99090158I. „ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION
APYLICA'PION/PERMIT
IILDIN--ADDRESS.69
IvIar—le11a
r71
11111" A
CON'1'ACn rnOnt::
❑ Consultant Fees Paid by Applicant (Initial)
}iA9ARDOUS MA'T'ERIALS DISCLOSURE
Will the applicant nr none building cel -Pant mora nr handle haentdoun mmerild
as defined by the Culrcnino Municipal Code. Chapter 9.12, and the Health and Safety
Cooke. Section 2553200!
0Ya EJ No
Will the applicant or future building occupant use equipment or devices which
Oil humrdon, air ammmimon us defined by the Bay Area Air Quality Managnnent
DistricR
C] Yo ElNo
I hove mud The bnmrdmts asocials mquircmmab under Chapter 6.95 of the Cull -
Corona health & Safety Code. Seeriono 25505. 25531 and 25530.1 understand that if the
buildingo�grymneunendyham.1mnthatt iis my rtspnnsibiliry mnmify rhe srccupmt
of The mWnts which efly °ne66 io/lWt issuance of a Cenificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP10200AMPS
OVER 1000 AMPS
SIGNS ELECI'RICAI.
SPECIAL CIRCUUUMISC.
TEMP. ME11:R OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - 171X I ORES
NEW RRSID1INI'IAl. ELECT R
SQ FT.
I
a
O
0C)
atU U
F ZIt1
LICENSED CONTRACTORS DECLARATION
I hereby union that I am licenced under provisions of Chapter 9 (commencing
with Section 7000)of luoloon 3 of the Iuoum,sandl'ruf csinns Code, sad my lieensc is
in full force and effect.
License Class Lie. p
Date Carlin r
QTY
BLDG ELECT PLUMB MECH
❑ ❑ ❑
BACK FLOW PROTECT. DEVICE
W
ZOyZ
ARCHITFLT'S DECLARATION
IwJecamdmyplansnhall bcusMo Twblie records
JOB DESCRIPTION
RESIDENTIAL,
O SFDWL D KITCHEN REMODEL
OADDITION EI PLUMBING RE -PIPE
❑MULTIUNIT ❑STRUCTURAL
MODIFICATION
D INTERIOR DCHIMNEY REPAIR
IMPROVEMENT EJ SWIMMING POOLS
D BATH REMODEDREPAIR ❑DEMOLITION
D OTHER
OZ -a
GAS - EA. SYSTEM -I INC. Y OUTLETS
OCC. GROUP
F F W
Licensed Professin ed
GREASMNDUS'rRL WASTE INTERCEPTOR
QZ,YB;
OWNER -BUILDER DECLARATION
PLANCHECK FEE
C a Q
XpCil.: y
W 3 a T-
1"u'0Q
}
wQQ
d e e•
I hereby affirthat I am exempt from the Contractor's License Law for the
affirm that
fullowing wston. (Section 90315, Bovines and 11 lcssiuns Code, Any city orcounty
which requires a permit hr consumer, alter, improve, demolish, or repair any structure
prior to its issuance. alm¢quires the applicant for such permit to File a signed statement
that he is licensed pursuant to the provisions of the Contractors ctors License law (Chap,,,, 9
(commencing with Section 7")of Di vision 3 of the Business and Professions Code)or
Ibat he is cxmnpt lwmtnnm nod the boas Err the alleged exemphmn. Any violation art
Section 9031.5 by any applicant for a permit subjects the applicant in a civil penalty of
ENERGY FEE
WATER HEATER WNENFUELECfR
GRADING FEE
F Z }
= 0
p.
w
a., mme Than five hundred dollars 651X)).
D I, as Owner of the progeny, or any employees with wages as their sole compensation,
will do the work, andthe structure snot intended nrnffcred forsale(Sec. 7I Rusineus
and Prof comers Code. ]he Contomor'c lieensc lanes dews nm apply lie air tnvner of
property who builds or hnprovex thereon, and who dna such work himself or through
$❑Itis PFIi
WATER SERVICE
PAID
his own employees, provided that such imP+Ovmnen6 art not intended no offered fill
NEW RESIDENTIAL PLMB. SQ. I7
Date ReceiptN
sale. It, however the building of improvement is sold within one year orf completion, the
TOTAL:
owner visit have the burden of moving that he did not build or improve for pur-
TDTAL
BUILDING FEE
e - Of lade.).
❑ I, as towner of property, am ewe toively colo ing with lmcased contractors w
SEISMIC 17EE
nmurel the project (Sec. 7GI Business and Podisslons Cade:) The Contracnnr's Li-
PERMIT ISSUANCE
ELECTRIC FEE
ne law dome not apply or an ownerf property who builds or improves Hereon, and
QTY.
PLUMBING FEE
who contracts for such projects with a contmmor(s) licensed pummun to the Contractor's
AIR I IANDLING UNIT (10 10,IX0 CFM)
MECHANICALPEE
License Law.
❑Imoo eacrofo^See 1 B k P C fill nils ecuson
I �/�TT�
AIR HANDLING UNIT (OVER TO." CFM)
CONSTRUCTION TAX
D
17XIIAUSI HOODOI
HOUSING MIT IGATION FEE
4—
Ihlaid a0innun er Cena ryone of the foo ingdedecr,Coons.
hcnte
HEATING UNIT (OVER 100.000 BTU)
Thew laid forbineCcnl ofCe Labor Cook. sure oPerfodsCOmpcn-
smion, as d lin Section 391X0 of the labor Cook. for rbc Performance of the
--
VENTILATION PAN (SINGLE RESID)
en
work for which Nis mannan is isued.
hick
BOILER -COMP (3HP OR W.000 B'IG)
D 1 have and will maintain Compensation ce, as requirtd by Section
BOILER -COMP (OVER 100.0010 BTU)
w rk to,
Qrde,rot themcrfor,aarwml the work forwhich This permit is loved.
ofthe he Performance
AIR CONDI 'ITONER
ISSUANCE DA Ii
7 sp — F
,CLabor
My wmkcra ctompemxtmton Insmmnea ear;er sen rauoy nnnnber aro,
My
Caner: Pnliey No.'.
CERTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Iris section need oat be cmmplecd'dlim .no, is for one hundreddollars(SI())
u Iczs.)
that in the performance illthe work for whijM1this pentonis Issued, shall
z
Z
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a�
5Z
`41"
(:)
>^ D.7
tL
N
ay
torn , Lay Conan imy manner will, m become subject to the Workers' Cnmpen-
seninr olowyany
of Culihomoa. Data
Applicant
NOTICE TO APPLICANT'. If, altar making this Cefficate of Exsorption, you should
become subject to the Wodery C'nntpcusation provisions of the Luba Code. you must
fonhwill, comply with such provisions or this permit .shall ce deemed revoked.
CONS I'RUCI[ON LENUINGAGENCY
1 hereby off ran that there is it construction lending agency liar the performance of
rhe work or which this permit is issued (Sec. 3099, Ctv. C.)
Isnote', Name
Lcndcr's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating m
QTY,
U
C..) Z
M1uilAing annswetinn. unJ hereby umhmiw rcprucntative. otthis city to enter upon The
ahnaenmcntimmol property for inspection purposes.
(We) agree t0 save, indemnify and keep harmless The City of CuCenino against
liabilities, judgmems, costs and expenses which may in any way accrue aFaimt sail City
in consequence of the granting of into permit.
APPLICANT UNDERSTANDS AND n1LL COMPLY WITH ALL NON -POINT
SOURCE dj.GU1.A'1'ION
}iA9ARDOUS MA'T'ERIALS DISCLOSURE
Will the applicant nr none building cel -Pant mora nr handle haentdoun mmerild
as defined by the Culrcnino Municipal Code. Chapter 9.12, and the Health and Safety
Cooke. Section 2553200!
0Ya EJ No
Will the applicant or future building occupant use equipment or devices which
Oil humrdon, air ammmimon us defined by the Bay Area Air Quality Managnnent
DistricR
C] Yo ElNo
I hove mud The bnmrdmts asocials mquircmmab under Chapter 6.95 of the Cull -
Corona health & Safety Code. Seeriono 25505. 25531 and 25530.1 understand that if the
buildingo�grymneunendyham.1mnthatt iis my rtspnnsibiliry mnmify rhe srccupmt
of The mWnts which efly °ne66 io/lWt issuance of a Cenificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP10200AMPS
OVER 1000 AMPS
SIGNS ELECI'RICAI.
SPECIAL CIRCUUUMISC.
TEMP. ME11:R OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - 171X I ORES
NEW RRSID1INI'IAl. ELECT R
SQ FT.
I
WO FI'.
TOTAL
a
O
PLUMBING PERMIT FEE
BUILDING PERMIT INFO
ALTER - DRAIN for VENT- WATER (EA)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
FEE
JOB DESCRIPTION
RESIDENTIAL,
O SFDWL D KITCHEN REMODEL
OADDITION EI PLUMBING RE -PIPE
❑MULTIUNIT ❑STRUCTURAL
MODIFICATION
D INTERIOR DCHIMNEY REPAIR
IMPROVEMENT EJ SWIMMING POOLS
D BATH REMODEDREPAIR ❑DEMOLITION
D OTHER
FIXTURES-PERTRAP
GAS - EA. SYSTEM -I INC. Y OUTLETS
OCC. GROUP
APN
Z
GAS -EA. SYSTEM -OVER q (EA)
GREASMNDUS'rRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
�a-Pr1( OR
PLANCHECK FEE
COMMERCIAL'
ONEWBLDGIADDITION El DEMOLITION
❑TENANT DFOOD SERVICE
IMPROVEMENT
OOTHER
SEWER -SANITARY -STORM EA. 200 IT
ENERGY FEE
WO FI'.
TOTAL
a
O
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN for VENT- WATER (EA)
VALUATION
2 . ,SO Q
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
STORIES
TYPH CONSTI
FIXTURES-PERTRAP
GAS - EA. SYSTEM -I INC. Y OUTLETS
OCC. GROUP
APN
Z
GAS -EA. SYSTEM -OVER q (EA)
GREASMNDUS'rRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 IT
ENERGY FEE
WATER HEATER WNENFUELECfR
GRADING FEE
WATER SYSTEM?REAPING
$❑Itis PFIi
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. I7
Date ReceiptN
TOTAL:
TDTAL
BUILDING FEE
MECHANICAL PERMIT FEE
SEISMIC 17EE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR I IANDLING UNIT (10 10,IX0 CFM)
MECHANICALPEE
AIR HANDLING UNIT (OVER TO." CFM)
CONSTRUCTION TAX
17XIIAUSI HOODOI
HOUSING MIT IGATION FEE
HEATING UNITTO I 00.000 FIT)
HEATING UNIT (OVER 100.000 BTU)
PAID
--
VENTILATION PAN (SINGLE RESID)
Dam Receipt or
BOILER -COMP (3HP OR W.000 B'IG)
TOTAL:
BOILER -COMP (OVER 100.0010 BTU)
AIR CONDI 'ITONER
ISSUANCE DA Ii
7 sp — F
NEW RESIDEW AL MECH. SQ. FT.
OFFICE
I OTA L.I I ISSUED BY.
0