99090073APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION
NAME:
CON'T'ACT
A PPIA CATIONIPERM IT
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARATION QTT.
1 hereby office thw 1 am licensed under provisions of Chapter 9 (commencing
Z
with Section 7(m)(hof Di atm
a 3ofthe lmses.and Prifiroiuns Coae.and my beer— is
in full farce send effm
F- License Cb s Lie, #
ad Da¢ Comramnr
NCHITF.CI'S DECLARATION
Z� I understand my plans shall be used an public remrJs
WLicensed Professional
OWNER-RUILDER DECLARATION
Q I hereby affirm that 1 am exempt from the Contractor's License Law for the
U following reason, Section 7031.5, Business and Professloos Code: Any city or county
ywhich rcquirex it Lenoir to c(non mcf.alter, improve, demolish or repair any 'marine,
prior to its issuance, also requires Ne applicant for such Fermi no file a signed statement
+, that he is liccmed pursuant o the pro,,mons of the Contractors License law (Chapter9
Pon uncncing with Section 91(X11 of Division 3 ufthe Business and Professions Code) or
Cthat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more than rote hundred dollars ($51Xp.
Q❑1. asownerofthe property, army employees with wages as their sole compensation,
will do the work, and the atrocom is col intended nr offered for sale (Sec. 70 1. Business
_ and Professions Com: *Fire Contmctor'x License Law fres not apply it, ;in owner of
prapany who builds or improve thereon, and who dues such work himself or through
his own employees, provided that such improvements am not intended or offered for
sale. IL hawcwmthe bulldingar repro and in sold within one yutr of enntpletlm.the
onerser-builder will have the burden of proving that he did not build or improve for pur-
posc of sale.)
❑ I, Or, owner or he Inimeny, am exulusivcly couloodn, with Ronna) c umou,n rs to
orowet the project (Sec. 90,). Business and Professor-Ca1e:) The Contractor's
cenoc law docs are apply to an owner of property who builds or improves Ihercon, and QTY.
who contracts for such propels with a contractor@) licensed pursuant tothe Cmunial ,
License Law.
❑ I am exempt under Sec. ,B& P C for this Mason
Date
WORKERS COMPENSATION DECLARATION
1 hereby off rpt under ur perjury enc of the following docker' io o
r] en, a, and pon,id l for by
a Certificateio370of Cun¢nuoCubansure for Workers Compen-
s 0 los hick this
far by Ss issued, 310() of the Ia1wr Code, for the pcdarmance of the
rote and this lsarmit is issued.
have and will maintain Wodrfo Compensationwork
Insurance, h of per by Section
91H) of the Luhor@ole. for the performance of the wok 1'or which this permit is issued.
My Workefs Qtmpenwtion Insurantt cortico and Palley nom'nM1er arc:
C -o -a- I.�Policy Nu.:.�a.
N 1 MPEN SLIONIINSURAN WONKE45
COMPENSA'Ill Ifthe INSURANCE
('(Tis section nttJ nm he completed ifthc permit is for one hurrdreJJollnm (S lfq)
r lass.)
1 certify that in the perfnmmnce of the work for which this pemnit is issued. I shall
not employ any person in any manner %a as to become subjem to the Workers Cooper -
,Z cation Laws A Cul'nerou" Ilam
Z 2 Applicant
is, NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
5 beconee subject it) the Worker's Compmrs Trion pmvislons of the Labor Code, you must
W forthwith comply with wch pros sicars, or this peorel shall be deemed revoked,
Q
CONS hem is a const LENDING AGENCY
U 0 Thereby affimnhat There isaronamctinn lending agency for the performance of
W P the wore for which this pemit is Meal (Sec. 3109. Civ. C)
Q U I<nder's Name
,r Lill larder's Address
G I certify that I have read this application and sate that the ehrve information is
Lit) c nein. I agree m comply widt all city and cony ordlnmnees and Mate laws relating to
U Z building construction. and hereby authsnixe representatives of this city to enter uptm the
ahowc-mentioned property for inspection purposes.
WT) agree ht save, indemnify and keep harmless the City of Criterion against
liabilities, judgments. seas and expenses which may in any way accrue against aid City
in xquence of the gmmi ng of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY Willi AL1. NON -POINT
HAZARDOUS MATERIALS DISCLOSURE.
Will the x,,b,am nr f inure huili ing tecmpenl,aore .,handle harardous material
as define) by the CulvertMunicipal Code, Chapter 9.12, and the Health and Safety
Cudc. Section 25532(u)?
[:]Yen
J Wdl the applicant or lou bJ rllding escaper, use equ neenl or devices which
it haturad air comaminynts yldefinnd by the Bay Arca Air Quality Management
E3 Yes
1 have read thera
hardous ma rials mluimmen6 under Chapter 6.95 or the Cali.
hmen Ifni, & Safety Calc, Sections 25505. 25533 rind 25530. 1 undcmtand Ihw Ir the
briklip,jamaininend,hogs, itterearm.lha it ism, responsibility mnonlythrncupam
eon tpnonn issaance of a Cenier f y
nICT R%!6
Owner or authorized agent x-`1` t
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDEN'I'[Ali
PANELS
UP 10 200 AMPS
101-i"AMPS
OV17R INX)AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUIT/MISC.
'TEMP. METER OR POUT INST.
POWER DEVICES
SWIMMING POOL F.LEC'FRIC
OIITLF-1:S - SWITCH12S - FIXTURES
NEW RESIDEN'T'IAL ELECTR SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALFE R -DRAIN & VENT'- WATER (EA)
BACK MOW PROTECT. DEVICE
DRAINS -FLOOR. ROOK. AR -f, 7OfDx
EIXTORES -PER TRAP
GAS - EA. SYSTEM -I INC. q OUTLETS
GAS - ITA. SYSTI3M"OVER 4 (HA)
OR EASIJINDIISTRI. WASTE INTERCEPTOR
GREASETRAP
SEtVER - SANITARY - STORM F.A. 20() F1'.
WATER 1117AT17R W'NIPs+DELEC R
WATER SYSTEM/FREATING
WATER SERVICE
NEW RESIDENTIAL. PLMR. SQ. IT
TOTAL
QTY. MECHANICALPERMIT
I FERMI ['ISSUANCE
ALTER OR ADI( TD MECH.
AIR HANDLING UNIT' TO 10.000 CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEA'T'ING UNIT' (TO 100.10() BTU)
HEATING UNIT(OVER B10,01) BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3111' OR Ig0,000 [I IU)
BOILER -COMP (OVER 100.00T RTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT,
OFFICE _ J
FEE
FEE
FEE
LTJ
BUILDING PERMIT INFO
RLIR'i ELECT' PLUMB K�-
JOB DESCRIPTION
RESIDENTN IAL:
❑SFDWL
❑ KITCHEN REMODF.1,
❑ ADDITION
❑ PLUMBING BE PIPIT
El MULTI -01,111
El STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER -
-
COMMERCIAL
❑NEW BLDG/ADDITION DEMOLII ION
❑TENANT ❑ FOOD SERVICE
AREA
STORIES TYPECONSTRC
V10) 0
QILDING DIVISION FRISS
PLANCHECK
ENERGY FF.
PLUMBING FEE
MECHANICAL LEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
ISSUANCE DATE
47—( o.- 4i