27821APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFISIONmrol' - '
BUILDING DIVISION APPLICATION/PERMIT DING PRNGCTIDESNICAL
BUILDING PHOJK6'1'_IDF1Y'I'1F'ICATION � ',
PERMITNO.
27821
HUI//L'D�IINGADDRESS: LL % a�
,V IO'V ` e% NIT U. LOT#
SANITARY NO.
APPLCATIONSUBMITTALDATE
OW IiESN 1:: PHONE
CONTRACTOR'S NAME: LIC NO:
a J
N/C
❑
CONTROL#
RUT I ITECDENGINEER: IC NO:
Q {. O 6
ADDRESS:
'0 , CT: PHONE:
�# f $ 'R'= � •-'- �'+ a
EI:E#G,I�RIG PERMIT '+ g, !,#FEE
QeR;
`"°' - "'ii'�BUIL`DING PERMIT INFO
T PLUMB MECH
BLO ELEC1:1 El
nn II__ /
r -4-e- LA, -z^ V 415nZZ3
e'1
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm diet 1 mat licensedunderpmvisionsofChapier9(conunancingwlN
Scotian 7") of Division 3 of the Business d professions Cods, and my license is in
APPLIANCES -RESIDENTIALJOB
DI?SCRIPTION
zxl*tv
PANELS
fit fiamaind
j License Cl seffc Lim.#�IZa 1 i...
UP TO 200 AMPS
Date Convector
201 - 1000 AMPS
-jc ARCHITECTS DECLARATION
I understand my plans shell be mad as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDERDECLARATIONthe
SPECIAL CIRCUIT/MISC.
Connector's the
1 hereby affirms that I em exempt from the Cosions o License law
TEMP. METER OR POLE INST.
following reason. county
1n 703 1.5, Business and professions mli Cade: Any city co
umm, s
which requires v permit reconstruct, slier, improve, demolish, fi repair any attemum
Permit to filLieaseLad statement
sscensedprsunt
POWER DEVICES
that he totsfirovisins of
thatheislicensed oSection theprovisionsof the Convaztor's Lal Per Lew (Chapter
9(cotheis ingwithriroorOW)nfbasisim3a.11codaiussand Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
of
orthat on 7031.5 by Nercftmandthe Permit
erist sbjects thedeumpti in. civiny l Penalty
no, mom th LS by huire ndredapplicant ull... $500). tsubjects the applicant wacivil penalty of
not mnrc@an refibedredd ,ormyem).
❑ I,osownero0he propctty,ormyemployceswil6 wegesestheirsolecompermetion,
47 O O O
OUTLET'S - SWITCHES - FIXTURES
NEWRESIDENTIALELECIR S .FT.
Q
STORIES
'TYPE CONSTRUCTION
will do the work. and the structure is not Intended oroffemA for mle (Sce. 7044, Business
and Professions Code 'Me Contractor's License Law does not apply to nn owner of
property whabuddamunprove%mhercon, and whodoessuch work himselfortherughhia
employees, provided that such improvemems art not intendedor offered fm sale. If,
OCC GROUP
RIS.UNI'I:S
TOTAL:
however, the building or improvement is sold within one yearofeempletion, the owner -
builder will have the burden of Ihn he did not build or improve for f
proving p pumoaeo
TA $•T Y t, ...t -r i I Y i 1 :..
opTY + PGUMHING PCRMIT' t FEES'
.ism xtv pb♦»n,
PERMIT ISSUANCE
sale) ..
❑ las twnerofthe proparty,amexclusivelycontradingwithlicensed convmtm%m
Imearrel the project (Sce. 7044, Business and Professions Code:) The Cminicmr'e
Limnselawdr notaM)ywmownerofpropenywhobulldsmimpmves Nerean,md
FLOOD LONEL
APN
who contracts forsuch projects with acontructor(s) licensed pusuanuo the Communes
License Law.
ALTER -DRAIN &VENT - WATER
k l a ° " r PEE SUM_MARYr
❑ 1 em exempt under Sec. B & P C for this reason
BACK FLOW PROTECT. DEVICE
O T ID I.
