S 1285 - APPLICANT TO FILL IN IN FORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPI3RTIN0 BUDDING.-ElECIRICA], PF: IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PING PROG-AIECILINIFIC 1285
II1111.DING PROJE<9'IUENI'IFIL'A'I'ION
BUILDINGADDRESS: - SANITARY NO. APPLICATION. IMIT1AL DATE.
07 LAKIE /04 9
UW OR'S NAME I'HONI?: CONTRACTo11'S NAMI? Lr LIC NO'.
r N/C CON'I'i(GhEart 0— p
• ARCHITECT/ENGINFElf. LI O: Aq RF:SS: ❑
CONIACf: PHONE: 7 BU IIAING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
ARKInL-p ^ ❑ ❑ ❑
IACpNSED CONTRACTOR'S DECLARATION QTY. P�ECPR IC PERM I'F FEE
I hereby addition mot I ma licensed under provisions of chapter 9(conmti neing JOB DESCRIPTION
�1_ wlh Section Idc IDiv� I4_S1 Busineu and lkofensinns Calc,wJ mylicense is • RESIDENTIAL,
A4
,C)o with
Sectio undo .a�•kYG'C- n PERM I'i'ISSUANCE,
CWF in Bin � E3 SLOWS. El KITCHEN REMODEL
`4—u lateen. lass `' Lie'n APPLIANCES-RIiSIDENTIAI. []ADDITION El PLUMBING RE-PIPE
vFi Q WW Uae Comma
ARCHITECTS DEC ❑MUIXI�UNIT ❑STRUCTURAL.
F 7 m PANELS MODIFICATION
Z O 3 I undem
m �d my pUns,ball be rood ns puhhe nc,urnv
Oz`— UP T02,10 AMPS El INTERIOR E3 CHIMNEY REPAIR
P4f❑❑"'{Q{�a� LkrnsW Pmf,"ionul '201.1000AMPS IMPROVEMENT (]SWIMM ING POOLS
bd2," OWNFR43UILDFR D1i:I.ARA'I'ION OVER IIx111AM1'S ❑RA'IH REMODIiI/REPAIR ❑DEMOIJ'HON
CC CC I hereby Marta that 1 am exempt from the Contractor',License Luw Int me
'aax(06 U falmwing reason.(Section](131.5,Imoin,s and Professions Code:Any city or cnuntY SIGNS 131-EQI'RICAL ❑OTHER
Y13 W I" which requires a Permit to consnuct,alter,improve,demolish,or repair any structure tdki K-12
F'LLO prior to its issuance,also requires the applicant for such Permit to file asigrad statement I SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9
��q� (commencing with Seminn]nmlof Divixinn3 nfthcHuincss and Pm&ssion'Cod u)or TEMP.MID TER OR POLE INS3'.
'Lt� that he i,exempt mento m and the basis far the alleged csemption.Any vinitninn of ❑NEW BLDG/ADDITION ❑DEMOLITION
�q Section 7031.5" n licent ror a' 't subjects thcapplicunt mu civil by of POWER DEVICES
W^m by 00) su 'ccv Petr' Ste ❑TENANT E3 TOO])SERVICE
p, nal tnore,mm Hvu hundred Anllun($500). IMPROVEMENT
�Q I,mownenifilu d SWIMMINMIX .ELECTRIC
Props ,num,, entNoydivio,b Band Ins.lei(Sed. 04,Imseien,
O well dnihcorms wade: Ilse Cure is toss License La docs ral apply to an,owner of ❑OTHER
tmJ I'ndes,iotn Cale:'ILe Contractors License Law docs nm apply to w owner of OUTLli3'S- 3-FIX'TIJRES
property who build,or impmves thereon,end who docs such work hlmwlf or thmngh
his own employees,provided that such improvement,ate not intended or offered for NEW RfSll IAL EL J .R SQ PI'.
Side.IL however the building Or improvement issold within one yearn(completion,the SQ.F.FLOOR AREA LSQ.Pr
ranerbuilder will have the burden of proving that he did not build or improve for put-
se of sale). -
❑ 1,as owner of the property,nm cxelusively contracting with licensed cnatmutoty In T(TIAL
mstmci the project(Sea.7144,Rosinessand Professions Cod,:)The COn sba4v Li- _ -
wnseLawdoesnot apply to an ownerofproprly who builds or improve, hcram,and QTYPLUMBING PERMIT' FEE
who contracts for such Ptnjects with a colanchn(,)licensed pursuant in the Contmmnr's
License La,,, PERM 1'r ISSUANCEIt
I oro exempt under Svc. ,B&P C fonhis reason /
ALTER-DRAIN&VENT-WATER(Pet) VALUATION
Owner Date
q. WOR NEWS COMPENSATION DELLA RA I'ION BACK PLOW PROTECT DEVICE
1 hereby affmn under Penalty of perjury one of the following dedamtiws.
❑ Ihnvexul dl th.diu In uCanlfiaaeof Conscra no selNnsure frWorker'.s Coniper. DRAINS-I1,OOR,ROORAREA.GOND' STORIES 'I'YI'13CON81'It I1CTION
wuion,us providnl for by Srnlinn 3]1x)oC the lather CnJq for the Perfonnnnm
tire
work
-
work for which this Perini(is issued. FIXTURES-PER TRAP
bed 1 hove and will maintain Worker's Couper aina lownerace,as required by Section
]I.)of die LPe
ien Cade.tin the rforinwre of the work for which this permit i,issued. GAS-UA.SYSTEM-I INCA OLT]LTs OCC GROUP AI'N
Ca Work 'styc �yI c�yy randy No.:nu�p
Cu W `� ■111/3 mr Policy No.: r annIAJR GAS-RA.SYS'HEM-OVER 41EA1
CFKI'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INr13RCEPIY)N
BUILDING DIVISION Ril!S
(Thi,section need not he completed ifthe patroltis for one hundred dollars($ilxp GREASE'S RAI'
or IcvSJ PLANCf113CK 1131?
I certify shut in lbeperfnrmuncenfthe work torwhich thispermit is i.ssucd,l Shall SEWER-SANI'T'ARY-STORM EA.210 IT
nm employ any perenn m any moaner so as ai So,ron¢wbjeeuo me Worked Cotnper. ENERGY FEE
z ,z sat ion Law,of Califnmin.Date WATER IIEH 17R N'/VENT/ELECI'R
O APPlicw, GRADING FEE
I, NOTICE TO APPLICANT.If,offer making thn Ci nificam of Exemption,you should WATER SYSTEMITUREATING
a7 become subject to the Worker's Compensation provisions of the Labor Code,you mut SOUS FER
W
WATER S17RVECE
fodhwith comply with such provisions or this pennit,hall beJeemed revokeA.
aQ
.Wz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT PAID I to RewiP,M
1 hereby Orion that there is it conumatton lending agency]or the p,,Io mtertil"
L) the work for which this pernth is issued(Sec.3097,Civ.C.)
TOTAL:
L) lenders Address - TOTA
} W BUILDING FEV/
1 Adds that 1 hmn teal this application and s,o¢that the above infnmwuon is
Fy correct l agree to comply with all city and county ordinance,and state laws relining to QT'Y ' MECHANICAL,PERMIT FF.Ii
61z building construction,and hereby authorize repmaenw,tives ofthis city to enter upon the SEISh�C WiG
above-mentioned property for inspection pumases' TERMS'ISSUANCE
(We)ague no auve,Indemnify and keep harmless the City of Cnpenlno ngainst F.LECI'kIC FEE
habilidos,j udgnumr.enstn and expenses whichtnoy Iran,way aeeme agaiut said City ACI ER GB AUD'I'O MECH. SO
nnseyuwceW egnunit ndlliis perm". r y
APPLICANT ' UDR." )S IDI AMPLY WITH ALL NONPOINT A]14 fIANGLING UNIT Cl IUIx0CFM) v
SOURCE LAT S ECHANICAI. Ji
AIR HANDLING UNIT(OVER I0.E00CFM) IN x
eisagal It
Si aeofA I not/Ct vir Dale EXHAUST HOOD V
PP HOUSING MITIGATION FEE
f1A7ARDUUS MATERIALS DISCLOSURE
Will,hc uPPlicam or future building oecurymt xnsm nr handle hazardous nn,teriol HEATING(Rod LTO 1010,0010 BTU)
or,defined by the Culwniwo Municipal Code,Chapter 9.12,and the Ileallh and Safety
'Code,Section 25532(1? ZEAL ING INTI(OVER I00,000If'I'U)
❑Yes . ❑NO' VENTILATION PAN(SINGLE RESID) PAID
Dote Receipt or
Will the air co am or future building occupant y A equipment or devices Management
-
emit htvardom air uimmninams u JefnM by the Bay Area Air Quality Managemrn, BOILIiN-COMP(IHP OR I01.IXx10'I'U) T.TALY6 OJ 10
District?
❑Yes 0 N BOILER-COMP(OVER I(MLIMxI Sir SOL
1 hnvc ail he hnznmlous mamdols rcyuiraneme under Chvp¢r 6.9$of the Cali. AIR CONUI'IIONER ISSUANCE DATE n
Or...in H,alth&Salcey COde,Sections 2550S,^_55)3 mod 25534.1 uwdemimm Phil if the NEW BESIDES!I'I AL MBCI 1. SQ,FT. D
hadd'mgdues not cntuntly have a Irwin,,thin i,ismyn,ion6hilayto notify thcc
e oupant D ttt999
of the requirements nitich oust be met prim m i...c n e of n Cer ilicme of Occupmmy,
Owneroromhomcdagenl Done TOTAL: ISSUED By. / 0—
OFFICE
OOFFICE