S 2591APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING - EI,EC'I'It
IIUII.DIN(; DIVISION APPLICATION/PERMIT PLUMBING -.%fECHA1
RUILDING PROJECT IDES'
BUILDING ADDRESS: t "�
f/-) nf.LD PA /I r Alan Dr.
)NTACT': .. P.... `:4 I, —
pr�iz �u.6ia. 7G3-/ �3
I hereby a1Rnn that 1 am lieensed wader pmmmons of Charm, 9 (commencing
CWZ with Section 9IX0)of Dlnunn J of the Homeless and Prodesdnns Coleand my license is
FggO in full force and ellect.
aUU License Class LIC.N
y ZZw Date C.amr:rmar
ARCIII'1'HCI"S ❑ECI.ARAI'[ON
Fo`Zlundcrxwnd my plan,,holt he uecd a.. public CC III
OZ -_0
W Licensed Professional
OWNER-HUILDI;R DECLARATION
C, 6 I hereby affirm that I am exempt front the Contractor's Liccrow law for the
3 LLFU- following mar'un. (Section 703 I.S. Hu'iness and Professions Care: Any city of county
y which requires a pc'nuit econst
met, conset, ahcr. Intp, me demolish, car repair any structureF-WpN� prinrtn its i"t4al1c,alw+mquire, the appllcall ku—hpanrhuol lcnaigncJnmcri
hath .,bec-rd puraurdI he p snil. 1 1' ( o tmr,laram, I' (Ctrpm19
ly p, W (tont 6 in S<Ii ]010)1 e 's m 3the
alleged
JI f:' I,CourtIt
d a C meth he is emanpm Ihamfn,m and the basis tar the alleged uenmption. Any violation of
ago y Section 90915 by any applicant for a Permit subjects the applicant toll civil Penally of
am m than five handled dollars ($510).
iG❑ Las owncrofine prnpeny.u, atycmMayces with wagcsas tbeirsole cmnpensaion.
will Jo the work, and the structure is not intended orancted for sale (Sec. 91114. Business
1x1 w and Protes x Code: Go, Clinicactnid License Law does not apply Ina of
ti t I n owner
his o ny who build, or.. deCiuEa,ce, thmcun, and who docs such work biuncll' daredalh ar
his ,C,C, C I.the building
that puce anniarmens cats u r inCar oI l o tdomd for
sole Ifnhower will
have
th ng ar en of fmnent is at h within are ild r improve
or the
cr-builder will have the bunlen of proving that he did not FxilA or improve for pur-
se oLwlcI
I, a. nwmr amcnmmc ,rvnITconst t h poorest (Se 9(W Business J I 1med
t s
e, l 1 1101 apply toad d fapty e h builds . p m Ih and
wht is loar such foroccis with a ourtractiaO I -ed pullamor toII Cort
Coe
EJ lam ex mil under Sec.. —. 11 p. I C for this rc
❑ Consultant Fcc, Paid by Applicant (Initial)
)'PY ELECTRIC PERMIT FEE
PERMIT ISSUANCE:
APPLIANCES - RES IDI?N'I'IAL
11
UP 1021X1 AMI'S�� ^jpp L
201-HIUOAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
WORALR'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury nnc of the fallowing decllar ions:
up, Ej I have sW will maimain a Ccaificnte ol'Comcnuo self -inure for Worker, Compen-
%.,I o, as pmviJcrl for by Section 99101 of the Labor Calc, for the p9rfornsance of the
work for which Thi, pond, Is a—cd.
❑ 1 have and w111 ma uldn Workers Cmnlnn.ader, Inamor,c, as ....paired by Sol
))00 of rhe LaMn Cad., fill he fac tormancc of the work fur which dmis pend ire i, issued.
My Worker', Comforet iaa Insurance comma, land Policy number, sere:
Carrick Policy No.:
CERI'IFICATEOF EKHMPTI(IN FROM WORKERS'
COM PENSKI'[ON INSURANCE
(Mss, tion need an b,campleted it permit i:fornnehundred Jnllao,6110))
ill v)I rani I the al laa the perfunaana lotthe w,n k lar whlchda,pc red, I shall
mot employe any per..... inan'.1reacr o,la%m Iacumc subject In the Worker, Coanp_n
rZ 'arm, law, of California. Date
z O Applicant
NOI WE EO APPMCANI': If, after making this Cer ificate of Exemption. you should
? become subject um the W'l,kers Compensation pro, emans of the lallr Cmle, you must
D.I forthwith crmply with such provisions nr tbi'pennil mall be damned mvnked.
Q
Z) CONSTRUCI']ON LHNUING AGENCY
U OIbe,ehy anhat ENt'here le a,vaalntell... I lending agency tin, the perfonwaec ill'
F the work fill ma,i d, peanuts i ... om(Sec. VI Cr, C.)
O Ulander', Naos
Icader,Addn'z%
I" d I mnify that I have mad this application and nam that the rdi uncommon is
h correct. I a gree to comply with all city and county ordinance%anJ .'late lawvcluting or QTY.
U Z builJmil,ru nmclion, and hereby ..ill ire opmmntatives of this City hoc enter uptm the
above avd pngxny fm'mspect n prtmn
(We) aij,c to,uo
ve, iad,u ily send kcCF 1 u anlc,a theCIIy of Caienie" u&'rind
Iiubilities, juJganentx, sera., send expense, which may in any way accrue apain.n ,aid Cimy
in asequence of the granting of this lrrnmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULKI'IONS. ,
(IA/.NtDOUS MKI 111tIN.S DISCLOSURE
WIII meappliemn ar,mum built ncaapaat marcorbunallc Iweaudous reel
as defined by mine Culmina Municipal Cole. Chapter 9.12, and the licath and Solely
Code. Section 255321,))
E] Yes ly
Will the applicant or future building occupant use equipment or devices which
Ill hozunlou' air cautaminanu as defined by he Buy Arca An Quality Management
Dimecf'
❑ YC,
1 have rcml the II..dom motorial, nyoimmm�ts under Chaprtn 095 of the Cali -
forma Health Nt Su coy Curb. Sections 25505, 25599 and 25594. 1 undetsmnd that if the
building da,%ren Currently have a tenant. that it in any respnn,ihilily to modify the occupant
,nm.....oimov.nry wL1choma Izz, t ndry toissuumx of o Cenilicpe of Or4rigncy.
SPECIAL CIRC GIIIM DSC
HEMP MIiFBR OR I'OLF INS'F.
POWER DEVICILS
SWIMMING POOL ELIiCfRIC
ou I LET'S- S W i rcuE.5 '� FIXTURES
NFW RESIDEN'I'I AI. E61
h [TIMBINi P IT' , IJ FEE
I SS NCE J
;MR-IIRAIN IC VI?N'f- WATIiR IEA)
BACK FLOW PRC VCT. DEVICE
DRAINS- FLOOR, ROOK AREA COND. ^7
FIXTURES-PI?It'IRAP
JOB DESCRIYI'JUN
S 259:
NFLARY NO.
APPLICATION SIIIMIITA
❑PLUNIHING RE -PIPE
❑MUI]'1-UNIT
2-z3 5
NIC
MODIVICA'I'ION
CON 'I'Rol. of
❑ Cl IIMNI:Y R17PAIR
IMPROVEMENT'
[]SWIMMING POOLS
❑ BATH REMODEURRPAIR ❑ DEMOLITION
❑ OTHpR
BUILDING PERMIT INFO
BLDG
I711I1CI' PLUMB MSCI
LD
H'
)E4, Mf ❑
JOB DESCRIYI'JUN
R IDE F
SFDWI.
KKITCf11iN REMODEL
❑ADDITION
❑PLUNIHING RE -PIPE
❑MUI]'1-UNIT
❑S'I RUCI URAL
MODIVICA'I'ION
[I INTERIOR
❑ Cl IIMNI:Y R17PAIR
IMPROVEMENT'
[]SWIMMING POOLS
❑ BATH REMODEURRPAIR ❑ DEMOLITION
❑ OTHpR
COMMERCIAL
❑ NEW BLDGIADDI'I ION ❑DI:MOLI'IION
❑TENANT' El FOOD S17RVICE
IMPROVEMENT
❑ OTHHR
$ISQ, FI'.
Gid
S'1'!)Hl fti / II ",... vNm
GAS - EA. SYS'I EM -1 INC.4 OU'1'Liz, I'S OCC
.
GROUP
GAS_ EA. SYSIEM.OVER4 -// 3 -3
-1 'Pans WA. [ME OR BUILDING DIVISION
NN FRS
r
LAS FIK ' PLANCHECK PER
I
S. ER-SANI'I' t S'1 1 IiNERGY ITII
KFit I : iR WN HNI'IELECTR GRADING FEF
ATER SYSTFLIIfRHA'I'ING SOILS FIRE
PLMH, SQ. FI'.
MECBANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO 1,1Ii01.
AIR HANDLING UNIT BTO IBRO CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOG[) (W/DUCT)
UA'I'ING UNIT'(IO W,q)0B'IL)
II EATING UNIT' (OVER 100.010 R'FU)
VENTILATION IAN (SINGLE RISIU)
HO1LER-COMB' 131IPOR 100.010 HTII)
110ILER -COMP (OVI?R I00,N)O R I U)
NR CONDITIONER
NEW RISIOIiN-AL MI:CH. SQ. IT.
OFF
PAID
Receipt #
TO'1'AI
rINGFERZ
Of �(
FI7F,
ELF
MECIfA ICAL' ER
CONSTRU TION DAX
HOUSING MIDGAI'ION I'IiI,
pnu)
Date
ISSUANCE, DATIi
2 Z3 --q %
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