S 2288 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP13R'1'INO
BUILDING-ELECTRICAL r1:KMrr No.
BUILDING DIVISION APPLICKI'IONFI'P;RMIT rLu\unrvc anccunrvlc,\I. Q 2288 2 0 8
I41II1.1)1NG PROJEC`F IOEN"TIFICAIJON S O
SANITARY NO. APPIACAI'ION SUBMITTAL DAT;
BUILDING ADDRESS:
/ 0 ?2�(l a 2 Acv c fwE /o z
V�'j,R,S�VI (?�6 PHONE Z CON'I'KACIOIj;S NAME: LIC NO:
" I�JC TY —NIC CON'I'KOLN
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IKC'UENGINE1lR LIC NO: AUUHH.SS', ❑
YAWL
LONT99cT. I'UON1i: BUILDING PERMIT INFO
SS G y�xnlC� ��o�)'rj 3/G 36 ❑ Consuhant Feel Paid by Applicant(Initial) BLDG ELECT, PLUMB MECH
0—
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hm mm am w
ereby affirm I rcend under pmxixi,aw of Ch,,c,9 bontmendng JOB DESCRIPTION
Z. veldt Section]IXNl)of Ulvicion3 n11hu Buxinexe rend Prul2senm Cute.rend my Gecnw is P'1jDF.[_1Tll�:
Plight l'I'ISSl1ANCli f Q
Cin full l orae amdcfeel, �)Wl. ❑KITCHEN REMODEL
aUU Limnw Cle,.c
Lie. API'LIANCIiS-RIi51UEN l'IAI- 3s 5-17 ❑AUDITION ❑I'LUMItING RIi-PII'13
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ARCHI HI"S DECLARATION PANELS ❑MUI:I'hUNIT ❑STRUCTURAL.
IC
F h L MODIFICATION
1 undcrslnnd my plan,shall M used ax public record,
OZNfill TO 200 AMPS C]IN] El CHIMNEY REPAIR
F v,Fad Licensed Profcssionxl 101-I00AMPS IMPROVEMENT 0SWIMM[NGl'OOIS
CYC; OWNER-RUILDER DECLARATION OVER Big)AMPS ❑OATH REMODEIJREPAIR ❑OLMOI.ITION
C C Q 1 hereby nthat 1 achirp,from the Cr mne,License Law for the ❑(/['ITER
X p, nation min u
U following reason.(Section 7031.5.Bucinms and Profession,Coca:Any city or coumY SIGNS ELECTRICAL
tD 3 r1 y which require,a permit or ntoshuct ove,alter.Imprdemdi,h,or repair any,uucmre rt/a4xz AIO cJ C-f
.F.LLo) prior tt 1:.. ,,fiec,the pple tf IM OIIarl signedalnem SPECIA1,Cl Ul"UNINC. A
W 6 dull . JP t1 tl 1 Its Com 1 1 I (Chapter AJ •COMM R§ C1AI'
W (cot sc,roc meal on ianphUv'' , hladla, ...ex, II I ..' txCdc)m I'I M ' HR OR I' L131Nfi'1',
a Xe y' Ihm he is exempt therdrwn ImA the M1u,i,for the ulle6e:l exv,sol ,,Any vinlm t n of ❑NI:N NLUG/AUDI'T'ION ❑DI3MOI ERVI
pay Section 91131.5 by any opplicare for a permit subjects the npplicum m n civil pmaltY of PO ' ICIis ❑IMPROV ❑FOOD SERVICI3
Sol more than five hundred dollars(851X). IMPROVEMENT
f2G ❑Lmowner of the propeny,nnny cmPlnycc,wits wages as their sole nmtpanv0un, SN'IMMINGI )OL[LIiCTRIC
f- ❑Ol'HER
willdo the wnrk.md,comet eix not imendcd,noRced for I—Business
63m and profession,Code:The Contractor',License law doe,not apply u,an owner of ()IITLITS-SUIT 'S-pIx Tums
property who build,or improves Iwrcan,and who dues wcb work himself or through
his own cmpl0yccs,provided that such intptavemcln,are not intended cr offered for NEW RESIDENTIAL ELECI'R SQ FT.
wlc.It.however,thehuildingor int ti„old withmune f contplctioo.the SQ.FT.FLOOR ARBA $ISQ.FT.
b Pmvemten )'earn //r S
owner-builder will have the bunlcn of proving that he did not bnIIJ or improve for Pm CJ(Y /�I,/
pw ot. ).
L] ba,owner of 1h p l ty Y t i b"'It I'' d—nars,bar,to -:W1-2
co-Ireclt project(S 7(94 B ' -and1 t .e C lef'I le,C t u Li- (Py
w Law doe,not apply to an 1-or, f poveny who hinds or ntprtven0cn n and QTY. PLUMBING pERMI'1' FEE `733 "�
who cenitncts mr.,uch projects with a contractors)licensed purouanno Ne Contractor',
hiacnsc law. 1'likbfl'r ISSUANCE S-sb
1 amt exempt miner Ser. .It AA,P C for this reuwn
- AI:FER-DRAIN&VENr-WAfiill(EA) VALUATION
nal Data Z
WORKER S CONIi'ENSAHON DECLARATION HACK II.OW PROTECT.DEVICE
I hereby of ser under penalty of perjury one of the foilowing drelarutiune.
