99100083APPLICANTTO FILL IN INFORMATION WITHIN
LINES BALL POINT PEN ONLY
BUILDING. EmPurRICAL
BUILDING DIVISION APPLICATION/PERMIT
95 D(
50001
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OFFICE
IYI � / V �
kiCII1TECfAiNGINEER: � LIC NO:
ADDRESS.
P E L .RS01
❑
DNTAC PHONE: _
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Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG a PLUMB h1CjC�H
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LICENSED CONTRACrORS DECLARATION
1 hereby affirm Nm I am licensed under pmvi,ions, of Chapter 9 (commencing
with Sedion700CJJ11fIoo�fec}}D�nO,ion3o/f�th,ina,mcssand Pmlessinns Code,:mdmy license is
Liver. ClassdC^YO 'C .# 3 b 09 r3
1],�
Dec ConarniziTSDECr
Q'rY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RE IIJ� ENT'IAL: ��yy
❑SFDWL Y7K1'1'CHIiN RIihl0Dli1.
❑ADDITION trLUNIBING RE -PIPE
❑ MULTI UNIT ❑STRUCTURAL
MODIPICA'I'ION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
PHRMI'I' ISSUANCE
APPLIANCES -RESIDENTIAL
,
p
Z�O
ARCHITECTS DECLARATION
ns ut he used ns public recordsz
1 WeraA ;mmy plash
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PANELS
UPTO 2tX1AMPS
4t:
Licensed Professional
201-100(IAMPS
if?
O e, U
OWNI:R-BUILDER DECLARATION
hemhy eflirm that I wn exempt from the Cninmcmr's License Law for the
following reason. (Section 71D 1,5, Business and Professions Code: Any city or county
m a1¢e improve, demolish, or repair any stmeture
❑ BATA RHMODfiflIEPAIR ❑DEMOLIT'ION
❑ OT1111R �-�r---�
OVER 100OAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
,i!` hf Cry E
Oy
'j
�0
S c C
^,y
which requires. permit comtruct,
no, its issuance, 1110 fifi res fleapplicantfor such Permit to file a signeds(atement
that he is licemel punuanl to the provisions of the Conmerors License Low(Chapmr9
(commencing will, Section 70M)af JIMAon 3 of the Busfness and l'mfessionv CnJe)or
that he is exempt therefrom and the basis for ,he alleged exemption. Any violation of
Section 7031.5 by any applicantfor a permit subjects the applicant) a civil penalty of
TP.MP. METER OR POIA INST,
COMMERCIAL
❑ NEW RLDG/ADDITION ❑ DF.MOLTI'ION
CITENANT ❑ FOOD SERVICE
-
POWER DEVICES
F,
Sp❑1.
alla 3 m
not more thou five hundred dollar:155(X)).
its ovemrof the property, ormy employees with wages as their sole mmpcnsutinn.
will Jo the work, end the structure is not intended oruffered ftuxale (Sec. 7014, Business
and Rofeseions Cale: The Corr Hors License Law does not apply to an none, of
Property who builds or improv s thereon, and who does mah work himself or though
his own employees, provided that such improvements are not intended or ofYamd In,
sale Khmvever, the building or inlpmveecou is sold within one year ofcompletion,the
IMPROVEMENT
❑ OTHIiR
SWIMMING POOL HLL'C'I'R '
OUTLETS -S W ITCI IFS -FIXTURE
NEW RESIDENTIAL FLF,CI'11 S
- SG [If. FLOOR AREA
$ISQ. FT.
owner builder will have the burden of proving that he did not Wild or improve for pur-
TOTAL:
pose of safe).
1, ns owner the property, on exclusively canoeing with licensed a miscalls to
r o
a _
QTY. PLUMBING PERMIT FEE
mmo-tc, the project (Sec. 7044, Business and Professions Code:)'[ tie Contractor's Li-
cense Law does not apply to on owner of property who builds or improves thereon,and
who contracts for such pmpmu with a contramons) licensed pursuant ro the Comranor's
PERMIT ISSUANCE ^ ,
_
Liansc Law.
❑ Itet exempt under Sec - ,B& PC for this rcmon
Owner Date
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
WORUR'S COMPENSATION DECLARATION
I hereby.aftrm perjury one penalty of perjuane of the following declma(itoo
❑ I have and will maintain it Cenificam ol''Consennoself-insure fnr Wrker's Coutpen-
sution, as provided for by Section 37M of ,be Labor Cale, for the performance of the
work for which this permit is issued.
BACK FLOW PROTECT'. DEVICE
DRAINS- FLOOR, ROOF AREA, COND.
