99100107 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY •'
FBUIMINGADDRflSS
PERTINO BUILDING-FJIETCAL DJT o7 PERMIT NO,
IVISION APPLICATION/PERMIT PLUMBING-MECITANICAL 0
BUILDING PROJECT IDENTDICATION
: " 1'vSANITARY NO. APPLICATIONSUBMITTAL DA ''1u�� L)PHONE: C Cf R'SN Sf@ LIC NO.
�0x/ N(C COqoq
M1IHOLM
CIf[�Q•j'Q;NGINE NP
UC NO: •Y ADDRESS: art ❑
CONTACT: �S• fy P.UONE: L dNLDING PERMIT INFO_
..LONE7 —�3�t ❑ Cort+Wlanl FceA Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED On,Io CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
tum 70(oa Harmon ftheBd Ander{xovotoo of C Code,
my
JOB DESCRIPTION
Oay Ih Secritm 1011fpolliviaion3 o(Ne Buaircss and!Peulessiuu COJe,uxl my heen¢u
00
with PERMIT ISSUANCE
In full forts erdll h"R cIT FOWL ❑KITCHEN REMODEL
cd.UU I.iccnsc Cl s Lic.0
APP ANCES-RESIDENTIAL
NGd lw,^ Cmraym ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECI,A ATION' El MULTI-UNIT ❑STRUCTURAL
z ono- I undeatwW my Pleru slWl le used as NNW rcdxda PANELS ,,,,,Annnn...M..,,ODIFICATION
OZ-O UP
2WA ❑INTERIOR �HIMNEY REPAIR
FyCW Licsnwh Prufnesionnl 201.1000AMPS IMPROVF.NENI' SWIMMING POOLS
X'-i OWNER BUILDER DECLARATION pyliR 1000AMPS BATH REMOD•IIREPAIR ❑DEMOLITION
W ¢ I hereby affair that I um exempt Ttom the Convecmh Lice.Law for tlr
k O a O follosvity rraun.(S«lion]031.5,Bashers ved Profession•Code:Any city or coutuy SICn'S ELIiLTItICAI. tR
LL1�+p, wnien reynires n pcntth m ronanrct,vino.impn,va,dennlinM1,nr relpir any swemm
I-u'OC
..GGyyJ prim to la issuaras.also rtquim the epplic.nt fn such pentdt ro filevugmisurcmeml SPECIAL CIRCUIT/MI. - e C
Wp0 (cnmmeresl ngwiNSectwo"I1100)o'Oivium3afthcoBusi lneswd Pmfcssiarul CWak)ar TEMP.METER OR 121NSP COMMERCIAL
6 d e n Ion he ix exempt dwvefrom and tic basis for that alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�N Section 911.315 by any applicant For npemdt subjects the applicant to a civil PcoWty of POWER DEVIC TENANT ❑FOOD SERVICE
as mac than five hutdrN"Iters(550(y,
IMPROVEMENT
PM['NT
Fxd Lax oworal'Ncxn n
� ❑ I Pr y.mmy cmpinycen with wages let their udr canpcnwim. SWIMMIN )L ELECTRIC
will do Nat work,and thesmetute arta intcMelaoRereJ fm sale(Str.lDhi,Bvurau
13 and Professions Cosh, e PCoul.amn Liecn.se law de.nm apply m on o rrr of OULI.EfS-SW ITCHLS-FIXTURIS O
Pnopcny wIoa build•or intpmvn OWWon,vnd who doe such work himself or through
his own emphryar.ProvidN that aah imptosetnroa are not intended a nRereh for NEW RESIDENTIAL ELF.CIit SQ FT
sada lf.htwever.thebuildingorimpovencntiswldwitNnorc Ywrofermplaion,de SQ, ARS` LSQ.PL
tier-buider will hase the burden of proving Net he did rwr Maid or imgm ate for per-
Pm
I,as tr.am of the Pmpety,am exclusively..be,with licenred contramons to TOTAL.