Ibuvc and will mainmin nCenlBcum ofCnn,em losdf-insure for Workers Cnmpen- DRAINS-FLOOR.ROOF AREA.CO ). STORIES
'rYPI?CONSTRUCDON
,:niun,as roosted for by Section 3700 of the Lubar Code,for the pblorn,ar,r of the
work for which tai,perp it is oleall, FIX'1'UKES-19?R TRAP
1 moa and will ml fon W..kcr',Colnpc'nmtian Inwruna,a,rcgnireA by Suction
3]Wotdtc falai,Crdc,for the perlbrnnymgee of the w.rk for whchhJt�h�is permit it i,wed..l GAS-EA.SYSTEM-I INC.4 OU'I I.1?'I$ OCC GROUP APN
My Wur s hon In nu/t//J`rand polcy NOY tttrY-IJ-ZAZ_0V GAti-EA.SYSTEM-OVER
CER
Q
Genic V
CERt11:ICATEOPISATION INN FROM WOkKT:kS GRIiASI%INUl18TRL WASTE INIIiRCIiI'IY)R
COMI'IiNSATION INSURANCE
BUILDING UIV ISION Flifti
Thisneaion need not he completed if the fermi,i,for onchummaddollxn(8100) GREASETRAP Pi.ANC KFeE
nr loss) Q2 1 L
I acridly tba,in the twoorn:mce of the work forwhi,h this pannil is issued.I,hall SEWER-SANITARY-STORM FA,200 IT. ENERGY FEE Li s`C�i
not employ any peroon in any manner xo as m became mlijecl ht the Worker,Comlten-
OZ 'an un Lowe of Callfnrniu Ham WAI'HE I U:APER WM:N'I'/HLECTIt G11A1)ING FP.
r\,blant
'z' NOI'ICE'f0 APPLICANT:It,alter making 0i,Cenilicum 111 Exempt ton,You should WAI ER SYSI CM REAPING
solus IIiE
F re,olne subject m the Worked,C...npc lmion provision,of the Labor Code,you must
tx � forthwith comply with such provi,iun,or this permit be dammed rmokcd. WAI VR SERVICE
410 /O-Z v� o7soz
D' CONSTRUCTION LENDING AGENCY NEWRESIDL T1ALPLMB, SQ.FT. PAID
] z Data Racipt p
V Ofamine wbich affirm that is agency for performance of
the wnrA for which this pcmmi,i,mcJ(Sol.3097.Civ C.)
(J [,de,,Namc TOTAL: 6 r
Lender's Address RCH.DINGFEE IS32A�1
comfy Ihm 1 have add Thi,ap,linnion and fait that the above rid...nation ix �
(req : tec1.Iagree mcomplywishdldlyand courtlynr,llnxncm"and xlaw laws lAttingto Qq'Y. MECHANICAI,PER MI'I' FEE SHISMICFFF Zp/, 70
V Z build ingnn.tmdionmul ncmhy notllnrim ml'racnhnlvc,(111111,a'ny to anmrupan the
abile-na ndnned P,,,,,Iy fur........Hots purpo,ee 11EKMI'IISSUANCE .ELECTRIGVE r
(We)agree or or,r,indcnmity and keep harmlu,x the City o1 Copcoinn agaitnt - -
liabilibes.judgments.cans and expenses which may in any way attmc vgaina,aid Ciry AI la OR ADD TO MECH. n �jis\ 111-4pIBIN(1FF,1
in ,mequence of the gramingoflhi,permit A ' 'I
/
APPLICANT UNDERSTANDS AND WILL COMPLY Willi AL1,NON-POM' AIR HANDLING UNIT(TO 10010 CVM) I l; u `a MECHANIy. 60 '
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 10,000CI
lgtm col Al IieunVCimtmeme Dam EXHAUST HOOD(W/DUCT) HOUSING I ATIONITH $Z
f1AZAk DUDS pI :RIALS DISCLOSURE
Will mcappllanlor linuu buil ng occmpaaa aneor handlelwz.unluu.mmotnal H HATING UNIT CTO 100,00011'I'll)
as defined by the Ca bealno M.... ;d Code,Chaplcr 9.12.1nu1the I want,and Safety IIIiAI'ING UNI T fOVI?It IIXLINllI IfIIA -
CoJe,Sectlon25532(al'.'
❑Yes ❑Nn PAID
V ILN'1IhN'ION FAN(SINGLIi kGSID) Data Race"I
Will the applicant or future building occupant use eyeipanem or device,which ROIL,ER-COMP(3HPOR 100.000 B'1IA
mit hazardous air umtuntinants a,defib d by the Ba)'Area Air Quality Management TOl'AI,:
District? BOII.ER-COMP(OVER 110,(X01HU) '1
❑Yes 0 N a L.
AIR CONDI I'IONER ISSUANCE DATE
I have read lac hwa;J m,lasereal,rN meena:m,unJcr Ch1gt¢r h95 01 the Culi-
Irmia Ilcalth&Snfdy Ctxl6,Suniom 25505,25533 and 25534.1 unJaxtanJ Ihm If the NEW KESIUEN'I IAL MECII. SQ BT.
hnildingdubsnot currently haves In then i1 is nylecrymsibintymnrnity the occupant
he ore . en6 whimhnm hu incl inn lswnce of a Cali"atm lx ttpancy.
U n orautht ralagent Da¢ TOTAL: (j` ISSUED BY-70e- /�NyOhI.GG+
OFFICE