00010088 APPLICANTTO FILL IN INFORMATION WITHIN RFD LINES-USE BALL POINT PEN ONLY <7 O/ U 0
4RI
TY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDINGOFDIVISION 'ERMIT PLUMBING-MECHANICAL. --
IIUIi.DING PROJECT IDENTIFICATION —
I RISS. SANITARY NO. APPLICATION SUBMITTAL DATI
d'AlGLS v L SOS O D
1v. PHONE: CONTRACTOR" AMIE: 1,IC NIC CONI 01,a
Y64
Cf11TECENNGINIiHH: LIC NO. ADDRESS �. ❑
c at✓ b
ON PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
uDel C4 El ❑
LICHNSED CONI'RACIOR S DECLARAI ION Q'py ELECTRIC PERMIT FEF,
1 hereby mnn,l That
I ant Rcamxd tinter prod"h,ns of Chapter 9(commencing JOB DESCRIPTION
M=Z wnIf Swlinn 7000)off)'{{anti Bnt the Basmcsh and Pfofesion,efts.and my lieenseis RESIDENTIAL
WO ]]]]]]{{{{ PERMIT ISSUANCE
F,UO Life(( Cla,v de ( - 7/ ?;2 ,�.,AT)DIL ❑KITCHENREMODEL
9zWLicense Clnss Lica' APPLIANCES-RESIDENTIAL (✓ADDITION ❑PLUh1BING RE-PIPE
r.Z W luta Comtacn,r
,o Q. ❑MULTI-UNIT ❑MODIFIFURAL
CATION AHCfII TIlCTS DECLARATION
Z p y Z 1 understand my plan%shall he used as public records PANELS MOOIIOCATION
rn— UP TO 200 AMPS
O Z ❑INTERIOR CHIMNEY REPAIR
FtiF'4:
Licensed ProfessianuE 201-I0XIAMPS IMPROVEMENT SWIMMINGPOLLS
<y+��
OWNER-If UILUEIt DIiCLARA'I'ION OVER IIHXIAMPS ❑BATH RI!MOOE1/RLPAIR ❑DIiMGI,ITIDN
x tz Ira a I Iwo,by eflirm that I am exempt from the Comraclor:License Law for the
k 3 6 U following reason.(Section 7031.5,Business and I'mfessions Code:Any city or county SIGNS ELECTRICAL []OTHER
W
Ca which which requires a permit to evionater,after,improve demolish,or repair any swcmre
1,-'E:fn for innnil,is,rane,ki,rxgaire,the milifirana toroach,omon to role a signed Vn-twin SPECIAL.CUCUO/MISC.
mat he is licensed pursuant tothe provl,ionsof the Contractor's License Law(Chupmr9ifutriAL
W 00 faommencingwi0'Scelion 700(fief Division 3 ofineBronessand Professions CMc)or TEMP.METER OR POLE INST.
Q.X c y that he is exempt therefrom and the I ais for the alleged exemption.Any violation of N 'BLDG/ADDITION ❑DEMOLITIONEd,yy Section 70315 by any applicant for a pontiff subjecs the applicant to a civil Penalty of POWER DEVICES Y TENANT ❑FOOD SERVICE
ool mrnc than Gve hundred dollen 5500). IMPROVEMENT
EC (] I,yr owner of the pmticsfy,orn,y cmploY«"wilM1 wages nr(heir vole enmFerasation, SWIMMING POOL ELECTRIC
F. willdndhe sork.and me,mact is ouxudedoroRefed I...le(Sec.7(IM1J,Business ❑Ol'HER
4�) m and Professions Code:The Contractors Licens law d«"not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Ila Foolery who builds or improver thereon,and who does such work himself or through
hie own employs,provided that such impoocinems arc not intended or offered for NEW RESIDENTIAL.ELECT SQ PT.
,ale.IL bowevoc the building ar lnlprovemenl is ,,to withino fe yvm of"onficnem.the SO.IT.FLOOR AREA s/SQ.PI'.
