99090145APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 41ci 0 11 U I _T
CITY OF CUPF,RTINO BUILDING -ELECTRICAL E
BUILDING DIn'ISIpN APPLICATION/PERMIT PIAMItING- MECHANICAL
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LIC NO:
❑ Consultant Fees Paid by Applicant (Initial)
I hereby obtain that 1 am licensed under provisions of Clapwr 9 (cmnmencing
�n Sectio 9000) of Division 3 of the Easiness andm
Pfcssions Code, and my license is
in full force and effect.
License Class Lie. a
lv, Cmar,xlar
ARCHITECT'S DECLARATION
1 understand my plans shall he used as Public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I ;or, exanpt from the Contractor's License Law for the
following reason. (Scatter 7031.5. Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, demolish or repair any someone
e
prior no Its issuance,nlso requires the applicant former par ,, file a signed statement
that he is licensed pursuam to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 9000) of Division at the Business and Professions Code) or
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
Sectio )031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars WILL)
❑ 1, as owner of the properly onny employees with wage. as Their vele compeneaion,
will do the work, and the structure is not intended at offered for sale (Sec. 91pA, Business
and Profession, Code: "the Contvaor's License Law does not apply to an owner of
property who builds or iniparvav thereon, and who dons such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
own err -budder w
ill have the harden of proving that he did not build or improve for put -
Oar
s owner of the pmpcny, am exclusively contracting with licensed contractors to
rostrum the project (Sea 7614. Business and Professions Codc) The Crooned x Li -
came Law does nm apply or an owner of pmPeny who builds of improves thereon and QTY.
who contracts Lorimar Projects with a contractors) licensed pursuant o the Contractors
License Law. �
[Dl am exempt andITAc. �—nr�-.' .: • B & P Color this I/%I %/
I hereby affirm under penalty of perjury one of the following Jeclarations:
1 havecold wil l maintain a Certificate of Coastal aself insurefor WeakersCompen-
salon, as provided for by Section 37W of the Labor Code, for the performance of the
work for which this permit is issued.
i] 1 have and will maintain Worker's Con,cosation Insurance, as required by Sec'
37M of the Iahnr Code, for he performance of he walk far which this .if is iss
M)' Workers Compensation Insurance cater and Policy number arc:
Cartier: porcy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,Itis scoter rad nut h<mmplctcd d dw pcmat is for oneM1undred dollars (EI
or Icss.)
I employ
any then in Ihe performance of the work for which this'he W is issocd. I shat
not employ any person in any manner soas In become xnhjccl to the Workers' Compero
',Z 'an on Laws of Califomia Dam
ZO Applicant
NRH WE'10 APPLICANT': 11, after nuking this CcniOcnte of Exemption, You should
.tva)lov subject to the Work Ys Comparemion provisions of the Lahr Cade, you mast
dnhwim comply with such proommis or this permit shall be deemed revoked.
LOd
.ti. Z CONSIONLENDING AGENCY
I hereby trillion that There re is ns aa construction lending agency lar the perfonnance of
w. P: the work for which this Permit is issued (Sea 3097, Civ. C.)
p U Lcndcr's Name
,r Lender's Address
I certify that I have rad this application and state drat the above information is
tin correct. I agree to comply with all city and county eminences and sale laws alsing to QTY.
V Z building construction. and hereby authorize exprescntatives afthis city to enter upon the
ah ve"incuioned pmpcmy for inspection purposes.
(We) a,eve rescan indemnify and keep harmless the City of Coleman against
liabilities,judgmenu, coxa and expenses which any in say way sceme, against said City
in consequence of the coming of this permit.
API'LICA UNDI3RSTA USAF�+�WILL COMPLY WITH ALL NON -POINT
SouxcE E L, 1'/D4/ f D l rte . 112A
1 IIAFAROOUS MA] F'MA LS UISCLOS WUE
Will the appl team or fnms building occupant store nr handle misstates mmerial
as defined by the Cuperlinu Municipal Cede, Chapter 9.12, and the Health and Safety
Code. Section 2553200'f
[]Yet 71 No
Will the applicant or future building occupant use equipment or des Ices which
tit Itacantons air mnmmiount,. as def rd by the Bay Arca Air Quality Management
isWmP
El Yes ❑No
1 have read the bazamous materials ayuiamcms uWer Chapter fi 95 0l the Culi-
fomia henna & Safety Cod, Sections 25505. L5533 cad 25534. 1 undcouud thus if be
building dgeSlan curaaby have irn cant, that itJs my re,msjbiloy to notify the occupant
I,LFCT'RIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPI'O 200AMPS
OVER 1000 AMPS
SIGNS (ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. MEI'IiR OR POLE INST.
POWER DEVICES
NEW RES]DEN] IAL
PLUMBING PERMIT
PERM1'1' ISSUANCE[
ALA ER -DRAIN & VENT- WAFER (EA)
BACKFLOW PROTECT. DEVICE
DRAINS - FLOOR, BEEF. AREA, CONE.
SEWER -SANT LARY-SHORM EA. 201 171'.
W'A'TER HEATER W/VENT/ELEC It
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. 17.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD 10 MECH.
AIR DANDLING UNIT TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.001) CPM)
L'XHAUS'I' HOOD (W/DUCT)
HEATING UNIT (TO 100.00) BTU)
I MATING UNIT (OVER 1 WA00 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COME' (31 UP OR 100,000 BTU)
BOILER - COME (OVER 100.000 BTU)
AIR CONDI 'I'LONER
NEW RESIDENTIAL MHCH. SQ, PT.
OFFICE
TOTAL:
FEE
n
❑ ❑ z ❑
J013 DENUKIPI IUN
RESIDENTIAL:
❑SFDWI,
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE.PIPE
❑MULTI"UNIT
[]STRUCTURAL
MODIFICATION
[3 INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
C]SWIMMING POOH
Q BATH REMODEUREPATR
❑ DEMOLITION
D GTE
21
COMMERCIAL:
❑NEWBLDG/ADDI'T'ION
❑DEMOLITION
❑TF,NANT
❑ FOOD SERVICE
IMPROVEMENT
❑OTHF,R
SEP 2 4
3 21 / C,
ops
BUILDING DIVISION FEES
PLANCIIECK FEF.
ENERGY PETE
GRADING FEE
SOILS FEE Poo
PAID
TOTAL:
BUILDING FEE
17EE SEISMIC FEE
EhIECTRIC FEF.
PLUMHING FEIi
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FIAT
PAID
Dae Raelptx
ISSUANCE DATE,
(:?-2L��-<��
BY: