B 0498APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING - ELECI'R
BUILDING DIVISION APPLICATIONIPERMIT
�o`�S7 iia;2w
,VNER 5 NAME:
COMACT:
ems- S.f3: 95'/32
Al.? 8 -,v6-0 .7 1 ❑ Canso tanl Fees Paid by Applifa it (Initial)
LICENSED CONTRA(TORS DLCLARAI ION QTY
n„ebTi
y aml Na, I am Ikon. d Local pwi,ion, or Ch,ce, 9lcomn umang
cc, wJ
Max,m Satian 00001o[Division 3 M lie Busiesaud Pmfcuiam Cak. and my licenxu
��� in full 0ecc"d VQUcct. C U', I.ic.X
Vi [)areC,nw,
6 a
ARCHr12CCS DECLARATION
z O 1 understand my Im rls shell ha used a pundit ramrds
oz -o
L ad Limancd Profca,iwul
OWNER -BUILDER DECLARATION
Y Q I hereby of rso Thal I nn exam, town he Contractor, I-ses. IAw for llu
U rnnrnvmg recon (Section ]031.5. Buslncu a0] Pmlevvirm Code: nay city «ttmmy
LL1It � walch requi ,, a perm' to mbatr l ells, impmve, demolish, a rtryo w)' .mature
��0g pr,o its i.asuaae, vlw l mocilheapplicanl fursuch pttmil to llcevgnce slaenen,
y�y That he is licenaeJ purwent to the pravitiamdBn Cuurxlorx titan,, LawfCharyer9
�QO (ceso eneing will Se Oun 700(no( Tvision 3 uflhe Business and l4afessiuu Cede)«
1 X M, Thin U, cnemis I,m,,ma vd the "is for die alleged emmpion. Any viulmion of
u] moi°^ 70313 by any epPliam
nl for v INr sainccu Jr alpf mino a d,il EenvllY of
mm mom,Mn Eve hundred dollen 135111).
f=0
Fl 1, wxr of We pan,,.y. or my amplyce, wind weM a Neu sale minlen,aaort
r. will do Fe work and the al memo,ism, truended,e offered! Gusalc(Sm. IIN4, Buninc.a
ad Professions Calc: The Contremor's Lcanse Law does not arTAY to w sonar Of
'o,asy who build. or isn"ors,ba ns, and who &— .,h w«k himreu«duough
hlv Own empIo,m , provided Hurt such impr,rvmni art not imemdd a onemi for
salt.It. luw Om,,, hadding inim(vavement is sole widbin ase year MrnmPlmion.Bre
rcr,larfl r will M1uve the hasten M pnwing the, be did mR build or improve for Pur -
,ma, of oak).
❑ 1, an Owner of the ,o,,Oy, in,, exclusively rnmraaling with Iicenwl conmavna to
mrwrvn the psajnl (Sec. TULL an.. and Rhea ins Coder) The coaam ctKs IJ,
rcc low Jour ort aEplY,u un awns n[prycnY who M1uilJ_<,e impmvcx thcmm, ami QTY.
who camvxn for, wh tsjects with a cormter(s) licensed urstiont to the CanllYtors
Ii. Law.
I em e.aop urvkr Sec. . B in P C fm an, rowan
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESI DFNIIAI.
PANELS
UPT020OAXI 5
201-100OAMPS
SIGNS ELECIRICAI.
SPECIALCIRCUIT/MISC. f
TEMP. SIFTER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
O(fILE1:S - SWITCHES - FACTURES
NEW RESIDENTIAL F.LECTR SOFT
I&Owmr Doc
WORKIJi'S CONDENSATION DECLARATION
hcmhy dons unJur pan.Jly of purjury,mc of IM1c fnlhw mg dnlurat co
I hereandwl0 mans ions•Cca,iticweofCa 1,1hto Tell -i. far WrmlooCwnpen-
v ase , an hk hkd (« o Senior T11X1 of,he IaGx Canada. Gv Bre pMurmexe of IN
wwk f«whdh this pundit is usual. -
❑ I lure and will maintain W«kers Aum orsmian In,umae, which his p +1 by section
Jmy Mthe Ichorlismafa Ilepcdomlana nf,M1e soak fouraiathis Ixrmil is i.ud.
My Workers Compenmtirn Immarce currier and Polity nurmbe+ve:
Carrico Policy No..
CFHr11 FICATE OF EKP.AIP ION FROM WORKERS'
COMPINS ATION INSURANCII
Me, satin ITN an be aanpklW if Bre peroom u fe, ate hundred dollu s (SI W )
ler.)
