99100073 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY G C' Q / �j
CITY OLCUPF.RTINO BUILDING-ELECTRICAL PIiRMIT NO
IJJu' NC.DIVISION APPLICATION/PERMIT P,[UbmING-NI?CHANICAI. S0001
5 IIUILDING PROJECT IDENTIh'ICA'f1UN
IIUIIAINGADDRESS: � SANITARY NO. APPLIC TIONS BMI'1'1'At,DATI
IkE
Loo d /PHON': COryy'ItACT t' NA LIC NO�, "Ocomalier C_�x(/ N/C IrIC ADUS5v ❑l Is ON BUILDING PIIRMIT INFO
rrRe/t �7Q, ❑ Consultant Fees PuiA by APDlicant(Iniliap nhl GLr:C" rLUMB MK lP"�/ .IJV(/` ❑LICENSEDCONTRACI'O :SDHCLAR ION QTY ELECTRICPERMi FEE
t hemby m affirthat 1 am licensed unde provisions o Chnpler 9(crnnmencing JOB DESCRIPTION
Cmz with Section 7")OfDivision 3 ofthe Business and ProfessionsCode,and my license is RPSIDENTIAL:
WOO PERMIT ISSUANCE
f-F__ in full force and affect. GSFDWL ❑KITCHENREMODEL
Q!„)UFU 1.¢enu Clens ick APPLIANCES-RESIDENTIAL ❑ADDITION - ❑PLUMBING RE PIPE
I- W Date— ,tmcmr
�Dh A f' TS ECLARATION I'ANI?IS El MULTI-UNIT C1 STRUM URAI.
vv�� r rsu ts' ux pnhlic marls MODIFICATION
OZ:1, U1110200AMPS ❑IN' ERIOR El CHIMNEY REPAIR
Li need no s. nut 201.1000AMPS IMPROVEMENT []SWIMMING POOLS
OWNER-B IDI?RDI?CLARATION OVER 1000AMPS ❑BATH REMODEURI:'AIR ❑DEMOLITION
IY Q 1 h by eMo.that 1 a emp,from the Contactors Limnse Law far Ne
K 0 6 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
4!3 LL which«quires a permit m construa,alter,improve,demolish,or repair any structure
1:4^0 prior to its issuance,also requires the applicant for such pwaritto file o signed statement SPECIAL CIRCU TOM ISC.
d that be is licaneed pursuant o the previsions of the Coutmetor's License Law(Chapter 9 COMMERCIAL(commeneiagwah Scallop 7fXXB of Division 3 of the Business and Fn re"i,en Gda)ar 'IHMP.METBRORPOLEINS'I'.
4 4 pC that s exemp
he it therefrom and the hasis for the alleged exemption.Any violation of ❑ EW BLDG/ADDITION FIDEMOLITION
4�y Sermon 7031.5 by any applicant for a permit suhjects Ne applicant to a civil Penalty of POWER DEVICES TENANT ElFOOD SERVICE
t more Non five hundred diallers($500).
F Z i IMPROVEMENT
Sp ❑Lasowner of the pmpeny,or my employees with wages as Neirsolc compensation SWIMMING POOL ELECTRIC OTHER
y will do Nework,andc. he Cont a not s License Law
loess of a ply to m*Business
vmr of
W F� and Professions Codc:The Contractors License Law does not apply m en asvner of OUTLIiTS-SWITCIIES-FIXTURES
0.3 us own whooyees.nr vided t s such
Land whoeas we h wnte himself f ehmugh
his own however,
the
pmlitias that such inm,nventld w arc not intended Or offerer,for NI?W RESIDENTIAL I!I.HCfR SQ Irl'.
tele.ll;however,the building nrlmprovemcm is cold within one year fammlmimm the s} �1Q - f AIt1iA EISQ Pf.
owner-builder will have the huMen of proving that he JiJ not build ter impmvc fur our- —/ 1
owe of aile.). �•/
❑ I.u owner of the pmpeny,am eadusively wmac,ing with licensed amtrvemrs to TOTAL
onstruc,Nees net(Sec.o an wnerof amdny who builds
ui Ca improves
thereon,and
- 11
whooawdcesrruch apply mon ownerurnmetany whosedparimpto the ompacand QT'g PLUMBING PERMIT FEE -J't
who romracrs for such pmlemn wiN a umwcnrls)licensed pursuam m theCompactor's
License Law. PERMIT ISSUANCE
1 ea,exempt wide,Sac. .B&P C for this reason _
s ALL ER-DRAIN&VENT-WATER(EA) - VALUA'I'ION
' Dan//WORKER'S COMPLNSON D[CLARATte HACK PLOW PROTF.CI'.UI?VICE Jam'andI hereby alHred under penalty of perjury one of Ne following dealaationeI have will murnounn Certificate of Causin..self-insure far WorkempersCote- DRAINS-FLOOR.ROOT,AREA,COND. STORIES TYPEGGNRTkDCI'IDN
gap,
le on,as provided for by Section 37W of the Cahn,Code.for be performance Of the , 'f
work far which this Nrani,is issued Irl STORES-PER TRAP
❑ I have and will mainmin Workers Compensation Insurance,as requited by Soria-
1700
or iam1710 afthe[Abu,Coda.(r ithe pvrm
forthcuonr
t the wk for which this permit is issued. GAS-EA.SYSTEM-I INC.a OUT S - OCC.GROUT' r APN
My Workers Compensation Insurance carrier and Policy numher are: 'k[��o� l/11,,--t
Cartier: N.
