S 2478APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CI'T'Y OF CUI'RRTINO Bull 1)IN 3 - ELECTRICAL
nU11,0ING DIVISION APPLICATION/PERMIT vLuhlxwr.-hm:cunmc,u•
BUILDING PROJECT I)ENTIFIC'nl'IUN
I'ERMI'I' NO.
O A 7 O
O 4 1 O
BUILDING ADDRESS.-
//
SANITARY N(I.
APPLICATION STRAIT['[[[AAL9DATE
(IWNEIiIS NAME: PII
ARC111TECT EER: - LIC NO:
CON1EACi OIR'S'NAMF, LICNO'.
AUDRIi.SS
ap
❑
CONTRDLk
oo,
HW
a zUzu
iZIi<w
Fly
Z O vi 7
OZ-
���,W
f `-I
C"� -I
C Q
��LU
3 U.
Fula
J
}c
Q C�(cv
Q. p, o y'
XI
^y
F Z Y
Q
�
F
3 m
zxatl
O Q
{r4 p)
a ?
(A
=z
U0
f�q
U z
'
CONTACT: PHONE:
O d
.2�7a^ ✓ V
LICENSED CONTRACTOR'S DECLARATION
1Touch amnn that I am lictosod node, onekina, of Chapter 0 Ronameneing
with Scrm..]IXNponnvidon 3 DTe Rm,mc,,.m,Vmf...ions Codu mat ylicensei.c
mfullforceanduct. /j g�O /� �i 7-
Liccnvc Class Licp (n�7 7
Date Contractor
�/-7'/1
❑ Consultant Fees Paid by Applicant (Initiaq /
-•' BUILDING PFRMIT INFO,
[LUG IiLEC' PLUMB MECH
❑ ❑
Q'p}', ELECTRIC PERMIT FEE
-r ._
JOB DESCRIPTION
RIiSID1iNTIAL
❑SFDWL ❑ KITCHEN REMODEL
El ADDITION El PLUMBING RI_PIPE
❑MG111'1-UNIT ❑STRUCTURAL.
MODIFICA'T'ION
❑IN'ITRIOR ❑CHIMNEYREPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH R1iMODIi1JRIil'AIR El DEMOLITION
❑OTfiliR
'Hh11T ISSUANCIi
APPLIANCES -RESIUI!N'I'I Al.
ARCHITECTS DECLAIATIO
I'Indelsland II s shall he oval v pu Ia rec .
1'ANI!I.5
I1P'f0200AMPS
LicnnseJ Pmtexsi
DN' E II.DI3R DECLARA' N
1 herchy afxmt that am exempt Tram the Qt redoes Lice Lase far the
fotlnwingreason. (Section 7031.5. Business and Prnfe..ions Code: Any city or county
which requires a permit to tvmshif alter, impmvc, dram liah, or mom, any xtn¢ture
prior to it,'1 y fletipplicautter h bamnot torile a signed statement
that he,, 1 Ip tt tl '. t' IJ C t t 1 (Chapter 9
es,igwlnSw t...odthebasis tro call,, The msvcut lnlAnysCWc) or
Ihul he is exempt Ihcrclrom and the Haul. far the idlepeJ exmnpinn. any violmlon of
Section 7031,5 ny llny applicant for a permit object, tho applicant to neivll endly of
mm more man lire hundred dollars135110).
OLothe%orol the pmpeuctre istaended withered for sale 0,W, Business
will dathew'ork, Code: heContunots Licensarawdo forot apply it, an Nosiness
ted Pmfe.siona i[d cu The sox th mtx License Law moo: not apply t, an mann of
thereon, and who noa such work hlnwdl or through
his own antploy. fle p..ild l Lha smcn impnwctncntx are Out iNmulul nr nlfcrcol far
his a m who hods). or.. d,d that
'at'. If. huwevtt, mu M1uilAng of impmvcumnt ix xuld withinoncymunl'ovntpldinn,the
Poer-hander wIII hove the burden of proving 11141 he did not hails) ur impnrvu for par-
c of.ale).
❑ I, as comet of the prapcn3. am exdusivdy ennvaNmg with b"nsed "man cors to
onstrum the pmjca (Sec. ]BW. Business ams) 11 fieWo., Cade)no Contractor. Li-
y who Inilds or lmpve, thereon.and
Law does not apply roAnuwneowner prnpcnm
wseho commas far wch projects with a cantmed u(s) licensed pursuant) the Contractors
Licanve taw.
❑ Iam exempt ander Sec. ,B&P C I., his ea,on
201-1000AMPS
OVI3R 10f0AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'I'I:T11'MI:'fER OR I'OLI3INN'g
COMMBLDGAI:
❑ Nli\V BLDGIAUDI'I'IUN ❑ UI?M0.1'I'ON
❑IMPROVHNAN El FOOD SERVICE,
❑OTIIER
OTHER
MOWER DE CP
SWIMMING ':1'k
OVI'LI3TS- SWI 'ICHPS- "'U lis
NEW RBSIDGN'fl Al. 1!1.1!C SQ I•I'.
SQ. FE FLOOR N213A
SIN Q, PI'.
- .1 OF
- -
QTY. PLU BING PERMIT ' ,FEE
PERM I'1' ANC[!