drnte Law
a t desonot15rc.]lint,w,amaaandrty who hurclaor)braes mecmr'aaJ - - -
rnelawdaanotapphymvnowrcrdprnpenywh�Moldrerimpruvemelanin.rand QTY. PLUMBING PERMIT -. FEELicense '
won cantrewa far such Imjeaa with a convannrtN licrnrd pursuant m rhe Cuntnanh -
it
❑Lem LacmPt urMcr Src. ,HRPCfn this reason PERMIT ISSU NCE
ALTER-DNAI. VENf-WATEN(EA)of MVALUATION
Rrm UATION
Due
WORKERS COMPENSATION DECLARATION BACK FLOW PR CT '7
DEVICE
�1 hcrtby.Itmdrr Fatally of perjury,txe of the following declarations:
aIhave provia It For byneetion17W of Consenno Coce.for cWnrkcrsCompdoe
DRAINS-F1WH, )F,ARBA,GOND. STORIES TYPE CONSTRUCTION
sation,w ptvvitkd For by Section 31W of Ne Irhur Cine,for that perfamarec or the I
wp.,' Fri done permit ix orlwe FI.YIURE$-PF.R TRA
have med
tain
J"lOO of the laMxwill
Code.�fm the per(smmarx<d flue,ark fn which Mia patron isnomed. GAS-EA.SYSTP.M-I I 40 S
M'Wnrkern(' ' Wi ed Poli y n r OCC.GROUP 4 APN
(•Tion�lr4-Yi 'y��s},e camt+Polic No.: 7i zy�S GAS-EA.SYSTFI.1-OV f ) 1 /�
CERTIFICATE OF EXENIM01, FROM WORKERS&pa 1 1 � dp O
COMPENSATION INSURANCE ` GREASEIINDU$TRLW INTERCEPTOR
"BUILDING DIVISION FPPC
(fbiasenion rcN mlhcmmPlmW if Uepandt iafo-meburchcd dollars lSl W)
GREASE TRAP
on less.) PLANCHECK FEE
Ianify that in de perftmty e.011cwak for which Na Permit is is�lshall SEWER-SANIT Y-STOR EA.2WFT
nm nmplo,any pe-,a to tiny manner w m to b mntc utbpo to the Workers Co.,pen- ENERGY FEE
zz in.Law.d C.liforee,Dale WATER If R WNEN'OELE
0 A,Hcem GRADING FEE
= NOTICE TOAPPLICANT:If,after treeing this Certificate of 13xewtion.You ahvud WATERS VTREATING
F tubera,suhject 10 that Wakefa Cuntpensumn Pnrvisivm of the labor Code,yow muu SOILS FEE
forthwith comply well such proves ow or this F,aut shall br deemed nevtAeJ. WATER SERVICE
0
z
CONS'1'RUCI'[ON LENDING AGENCY NEW RESIUCYIIAL PCMB. SQ.FT. PAID
U Q IhrrNY alhrm that there is a.mstrtxtitm lerdioe agrncY fat Bre perfomwcc of Date Hacihxx
Or. the work for which Nia Finnair it issued(See31x)1.Cat.C.)
F' IcttticrSaint, L
'a NTOTAL
WLinder,Addrna TOTAL:
y I ceony tow 1 have tad this application etd wme tout the aMve inno mumu is BUILDING FEE
y sweat.lapeelom plywffi BcityedcmntymNmmn adRaelewxneluingm QTy. MECHANICAL.PERMIT FEE s
V z Funding cu..mera n.and Mrehy uuNovvrepmmmativn of Nie mty to ewer upn ton SEISMIC FEE
above-mrnrc
tiod Pmpeery for irttpUlimm pvtpnsex PERMIT ISSUANCE
(We)agony to save,indemnify and krep hmmcss ni
lthe Clay of Cupcno against ELECTRIC FILE
r Iwbidilimjudgmcros,core,and expemaswhich may in any way acrae egaiml.said City ALTERDD TO MECH. PLUMBING FEE
in corssequeree of 0e panting of Nis hermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLL UNIT ITO to."CFM)
SOURCE REGULATIONS. - MECHANICAL FEE
AIR IIANDLING NIT(OVER 10.000CF CONSTRUCTION TAX
Sigreutm of A,limm CArmnor Date EXHAUSTHOOD( UC) HOUSING MITIGATION FEE
HA9ANDOUS MATERIALS DISCLOSURE
Will the,applicant or future building acapant some or hurdle Imsrdme tratcriah HEAIINGUNIT(T01 ,gIDB
ax dcfted by thio Cu{xnitm M..ipul Crate,Chapter'),I2 and he Health anh Safnv
Code Seem.25532(.)1 HEATING UNIT(OVER I . BTU)
El Yet, 10NoPAID
VFAREM
D)FAN(S REDI Dom RccciplN
S
Will tk apphem l be future Molding txcu atm Ase cempleem or deviea which
I nominal air catwmtana m detlrcd by die Be,Arra Air Quality Manvgeneml BOILER-COMP(. OR 1A BTU) TOTAL
mt1 BOILER-COMK'
(OVER IW.gp )
�Ye Naa
1 have teed Ne h oawk-inamnaLs AIR CONDII' NEH
r5.m 533 no uIE55 Chapter rtHS nl tint,Cul,- ISSUANCE DA7F�
fronto g does A Svomb Cade.e a an n t,bol 255JJ mtd 23533.1 undenvarth Nu if an NEW RFSIDFNf1A1,MECH. SQ.FT. 7 D, /�/T(
budding thea tux cmrtnthy neve a^^"nh Nut his my to ptvuihiliry to ratify Ncxarynt Z
of thertgaimmnH which muu e ' to I' ae of.Cenirxate of O<cslmtxy.
Owrerwau Uuc TOTAL ISSUED BY:
OFFICE