S 1569OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY I
BUIL :NG
CITY C NO
PLUMB ING-nD?CEnN1ON'
1'E ITNO
I
1569
�
BUILDING DIVISION APPLICATIONA'F,RMIT
DI DIVISION
I4UIhDTNI: I'RIIJI2C1'IDENTIFICATIUN
(
41UIIAXNGADURIi55: r
SANITARY NO. I
APPIIICAI' )N SUBMITTAL DATA?
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CONTACT: � PHONE.
BEHEDINU PIVNIETINTO
Hhoc Ii1.liC' rLu MliCl
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONI' RAC 'I ORIS DECLARATION QJ'Y ELEcrRIC PERMIT FEE
JOB -SCRIP'I;ION
I hereby arnrm that l am licensed ander provisions of chapter 9(commencing
WOO
'Ih$enion pfMNlpKDivisinn9nfthc l3usiuens and Pm@ssinna code, and .ray license is /
w' PIiRMI'r ISSUANCIi
'cel.
_ESWE
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,n full force an `
❑ SFDWh �,KITGIIIiN k13MODEl.
F
U
I cmc ClC c La. n
''c APPLIANCES -RESIDENTIAL
KADDITION ❑PLUI1BINGRE-PIPE
ZU
h
U t- Commcmr -
❑MUEN-UNIT ❑STRUCTURAL
Q G
ARCA li(T, tl?ChAkAI'ION
E., Z.
zb, K
PANELS
y Ions hu - u ice Ms `
MOD119CA'I'ION
OZ—
�n /wr%J UPT0200AMPS
❑IN'I'IiRIOB ❑CHIMNF,Y RIiI'Alli
@1PkOVEMENT E]SWIMMING POOLS
sed olesmon I 201.1001AMPS
O ,ER -BUILDER DECLARATION OVER I11UUAMPB
❑HA'I'TI Rl?MOUI?VRI3PAIR DEMOLITION
P. U
I hereby affirm that1 an, exempt from the Cmvmdor's License Law for the
❑ OTHER
�y(O
a
following ranee. (S.ien ]11]1.5. Business and Professions Code: Any city or countySIGNS 13LF.CI'ItICAh
u] W y
which requims a permit a, emdlruel, alley, improve, don irli, m repair any ormarrc
1pp'�O�JJQ
primu,I issuance, also requires neapplienl to nu ch permirw file. signedslmnnem SPECIAL CIRCUIT/MISC.
tha, lm is hecnwilptowimu to the pn,kitai,of the Comraceors License Lew(Chapter 9
COMMERCIAL'
WW
(commencing with Sectime]0110)of Division J of the Business and Professions Code) or TEMP. NIITHR OR POLE I NS'I I C
tL y pg
that he is usen,pt mere a and the basis Ga the alleged cxmnplion. Any violation of
NEW BLDG/AUDITION ❑ DEMOLITION
R•
Section 7031.5 by any applicant for a permit subjects the applicant ma civil pewllyof POWER DEVICES
TEN NT El FOOD SERVICE
YXI w
of mmclhan live hundred dollnrs($50(h.
OVF.MEN'1'
�=Q
SWIMMING POOL ELECTRIC
employees wilhwagcsastheirsee
❑ Laeawner of the propcnyare
TI IHR
k O
is er 044'Brmien,
will do won, and e.c sn is not u,sr;)f
ply
License aw dos nal a to an own
and Cale: The Contractors Lice s
du docs not apply 1. an owner of OUTLETS- SWI 'fC11E5-PI%9URPS
n, whioma
pus who builds or ffiaro through
thereon, and who docs xuch tints
videdvcs
his own employeese provided Wal such improvements am not intended or offered for NEW RESIDENTIAL t3Ll?CTR 3t SQ PT.
own d d or of
SQ. PI'. FLOOR AREA
5/SQ. I'p
xale.lf, hoxxvea the.uilAing nr improvement iz sold withinnnc year o(cumplctinq the
ut-
r -builder will hove the hutden of proving that he did not build or Improve for put-
prince
p�orsele.)