AIII'ER -DRAI N'I-WA'I'17R BEA)
Owner Doc
VAhI1KI'ION
�.p.� O
WORKER'S COMPENSATION DECLARATION
1 herchy a1Grm under penalty of perjury ane of the fallowing Jedamtions
I have andwill mainmin mCcnifica¢nf Cnnunnn self- insure far WorkersCope.-
salon, m provided for by Section 3]00 of the 1aMm Code, for the ped,,n,t.E,c of the
work far which tnls,amtit is issued.
❑ 1 have and will maintain Waded. C.... w.nmman Insurance, m ud,urcd by Section
3700 of the Labor Cuda, nim the rformancc eflhe wmk for which 11's tI, "tied,
pe perntl
MY Wnrkeh Cnntpcn.alinn lnsumncn currier unJ l'ullcyn eve'—f— /
Cori Policy No'
.HL TF.OF E%EMI'1'ION FRAM WCOIRREICY S..fi./j T7
COMPENSATION INSURANCE,
(Doxection neer not be completed ifthepemtd is forone Tummies) dollars($100)
or les.)
1 runty ttr Yn the p f o of he workfar which hisPermit I, isdIthinISI:WhR-SANITARY
not pl Y any P r. m y .: t �. bl t t m W A: C open
1 '['lint U
NO
NOT ric saltier, 1, t - ,after mukl tg th'. rwo cote'h xentpi ot, Y'
become subject y m Worker's Compensation on sine a( the WMrc Cone, you must
fnnhwith comply !In such pnnasmns nrthiu ltomtil shallhdeensd rcvnkeJ.
CONSTRUCTION
con,lo lead AGENCY
Iherchmich,o lhumou, i issueuwctianlendingagency for theperlitnnvnee of
'he work too which mi. permit is issued (Sec.PM], Civ. CJ
Lcdcr:sAdde -
BACK FLOW PR OTGC'
DRAINS -PLO R, ROOP.A ND.
STORIE
'OCC GROUP
TYPE CONS'1'RIICI'[ON
AI'N 1 I
35�"2�0��
MIXTURES ERT
GAS-IEA. SYS'1'fi (' 'ILBTS
GAN-EA.SYS'fL'M-O FS (13A
GItIiASFJINDUS'I'kf. WAS] 'Eh ERCEI k
BUILDING [)[VISION FES
GREASE [RAP
PLANCHECK FEE
STORM IIA, 20d FI'.
ENERGY I'LL D
l4Al'I:R HEATER WIVLNI/I:II:C'fR
GRADING FEE
WA'fl?R SYSTGM/fkls'I'INC
WAT ER SERVICE
SOILS FEE
PAID
Dom keccipla
NEW RESIDENTIAL I'LMIi. SQ, PII
't
-
TOTAL:
Lenoder's Adnrces-
1 ) I INC, FEE
1 cenify ma I have read Ihlc nppfcminn and Belo did the ubnvu btfunnation is
corm. l agree to comply with all city and county nrditmnccc and state laws relaingto
ads.,)a th
builiingconstrvaion.and hereby aulhe rc re ... atiet,of this city,, nor, urye
uMrve-nourianed p.,,my far inspection patty's.
Ove) agree nt save indemnify and keep hrmiless the Cily of C.,min. al1!
Iiabilitics,lud,remn, a'ssaod expOise whichas, in any way ucemeagainstvaid City
the gnia, of this permit.
in can sequence of o
APPLICANT UNDIiIZS'FANDS ANIS WILL COMPLY WITH AL1. NON-POINT
SOURCE REGI[ I.AI"ON S.
Sign reA dicnnfiCommem, Umc
TT!RIA S DISCLOSUR
Wt the appllcatn or future building o eiaipant store or handle hwmnlnm material
us defined by the Ctgsnina Municipal Code , Chupmr 0.12, cootie I Irchh and Safety
Code, Section 2553200?
L:1 Y's
_
Will the applicnnlo (more building occupant use equipment pr devise, which
emit hamrdous air cunmomment, an defined by the Tiny Arca Air Quality hlamagcment1
Di.arict".
E] YO, ❑
I T J tl h r t '' 1 (. d Chapter r )s fthCvl'
tom'H kh&S'1'tyC S t . 25511525533] 255341 J'.0 I1hat ithe
mull gd I - dyl ca t 1 Y l ,allyl Myth, upon
(IT The wh Ieme n tt Cenf alet f(ke patY
�
QTY. MECHANICAL1
IT FEE
1, CIFF,
D
PERMITISSUANCE EB
' IC FEE
AT *1 VR OR ADD TO MECII.
I'LUMI INC. FEE
AIIf I IA N DLI NO ONE IT, .JXFM)
" L NICAI, FEE
AIIt HANDLING UNI'I'(OVER D
CON ION TAX
EXHAUST HOOT)(W/DUCq
HOUSING MITIGATION FEE
HEATING UNIT G 0 H10.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Receipt Of
VI!N'1'ILAI'ION PAN (SINC,Lli ItIiSID)
BOILER-COMP(3fll'UR 100.00013113)
xOlLlilt- COMP (OVER IIM1.(N10 cru)
AIR CONDITIONER
ISSUANCE DATE ,
2� .,
ISSUED By. T-
NI:W RLSIDEN'I AL MI:CII.
'
Q�eIf�Gi yrt�uTllm D: /�
TOTAL:
OFFICE