S 0584APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
COFRTINO BUILDING - RLEC`fRICAL PrTITNO,
VISION APPLICATION/PERMIT PLUMBING. MECHANICAL 0584 V84
xnu nrNC PRn]FCT IDENTIFICATION
I hereby affirm thm I am licensed under provisions of Clone, 9 (commencing
with Section 7 dB.f Division 3 of Ne Businessland Professions Code, and my license is
in frillforce tad ecw3 ew 3 jk 1G /
License Class hic.p
ARCHITECTS DECLARATION
I understand my plans shall he used as public accords
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which mal a permit to construct, alter, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit in File a signed statement
that he is licensed pursuant to the provisions of the Contractor License Law (Chapter 9
(commencing with Section 7001 of Division 3 of the Business and Professions Cade) nr
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SSW ).
I, es owner of the proceny, or my employees with wages us their sole ammpcnsatinn,
will do the work, and the structure is not intended or offered for sale (Sec. 1044, Basin,,
and Professions Code: The Connector's License Law does not apply to an Owner of
propeny who builds or improves thereon, and who does such work himself or through
his own employees, pmvidrA that such improvemcros ase not intended or offered for
sale. If. hmvevee the building or improvement is sold within one yearofcomptetion, the
wneohailder will have the burden of proving that he did not build or improve for par,
pose .Piste.).
1, as Owner of the propeny, am exclusively contracting with licensed contractors o
amused the project (sec. 7)44, Business and Professions Cade:) The Commeors Li.
ansa Law does not apply to an owner of propeny who builds or improves thervan, and
who contracts for such projects with a cmntracmr(s) licensed Purolator to the Contractor's
License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
❑ Consultant Fees Paid by Applicant (initial)
4
)TY. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPT02N)AMPS
SIGNS ELECTRICAL.
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE INS'(.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL FLECTR SQ FT.
Owner Date
. WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of are following declarations
Fl I have send will maintain a Certificam ol'Consent n self -insure for Worker's Compen-
sation, as provided for by Section 3700 Of Ne labor Code, for the performance .1 the
wmk for which this permit is issued.
1 have and will maintain Worker's Compenutinn Insurance as required by Section
. N)of the Labor Code, for the performance of the work far which this permit is issued.
My Worker C. tion llJvrtanee caria and Policy nnombecom
�7�0 )AaI'O
Cardec Policy No.:�_��
CE.RTIM A'IF OPTION FROM WORKERS'
COM PENSA'I'[ON INSURANCE.
(This swtion Orion not her completed if the permit is for one humfeed dollen IS 100)
or Iws.)
I certify that in the performance of the work forwhieh this permit is issued, I shall
not employ any person in any manner so as to become subjecnn the Workers.' Compen-
Z otina laws of CalifOrma. Date
Q Applicant i
NOTICE TO APPLICANT: IL alter making Ws Ccnifieam of Esemption, you should
a; become suhjwt to the Workcrs Compensation pn visim s of the Labor Cade, you must
{✓a foMwim comply with such provisions or this Permit shall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
V O Thereby affirm that thele is ecpnswdion lending agency fonhe performance of
R. 17 -Lender's
the wok for which Nis permit is issued (Sea. 3091, Civ. C.)
Q U Lender's Name
U Lender's Address
{. y I cenify that I have read this application and some that the above information is
fr VI wreecs. l agree o comply with all city mal county odinances end state laws relating mQTy
U building construction, and hereby authuire representatives of this city m enter upon the
above-mentioned propeny for Inspection purposes.
(We) agree to save, indemnify unit keep harmless the City of CuNnino against
liabilities, judgments, costs end expenses which may in any way accrue against said City
in conscuuence of the starting of this permit. , n
dl Ne applicant or furore it ng occupant store or handle hvuNous mmedal
as defin v the Cucenino Munio Cade, Chapter 9.12, and the Health and Safety
Cl Yes ❑No
Will Ne applicant or future building accul an use equipment or devices which
mit hnrardous air Commodore', es defined by the day Area Air Quality Management
District?
E] yes ON.
I have read the hma dons mmedWs requirements uMer Chapter 6.95 of the Culi-
frmia Health & Safety Cade. Sections 25505. 25533 mrd 25534. 1 umkromnd slut if the
building does not currently have a tenant. that it is my respomihility to actify she Occupant
of she ruimrmnts which must he met prior to issuance of a Certificate of Occupancy.
PLUMBING PERMIT
ISSUANCE
DRAIN & VENT- WATER IEA)
NEIM DEVICE
GAS- RA. SY77EM. I INC. 4 OUTLETS
GAS- EA. SYSTEM -OVER 4 (RA)
GREASUINDUSTRL WASTE INTERCEPTOR
GREASE'TRAP
SEWER - SANITARY -STORM EA. 200 FT
WATER HEATER W/VENIOELECTR
WATER SYSTEMG`REATING
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD tW/DUC91
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,NK) BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR IN),001 B1'H)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. ET.
OF
0
PERMIT
FEF: P d D
MAR 1 3 r
VAL 1
CITY urluranitivu
STORIES TYPE<
OCG GROUP
BUILDING DIVISION FF7I
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date IU -ml M
TOTAL:
BUILDING FEE
PEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Rtteipt9
TOTAL:
it -
LOB DESCRIPTION'
IAL
❑ KITCHEN REMODEL
❑ PLUMBING RE -PIPE
rBATH^`
IT 0STRUCTURAL
MODIFICATION
❑ CHIMNEY REPAIR
MENT 13 SWIMMING POOLS
OD PA ❑DEA OLRIO
BOTHER �—
COMMERCIAL;
❑NEWBLDG/ADDITION ❑DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. IT. FLOOH AREA
&SQ. IT.
FEF: P d D
MAR 1 3 r
VAL 1
CITY urluranitivu
STORIES TYPE<
OCG GROUP
BUILDING DIVISION FF7I
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date IU -ml M
TOTAL:
BUILDING FEE
PEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Rtteipt9
TOTAL: