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S 3377APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY ON'CUI'ERTINO BDu,DmG-ELECTRICAI, BUILDING DIVISION APPLICATION/PERMIT rLunwfrvc-nH!runrvu:Al, IfUI1,DIN1: PROJECT iBENIIIHCArION Pli 1'r No 3377 IHIILDIS9�i — SANITARY NO. APPLICATION SUBMITTAL. DATE OW 'S N ME' PHONE. 53^/'�,7 NDiACFOR'S NAME: LIC NO'. i F'/ff NIC ❑ CONRO I.M LIC No %1 /W��+r ADD SS: '.'� �n1 O / S• OXO -p Kc� �wR F CONTACT': PHONE: I3UILUING PERMIT INFO BLD(: IJJiCI" PLUMB MECH ❑ ❑ �❑ I 14H,� 53-0 o ❑ Consultant Fees Paid by Applicant (Initial) I,IC12NSEDCONTRACI'OR'SDI7CI,ARA1'ION I hereby affirm that 1 amt licensed under previsions of Chapter 9 (commencing with Section901Xpaf Divisinn3offle Bv,inca,and Prefessions Csxle.and my licenw is in full bops and coin. QTY ELECTRIC PERMIT FEE JOB DIESCRI I'I'ION RFSIDFNTIAI' ❑SFDWI, ❑ KITCHEN REMODEL PERMITISSOANCIi APPLIANCES -RESIDENTIAL Liccnm Class Lir. of Date Contromor ❑AUIIDION ©+4AL HNG RIi.1'11'E ❑ MULTI -UNIT ❑ MODIFSTRUIURAICATIOO N MODIFICATION ❑INTHItIUR ❑CHIMNIiV REPAIR IMPROVEMENT 0SWIMMING POOLS ARCHITECTS DECLARATION I n oderatand Ty,Inns or,ol be used as Public rceotds PANELS UP To 200 AMPS Licensed Professional 201-H)COAMPS OWNER -BUILDER DECLARATION I lmreby nl'prm mat I amt ucntp, I to the Cnmractnrx Liccnac Law for the following reason. (Section 7031.5. Business and Professions Gide: Any city or county ❑ BATH REMOUEUREPAIR ❑DEMOLITION ❑ OTHER OVER 1000AMPS SIGNS ELECI'RICA], w'bich airlines a permit to consume, ahee im,mve, demolish, or (seal, any suuaurr prior to its lssovnce, also requires the apphcam for such pefmiuo rile a signed statement "hat he i"T ..ix " nry Liccnw Law (Chapter 9 (...menringwt ainn 9(XX)t iisinn3n Huslmcsn an Profersinn'Codgor that he is exem t efrnm J bvsis 'ar thI �Ileged se ion. Any violudon of Section 903 L5 a :mplk lora mtsu tx thea 'tea acivil pepahyaf SPECIAL CIRCUI'VM ISC. I EMP. MH' 1' ER OR POLE INS I'. COMMERCIAL ❑ NEW BLDG/ADDITION ❑ DEMOLITION' ❑TENANT ❑ FOOD SERVICE POWER DEVICES on,marc noft Wrcd dollars ($$lNp. "I. a, owner avt n�?�'IrmyryttglY)e age s rwle unnpar-bon, will Jo the soot Jmc dritbut6ris WtiglynJ �pryp l rtd e1Scc.Tw+. Bainesx and 1.....s n nJe'TM1e Cnntmcmrx License Lu At apply to on owner of IMPROVEMENT ❑OTHER SWIMMING POOL ELECTRIC OUTLETS - SWITCHES -Flal'11RE5 NEW RESIDENTIAL ELECTR SQ FT. pmpcny who s nr itnpnrvcc thereon. mA wbn lnxs m trk hinucll' n, Nnmgh his own amPl ,mviJeA IM1m such impmvemenav art nm tended nr afraid for saleH lmwev e8' ildin6or improvement i, sold within one ear of completion. the SQ. EC FLOOR AREA LSQ. PI'. ownerimprove fer put. TOTAL: puce.1 salt). Fl h as owner of the propenX am exclusively contracting with Iicem.sed am ourarrs no cenawmthe project (Sec. 7essannd Poeoust-NrTetc-ummcmr cells, Law (Io, aoanowner(if ywlit)builds ixthereon.Li- and QTY PLUMBING PERMIT FEE who,or raw, hierarch pnrjceu with o canmocle",) licensed ,.marc,)the Cnntraemr's Licence law. PERMIT ISSUANCE ,� C> ❑ I an ciente( under Sm. .H& P C for this reason N:I'ER -DRAIN & VRNT- WA'IIiR (EA)) ypLUATION Date Owner WORKER COMPENSATION DECLARATION BACK FLOW PROI IiCI'. DEVICE I hereby ulTvm under w,uauhy of Perjury one of the following declarations: I Cus: kers Cn i]Ibvvc and wllUnuintain nCcnificv¢nl'Cnmenuosclf-inure tar Wornnpcm nation, as provided for by Section 3900 of