SANITARY Y N
RECEIPT#
Owner More
DRAINS- FLOOR, ROOF, AR G, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
M1ereby from that I have it cernfica a of commit to relf-ins...... certificate of
1—%auon lmut�m1ce nrac<nired rnpYthereof(Sac. 38110, Lab C.) which
covers ell amp ' na�IQtyflltilw
Policy# I�VV
FIXTURES -PER TRAP
RECEIPT' #
PARK FEE YN
RECEIPT#
GAS- EA. SYSTEM. I INC. 4 OUTLETS
BUILDING DIVISION FEIiS
Company
❑ Cetifiedms ylhere ry furnished.
GAS - EA. SYSTEM-OVER4 BDU
PLANCHECK FEE
GREASFIINDUSTRLWASTH DITERCEPI'OR
GRADING FEE
❑ Cmtified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASn TRAP, ('y
SOILS FEF.
COMPENSATION INSURANCE
SEWER - SANTSA a TORM EA. HAFT.
ENHRGY FEE
(This section need not becompieled Hiles permit is for ata hundred dollara($100)
or less.)
M6HEATERW` /ELECTR 'a
WATERSYSTEMjdI), NG
` ,'
PAID
Dam Receiplp
I certify that in the performance of the weak for which this permit is fssueN. i shall
nm employ any person in my mama so as to become mct to the Warker%
Camp,... lion Lawsof California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cati cafe of < n, ou should
become subject to the Worker's Compensation provisidns of mh.IpNL`a�ode)yvumust
faMwith comply with mch pmvisima m this permit shop be dhemm rc oked.
�Y
NEW_RESIDE PLMB. $Q. FT.
m, ♦I^
TOTAL:
BUILDING FEE r
CONSTRUCTION LENDING AGENCY\1
SEISMIC FEE
Ihereby affirm that there is a construction lending agency fordte perfmmpQga°f
„ -
TOTAL
ELECTRIC FEE
me work far which ams permit a tuned (Sec 3(197, Ca. C.) I \ V r
Lved,ex Name
wed Address 4A
2'1g+(E+ AZw# E AF S Pwx an a
07'Y; aMECI IANICAI PERMI;F .",' NEIst' .
1 h v E
PLUMBING FEE
I comfy, that 1 have teed this appbm ton and .,.,allies love mfmmmmnla
o se, and with all city andcounryordinances ariscum Wiser upon the
correct.qnflo
buildirioa,art herebspectinprcoses. 0ves of thismyfebnmrupon the
above-propety fm mnify
s . . r bAS b x 1
PERMIT ISSUANCE
MECHANICAL IEE
ALTER OftADO TO MECfI.to
CONSgRUCTIONTAX
and keepous.
%ave, indemnify roti keep harmless Ne Ci f nine a aiincurnentsecoarsing
expenseswhichmay in my way
AIR HANDLING UNIT(TO 10,000 CPM)
in canf Ne Branding is pemtit.
AIH HANDLING UNIT (OVER 10,0410 CFM)
Sig m of Applicant/C—cu,s are
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
Will the applicml or future building occupant store or handle hiardou%maudal
m defined by the Capetian Municipal Cade, Chapter 9.12, and Ne Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
Cade, genion 25532(a)7
❑ Ye% El No
Wlli the applicant or future building occupant use equip imat mdevices which emit
BOILER- COME(3HP OR 100,000 BTU)
PI SUINCEDATE
A
BOILER - COMP(OVER 100,000 BTU)
oae
is as air commercials as defined by the Bay Area Air Quality Management
Diver' ❑Y i
❑No
MAY 231995
NEW RESIDENTIAL MLCH. SQ. FT.
1 have and the hi ardous materials mquiremems under Chapter 6.95 of the
California Health&Safety Code,Sectione25505,25533and255M. lundsu
erndthat
if the building dans not curtemly have a tenons, tlmm it is my responsibility to nmify the
^/'� 1
(♦ Ut- LuYL
LH
cupvnt of rhe requiremenu which must be met prior w issuance o(o Cmifiate of
.
Occupancy.
ISSUED BY:
Owner m eulha iced age n Dam
TOTAL:
OFFICE