STORIES
'1'YPF. CONSTRUCTION
FIXTURES - PER THAI'
1 have and will maintain Worker's Compensation Insurance, ns nurtured by Section
3700 oflho Lalmr Coude, for (lie performance ofthe work lir whluh this permit is issued.
GAS - IIA. SYSTEM -1 INC. 4 flCrf,Ej'S
OCC. GROUT'
AI'f1j/
My Workei�W, mpensa(ionlnalmmm carrier a ad Policy tiher are:
Carrier. /i lA�/ f (C Policy No O'- 6l -
CI:RTIICX1I.. OF EXEMPTION FROM WORKERS' IZIdO
COMPENSATION INSURANCE
/ GAS -IIA. SYSTEM -OVER 4(F.A)
_J
/
GREASEANDUSTRI. WASTE IN'1'HRCEMnR
BUILDING DIVISI[IN FEE}
(This section need not Wcompletcd ifiheperli( is foronehundreddlelawl$100)
or less.)
GREASETRAP
PIANCHECK FEE
SEWER -SANITARY -STORM EA. 200 IT
1iNERGY ]TE
I certify that in the performance ofthe work forwhich Nis permit is issued, l shall
not employ any peon in any manner o, us m beromc subject the Workers Cnmpem
WATER HEATER W/VENT/ELECI'N
Q z satins Laws of C:J;fomiu. Dee
Z Applicant
NOTICE TO APPLICANT: IL after making this Cerificum of Exemption, you should
a; Wa me suhjeat m the Workers CamPensation povisiom of,he Labor Code, you non
LkI forthwith comply with such provisions or t lda permit shall he del resol,rd-
a 0
CONSTRUCTION LENDING AGENCY
L) Ol hereby ulBrm that hem is a connoction lending agency for theper(o..raro(
Ne work for which this permit is issued (Sec, 3097, Civ. CJ
OU Lcadcr's Name
0 U Leader's Address
y reify (hot 1 have ad Ibis application d nam Iha, No aWve information is
iF.i TA correct l agree in comply with all city and county onlinanresand state lows offlingm
UZ haddingcnnximcke,amJ hmehynuthorizo mpresenanivu nithiscity tocntcr upon the
GRADING PEE
WATER SYSTEMITREATING
WAFER SERVICE
SOILS FTE
PAID
Receiplp
NEW RIiSIDENTIAI. PLhiN. SQ. FC
'TOTAL:
'TOTAL: ,
BUILDING FEE
QTY, MECHANICAL PERMIT FEE
SEISMIC FEIi
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ELECTRIC P rE -
above-mentioned property for inspectioh peopssa.
(We) agree to save, indemnify and keep harmless the City of Cultivation.ugninat
liabilities,judgments, costs and expenses which may unary way accrue against said City
' omegmence of the granting of Nis permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/
SOURCE REGI'.ATIONS.(�
PLUMBING 'EL
AIR HANDLING UNIT('1010,0X1 GPM)
A1F.CHANIC,A FEE
AIRIIANDLINGUNII' COVER 1H(s) FM)
CONSTRUCT ION TAX
(\^.'
Y ry
�� ( J Q. A s rQ^ /�•[�/
I
Si mmnre of Applicunt/Cnno-uemr Out.
HAZARDOUS MATERIALS DISCLOSURE
Will flit applicant or future Wilding occupant store or handle hamrdoas maimed
EXHAUST I IDOD(WIDUCI')
HOUSING MITIGATION FEE
HEATING UNIT 001 W.000 BTU)
as defined by the Coplanar, Municipal Code. Chapter 9.12 and ,he Health and Safety
Code, Section 25532(a)1
HEAPING UNIT (OVER I00,W(I BTU)
VENTILATION PAN (SINGLE RESM)
❑Yes [D No
PAID -
Date Receipt x
BOILER -COMP (3HI' OR I(XI,g11) B'UH
.
Will the applicant or future Wilding occupant use equipment m devices which
emit hazardous air contaminants as defined h the Ba Area Air Quality Marta leen,
Y Y Y 6
/�
'TO'I'AI' 3% s l
BOILER -COMP (OVER 1 W,M) BTU)
District'!
E] Yes ❑No
AIR CONDITIONER
I have read the hazardous materials requirements under Chapwr 6.95 of the Cali-
forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 understood Ile, it the
building does me cumnilyl ve a,enani Nai(ism res pmsibili,y m notify the«cnpar
`
ISSUANCE DATE
I
NEW RESIDENTIAL MICH. SQ. FI'.
f,hc req mcn,s whic a be tp lois a fa Cenific roof Occupancy.
X tS' IC -/8-99,
�' m
ISSUED BY:
TOTAL: -
wnvnmmthnnized agent Date
OFFICE