❑ I, ax owner of p,,,,qy, i exclusively comrnmlng with IicemN colntMmrs m Is UrAL:
j` r\
(p\r]
f, 1
_Y,
,nmmc, the p,.jcc, (Size.'1(uJ. Business sad Prolcsumi, Calcr) Me Contmmors Li- -
p
r W
.ItWf-
m Law does net.pply i i owner ofprope", who naldsurlmprove, thereon, and QTY. PLUMBING PERMIT FET:
who contracts for such projects with a contracumbd licensed pursuant o the Contractors
License Law, PERMIT ISSUANCE
I am exempt under Sec. . B & 1' C bodies mmon
QAII�/ �e ��I(1s�
MAY 1/ AMID
ACI 't?R- DRAIN &VF, '1'-WAI'F.R (HA)
VALUATION
Owner Date
�/
/ f (/U C0a 16JO
'I:CCI: 1,111A/
WORKER'S COMPENSATION DECLARATION BACKFLOW I'ROI'. I ' I
®�
I hereby affirm under penally of perjury one of the fallowing declnmllom:
/
Ihave and will nwimaina CeniEcam of Cnn.aenuoself-inmmfor Workers Gen,pen- DRAINS - FLOOR. 1001', A. 'D' N.,STORIES
TYPECONS'1'RUCHON
smion, m provided for by Section 37110 of the Labor Code, for ,he ..dorm..... of the
work for which Anis perma is io.ed. FIXTURES - P, TRAP
❑ I have and will maintain Worker, Compensation Ins.rence, m squired by'u'rom
00 of C„Je, font ork for which this .it, is
OCC (.ROUP
MIN
My WortM
,i`•,_• and policy fi�fly,rll QpO^e/
GAS-IiA. SYSTEhbOVER4([A1LCl'S
J,`ancie,
Caniec \�srr �V ` Policy No `k ` ei D O h
CERTIFICATE OF EXI 11HON FROM WORKERS'
COMPENSATION INSURANCE GRPASIYINDUSTRI, WASTE INTERCEPTOR
N il. 1 DIVISION IEIiS
(Thisseetianneednot be crnn.tatidd the permit is Baran, hundmddollars S 100) GREASE TRAP
or less.)
PLANCt113C - UI
I certify that in the P..f....... of thework for whkh thislwn.ilL —ne,d,Ishall SEWER-SANITARY-STORMI?A.2(X)FT.
no, employ any person in any manner so as to become subjectto the Workers' Compen-
ENERGY 11
Oz
sution laws of California. Dino WNFER HEATER W/V[IN I/ELECI'R
Applicant -
PFlk
GRADINkJ;/
Z
y
NOTICE TO APPLICANT ILvBermaking,his Certificate of llxemptian. yea -should WATER SYS]IiWI RHATING
F"
Wo me subject 1. he Worker's Compensation pnrvislom of the I.,dWr Cole, you mus,
SOILS Il?E
forthwith comply with such p rsisivns orthis himmil shall he deemed revoked. WATER SERVICE
Q
Uz
CONSTRUCTION LENDING AGENCY NIiW RESIDEMI'IALI'LMB. '3N5SQ. FII
PAID
U 0
IM1ercby nffnn that there lsvconstruction forthe perfonnancc of
Dale Recetpl#
30W.Cw.agency
the work for which this .email is issue] (Sec J09], Civ. CJ
L.nder.s Nunn I
Y01-1Ze Q
Lender's Add.. TOTAL:
BUIIDIN(i
fU
I Oml, that I have read this upplicneien.nd stat her Alm nhuve inlimnation s
1(y'
%1
corrcuLI ,.c1. comply with all caySnd roumyordinunms and same law, relining to QTY. MECHANICAL PERMIT FEE
U F]
bnilding mmtrac,ion,and.cyany vuthmiite fep,escmativu of Wiscdy to mver.pw, the
SEISMIC FEE
idove-memioned p,,,,.y rot inspection pm o a,. PERMIT ISSUANCE
ELECTS IC FHP
(We) agree to ,save, indemnify .rad keep harTleas the City ()I Cupertion ugau¢t
Imbilieies,judgmems,cosumad eapenamwhich may many wayacemaagaimrsaid City' 1 AGIER ORADI)TO MECII.
PLUMBING FRl3
in nscap,ence oldie granting ul ,his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10.000 CPMI
MECHANICAL FEE
SOUR REFUCA'1'IONS.
g.
;wM yrsOp �d AIR HANDLING UNIT (OVER IBM) CPM)
CONSTRUCTION TA
� D
Signature of ApplicanUContraclor Date` 1 EXHAUST HOOD(W/UUQq
HOUSING MITIGATION FEE
HAYARDOUS MATERIALS DIHN40SURE
Wlllthenpplicnnt or future huddingeccupanlsmre no handle It ...dmrs material HEATING ON 11 (to 100.000 B'I'Of
as defined by the Cupenino Municipal Cade, Chapter 912, and the Health and Safety
Code; Section 25532(.)9 ,/ HEATING UNI I (OVER 1, IX,11'IU)
�N'o
❑Yea
VIiN'I'ILAI 'ION PAN (SINGLE RESID)
PAID -
Umc Receiplp
Will the applicant or future building occupant use equipment or devices which
TOTAL:
cmitWAedous tureommninvms.s dcfneal by the flay Arca Air Quality Manusema I BOILER- COMP(3HP OR 100,000 BU)
District?
❑Yes BOILCR- COMI'(OVER IIID,BW BTU)
AIR CONDITIONER
txspti,cmems under Chapter of the Cal
I have read feu hemc. tions
ISS A�CI%UA'f13
understand
Se 2 5 255]3 and I u
fomia Henle, & Safety Cale Sections Ihat if the NEW RESIDENTIAL \tECH. 3 , SQ. Pr.
(`A (b/
.bar,, nobifi notify the
huildin6 deer urn curmntly have a tenwn, thea it is my mry,mxibility to ramify the rcenpant
'v
cn.cglswddh ux he tae, pdonniseuunce ofa Ceniliq of'st,may.
1 A
1 ` LDate
f^l
ISSUED BY: v `� O
Owner o uulhoneed agent TOTAL:
OFFICE