the Labor Cale, for the performance of the work far which this permit is issued. DRAINS -FLOOR. ROOF, ARIiA,CONII. S'IOHIF_S '1'YPIT CONSTRUCTION fFIXTURES- PER'IBAP (/ � ^ ❑ 1 have and will maintain Workers Conipemation Insurance, m required by Section 3700 of lha Lolfu,Code, fnnhepelf ..manm of the world or which"his l count is sued. GAS-IiA. SYST[M-I INCJ(RIILETS OCC, GROUP APN GAS - f�.SYSTEM OVERAIEA) Aly War 'c Cot Z., as pante c nibs d PolicY N"yat �,e{cZdC Cartier'. a "J CHR'I1M A'rEOFP,XE TIONpROMWORKERS COMI'uNSA'I'ION INSURANCE OHEASIYINDUSTNI. WASTE WTERCI?PTOR BUILDING DIVISION FEES _ GREASHTRAP YTANCHIiCK FEE udoll:uc($100) fMisssetion nttMna he completed! ifthe,emit, is furore hndleol r Luc) I really that In the proboonaucc ofthe wok for which this Permit is lxsuad, l shall mmploy any,�rn in anymanic, so),,, thee toe aubjmtmhe Werk... Cm,cn, SEWFR-SANITARY-STURMEA, 21X111'. IiNERGYI EE WATER HEATER W/VENT/ELECTR WATER SYS TEMTREATING GRADING FEE cation laws of Califnmia. Date Applican" NUI PCH 10 APPLICANT.Laftcr.raking this Ccnifcme it Tic ...Joit, you should ' become subject to the Worker's Compensation provisions of the Labor Code. you nmst frnhwith comply with such provisions or this permit shall be deemed svoked. SOILS FEE WATER SERVICE NEW RUSIDENTIAL PLMIL SQ. fT. I CONSTRUCTION LENDING AGENCY arc iac)mNmcbra lending agency folks pcptnnnanue of I hcrebv attinm that m.s the work forwhich this pcomit is visited (St 3099, Civ. CJ PAID Uata Rcceiplp TOTAL: OT LcndNear, 1 IsnJre, er'I Add Addrcess 1 certify that I have mad thirtyapplicationnd coup and atau mat the starve instmmtinn is j cored.logmcut comply and herebylcLyand county communities and sa¢hw,c,.,.gm huildng cnnnmmion, and hereby uuthurieu rcprcven"utivcc ntthis my m enNr upunthe HI111,DING IIS t CHANICAL PERMIT' FEE QTY.jA=Rk SIi15huC PEE - ISSUANCE ELECTRIC EIRE abnvc-mentioned pm,cny Iia inspection Pur,neex. (We) agree In save, in ammiy and keep harmless the City of Crpeaino against babilules. judgments. costs and expenses which may in any way accme against said Ciry D TO MECH. PLUMBING FEE 'ncnnequcmce of me granting of suis PconoAPPLICAN"T UNDERSTANDS AND WILL COMPLY WITH AL1. NON POINT' G (INET(1'010,000CPM) MI?CHANICALI-'i.li SOURCE REGULAT IONS. A IR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TAX Signature of Appliceml/Couler,o)r Dae HAZARDOUS MATERIALS DISCLOSURE Will the u„HeartoT locate building oecupam rare op handle haemdnus medal as dunned by the Cretonne) Municipal Cock, Chap"cr 9.12, i I the Health and Safety Code, Section 255320)'/ EXHAUST 11001)(W/DUCT) HOUSING MI'HGA'I ION FEE HEATING UNIT fro 100,000 BTU) HEATING UNIT (OVER 100,(XX) BTU) VENTILATION PAN (SINGLE RESID) ❑Yee ON. PAID Dae Receipti, Will me vpoftain or l5nure haddingoccuennt use cgemour.t ar Juvicca which emit M1manka, air contaminants as defined by the Bay Area Air Quality Management 3OHFR-COMP13HPOR 100.000311l1 'OTR L: BOILER - COMP(OVER Hill BTU) District,' Yrs ❑ No AIR CONDITIONER ISSUANCE, DATE �rimmem under Chat, I base moulds, hvunlonnuaedalato ter 695ofthe CAi- fomia Health & Safety C e. Section . a5. 25533 arM 2553]. 1 undcrsfy ma if the NEW HESIDEKI'IAh A1EC11. SQ. FIl2- th bu(ticr,xcnottot huvrat ,"hu lion pnneiblhtytnnotify the occupanty of the re neM1 nmxl ua p' w.msesla anticus urlpkcu'ncy. �Y ISSUED 11Y: ! r TOTAL: r auth cd ageal Done oFFIUL