I—
(- q� AIR HANDLING UNIT OVER I(h000CFM) CONS1 UJCTION TAX
1.
Slgnvuuan name, Umc EXIIAl1S'f HOOD(WNUC'D HOUSING MI'fIOATIUN FEIi
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future,building occupant share or handle hazallous materialIIIiATINC,UNIT(TO 100.000111'Of
us defnnl by the Culmina Municipal Code,Chirpier 9.12,anti the Health and Safety
Code,Section 25532(uJ9 HEATING UNIT(OVER I on,000 BTU)
0Yes [QNn PAID
VI?NTILAT'ION PAN(SINGLE RESID) Date Rwxip(a
Will the applicant or failure handing creation use ecialmaen(or devices which
emit hantnlous air concer nun efined by the Bay Are.Air Quality Manm
ageent BOILER-COMP pl{P Ok IIXIJIfA1 BTU) T< \L
District? MOILER-COMP(OVER 100,000 BO U)
i i
❑Yes Nn
Have -1(he mrdnm nateriuls trquimmeno under Chapter n.95 of the Call- A1µCONDI'IIONIiR ISSUANCE LATE
Enmia Health&Safe 'one. 'lio�i bin i,25513 ane 25511.1 undencmd that if he NEN'NISIUF.N'DAL MECH. SQ.FT.
builda'doecn: vfrndyba tetpm.minitismyre.Punvibllitymnotifytonocuupom
a fficreyuirece- s . lobm .t e et prior to issuance of a/ f,9ehil oOf, my.
Owner oramberizcdngern fDt , TOTAL: ISSUED BY
OFFICE