I each fy the, in Ile perfone ace of the -A flu which dn' Person is woad, 1 shell
owl employ any parsac in wry menlq IahcLo,ltc svbjeU m the WMers' C«npen-
O z .'lion Iowa MCalytpU I T V -Y3'
z O Applkent%L
r%I
NOTICE APP ICAN'I; If, attar OIA mg Ia, Ccnlfam of 17 scimPom, Yalu ehmd
F+ becarc sublar ra the Workers U.N. pnn'ia4els of t e lab- cede, you nlu4
Lak7ti fnMwith comely withsachfnrvi,iam, a this Pcrmil shall he deemed revoke.
z CONSTRUCTION LENDING AGENCY
U
1 h,vchy alarm Char share in a conRluction limaing'VmY fa du perfmmnux of
Fr the work for which this Mlmit is iuunl(Scc.3090. Civ. C.)
Lmdf', Nunn
WIcMn's A,dncxs
LYr I anile, no I have Icd this a,,rnrnu and tame IMI the eMvc infnnna,iun iv
y career. 1 vgrte Ia comply with all city and toady adilmnas and aisle laws renting to QTY_
U building cmmnmuon, and nneby uulllwirc mprCYnlalivp of,hi. city In shier ulXm IIIE
nNwe-mleaOureJ properly fa impation pouf
(We) agree w.aaa, indemnify W keep bermkcs Blc City M Cupcelm agpia r
Inbililic,, Imlgmems, cos. mo,expemes which may in any way.chic aim, %aid Cay
in conssom,ni of Ile granting of Ni. Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONI'OINI'
Will Be vpplicen, a future bui1i ing occ,esm slmc «handle huaa dua, mmoial
my deGmal by,M Culp Or Mi miciWl Code. CTvger 9.12, it the licahi, end Safety
Code. Section 25532(.)?
❑Ya
Will ,he 9,, licvnl,s more holding,rcupanl use meilancnl or curia, which
mi, au m'and.. a dcOrrd by ,nd Bay Arca Air Quality Mvugemem
iisin'f
❑Yes LS.o
I bare Ted the ba,,nia u macrids mTuirmems under Chan fi 45 of Ole GIi-
fares IIdN & Start Code, Salkn, 25505. 25533 sod 255:4. I Imtlwand Thr, if Ile
a building does m, cumendy have a,mwm.that is my ms)nmibility In nodi fy Be seem
PLUMBING PERMIT
PERMIT ISSUANCE J,
ALTER - DRAIN &VENT - WATER WA)
BACK FLOW PROTECT DEVICE
DRAINS -FLOOR. ROOF, ARE L4111,PU.
FIXTURES -PER TRAP 1j 'ei
GAS - IA. SYSTEM -I INC.4 OUTLETS
Ms -EA. SYSTEM-OVIiR 4 EAI
GRFASFANDUML WASTE INTERCEPTOR
GRFASETRAP
SEWT3R- SANITARY -STORM EA. 2(10 FT.
WATER HEATER WHEN-VELECTR
WATER S YS'TEM/fR LAID NO
WATER SERVICE
NEW RESIDFNIN. PLMH, SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO NIECH.
AIR DANDLING UNIT (IU I0000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFNH
BX IIAU.ST HOOD (WIDUCq
IBATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,00) BTUI
VFNT'ILATION FAN (SINGLE RESIDE
BOILER - COMP (3HP OR 100,000 BTU)
BOILER -COSIP(OVER IOT001 BNI
AIR CONDITIONER
NEW RCSIDENf1AL MECH. SQ, Fr.
OFFICE
FEE
FEE
50001 40E0 4 9 8
SANITARY NO. A IIIII.ICAI'I()N SUBNIITTA1, I)ATI
DING PERMIT INFO_
PLUMI� MECH
JOB DESUKIPIION
RR SID�IAL:
❑SPDWL
❑ KTICUEN REMODEL
❑ADDITION
[I PLUMPING RE -PIPE
❑MULTI -UNIT
❑SBUCTURAL
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
❑SWIMMING POOLS
,�IMPROVEMIWT
2TBATH RENIOOEJ/REPAIR ❑ DEMOLITION
❑ OWER
COMMERCIAL,
❑ NEW BLDGeADDI'I'DON ❑ DENIOLITION
❑TENANT ❑FOODSERVICE
IVIFAwFXF,NT
❑ O VIER �-N�r— 1--r��
AO O
I/
\ -3 rsq I3
BUILDING DIVISION FRCS _
PLANCHF,CK FIJI
ENERGY FEE
GRADING FEE
SEISMIC FEE
ELECTRIC RTS
PLUMPING FEE
MECHANICALFEE
CONSTRUCIION'LAX
HOUSING MITIGATION FEE
PAN
h¢ Rc a, Is e
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1
I ISSUED BY: _
A