owfor-builder :llhave th burden f proving that he did not bull or-improveput-
pooffif'ste.).l 7
❑1, f thepn+pery, sly t t 6f.1 TOTAL �T O
sir t me I(Sus 71Uq li and 1 f fe I {,L —siIiiiiiiii, will
,cl 1 to ply( rpmpenr n nail r>
FEE 0
who commas fur such projects with a cunuacu'rtz1 license)pursuant m the Comracmr,
License low.' rrn,, t! -y I-g TERN
fI'�IS A
I am exempt under Sec ,B Ctop1{ijte5son
.1-D4IN,&VC !R(CA) VAIAATIO!q
caner D: �. - IO
WORKER'S COMPENSATION DECLARATION 7ZIF FLOW PRUfrf. OODf /
I hereby affirm under penalty of perjury one of N p-
IM1aveandwillmainminaCcriGcum of R,mcnnn ul "Cs �o` y I , DR IN.,-rF'LOOR R , STORIES TYPE CONSTRUCTION
,inion,us providcJ far I,Section 391X)of the I.ntv,r Cr I
work for which this peona ,issued. 'l�i�PE R
I have and will maintain Workers Compensation Insurance,as required by Section
37M of the tabor Coda.for the performance offhe work for which this permit is issued. GAS-FA.SYSTEM-1 INC.q OUTLETS OCC.GROUP AIN(
My Wmri,orkk6,p' tan fen4t[e2 frq It l'nl cYand 'Nicynn a2: CAS-GA.SVS'1'IIM OVER4(13A) � LCI O'i
CERTIFICA7 E OF LXFMIvFION FRO. OR F,RS' GHIiASF/INDUNIEL WASTE INTERCEPTOR COh11113NSATION INSURANCH BUILDING DIVISION VE-ES
(This socio.need not be complete 'Mfie Permiu,for one hmMret dollars(S I BE GR17ASETRAP
nr Ics.) � PIANCNECK PEE
Icciifyier none um,cofnew...k lir be Rx pennil isissued.Is hall SEWER-SANITARY-STORM IA.Nut IT.
not employ any person y tnanncr m as¢,I+wome s ccuo me Workm'Coml,en- ENERGY IFIL- -
Z lotion law,of Cal' Doc WATER HEATER WNENT/ELECfR
Z2 Antillean_- GRA 1, FF.F. ^ n ^
NCYE ICE TO ATLICANT:If,finer making this Cerificme of Exemption,you should WATIik SVSTIiM71R13A'fING L/'1J U
.N. S0 EL, FF2
a ,
farm.
to
ay the Worker'.Cnmoormi, puni"innsdlbe Laborevoked. must t fI
(nrhwidh romtily with such pnrvisinns or thin permit sM1ullMJ«meJ revoked. WATER SERVICE
a' CONSTRUCTION LENS� AGENCY NEW RESIDENTIAL PLMB. SQ.FLA- BUI
pita Receipt a
UO I hereby alfinn door mere is a conn 17;,n lendingagency For mop A'ortnauea til
ELF the work forwhich orispenni�isi,nuc xr.3097.Civ,C.)
Q U IsnJc'Namc TOTAh:
D.1 La.iees Addmss TOTAL: f
M 1 certify that 1 have ad This application..it sure m he above information is (I
0a ..,l ugrce mcontp wimall it,andamnty ordua count state laws relating to QTY. MECHANICAL PP,RMIT FEE
V Z building comiracr nm
fidherchyauorisx« mmv
pmr uhf lhi,city ma
enter pnn the 51315MLC PEIi
above. farm otieryrmiapectiotirmi a PERMIT ISSUANCE,
(We)a m save,modenmify and keep s bus the City of Cio,stuo against ELECTRIC FT:C
Iiubililies,j gmcm..colds andcxpemxs tonic to any way sccmeagaingmlJ City ALTER OR ADD TO TECH. PLUMBING PI3G
to I c of the granting of mi,Pem,
APPIw NT UNDERSTANDS - DIMPLY WTIT ALI,NON-POINT AIR HANDLING UNIT(TO 10.0o)CFM) MECHANICAL FEE
SO REGULATIOI .
/ d0 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
gnatorenf Appf,;mr1Cmum,ro, If EXI IAUST 11001) WIDUCT) 1 IOUSINGMI'DGATIONFEE
.IIAZARDOUS MATERIALS DISCLOSUR
Will me applicant or future building occupant store of handle hmardous material HEATING UNIT LTO 100.00(1 BTU)
as defined by the Curiumno Municipal Cole,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)I HEATING UNIT(OVER 100,000 BTU)
❑Ye,
L)No VENT LAT ION FAN(SINGLE RESI D) PAID
Dam Raripla
Will the epplicam of future building a:cupem ua xyuipmem or devices which III
BOILER (3HP OR 1(10.000 BTU)
W
it hazardous air conuminans u,defined by the Boy Arca Air Quality Management TOTAL '
suicB BOILER-COMP(OVER IfS,001 BTU)
Ye, 0 No
I have mail the hazardous mamrads requiremems umber Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
mono Health&Safety Cole,Sections 25305,11 it 25531 L understand mm d me NEW RESIDENTIAL.TECH. SQ.FT.
furth not'amoiy have a c :md:hvt'u'. y rexpumihillty to noti ly(be(occupant
oft rents which s niOcumM a y.
6
her or amhorizeA agent Die TOTAL ISSUED BY:
OFFICE