POP, : GAS-HA:SYSTEM-OVER ?A) �[/�7 -� V I
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASUINUUSTRL S'TEIM'ERCF.PTOR
` COMPENSATION INSURANCE BUILDING DIVISION FEES
-. - - ,.(Thin section to not M completed ifthe permit is formic hundred dollars TM00) ORHASI?TRAP
nr taped PLANCIIECK FEE '
I certify that in the performance of the work for which this Fermi,is issued,[,hall SEWER- NITARY-STORMEA.20UFT.
not employ any Persian in tiny manner so as m Moonie subject to the Workers Compen- ENP.RGY FHE
� z
at ..Laws of California.Dene WA'I'F IIIi
APPliaaut ATBR W/VI!N'I'IHLI?CCR CNAUING PEE
Q
NOTICE TO APPLICANT.If,after making this Certificate Of Exemption,you should ATER SYSTEMnREATING
a ; becme osuhjecl I,,the Workers Compensation provisions of the Lehr Cale,you most
LEI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
V O CONSTRUCTION LENDING AGENCY NIiW RESIDEMfIA1.PLMH. SQ.PI'. AFE
PATO Date Remipt p
1 herehy tuff irm that Nere I,.construction lending agency for the Nufommnce of I
IL p-t ,he wnrk for which this panni,is issued(Sec.3097,Civ.C.) d T 00 T
U Leader's Numc L
V L ender's Address IY)l'AL:
S _ ❑1111. 1 GFEE
1 certify that I have read this application and drateiva that the since iws rmn ing is
r0 cnrmn.Iagrecmcomply
nd with all cityandcountyOrdinancesoftiscoy and t eatrupingm QTY. MECHANICAL PERMIT SEIS I .FEE
V z abArngeonsuuationv" hertbyamhonve rccresentatives mf Nis city mement(smthe V
r nbnve-mee)agrdpmpeny for inspection keepha. PHRMIT ISSUANCE
(We)agree m nave,indemnify and keep humdess the City n(Cnpeninn against ELECTRIC FEE
Ilahildies,jal,news,coosunof penins which may in anyway scenic against said City AUTERORADDTOMECH, PLUMBING FEE
in cunsequanoa Of Nmgntmin fy Fermi,.
APPLICA NI A" 6 DW LLT COMPLY WITH I,NO AIR HANDLING UNITTI'll 10T00CFM)
SOURC/f I I' N: MI"CIIANICALFEE
/O / AIR HANDLING UNIT(OVER 10.00(i CONSTRUCTION TAX
Si m m JiOuw Co hear ( ! ate EXHAUST HOLD(W/DUCT) HOUSING MITIGATION Mr.
HAZARD US MATERIALS DISCLOS RE
W41 Neupplicamor fJ/4r building occupant store or ollc haaMO.,material HRAI'[NO UNIT('10100.000 H'OJ)
as defined by,hc CupcMae,�eal Code,Cbapwr 9.12,and the Huulth tend SaferynJe.SeRi y 255C20p't II3AIINO UNIT(OVhR IINI/NNJ BTU)
VI?NIILAT'ION PAN[SINGLI?NESID) PAIDDate Rmcip,M
f Will the app icenl Orre building accupaml use equipment or devices which BOILER DRI'OR IIXI,IXq BTU)
it haaNmus air contaminants as defined by the Bay Aron Air Quality Management T(ypgh:
I s. mO
ns�v17 HOILER-COMP(OVER IW,WUBTU)
❑Yes �
(hove re eltun uls ,s under Chntrfi95 fthc Cali- AIR CONDITIONER ISSUANCE DATE.
require p
fornin Ifetil, nl',y .255115,255',13 and 25 1 t Aerx,u A then if the NIiW RI:SIDEN'1'IAI.MI!CII. SQ.RI'.
Wif in` c t et t hatitismyrespmsibili,y On,ii ,c c..pant G fvy
Of tre em normismunce of was,
t
Own,ora eJ agent Inue TOTAL: ISSUED BY'
r
OFFICE