S0001 99100129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I njesilaq
CITY OF CUP6RTIN0 BUILDING-ELECPRICAI. RMIT
BUILDING DIVISION APPLICATIONIPF.RMIT P1.uMBINc-nlEcxpNlcnl 50001
IIUII,DING PROJECT IDEN I H ICA'IT11N
SANI'I'A IJV N(l. AI'1'hICAl1UN SUI3MITIAI.DAT
BUILDINGADDRESS
/039/ ;no Ca • 9��� /O -L I=9
OWNER'S NA ': PHONE: CON RACfOR'S NAME: rON LIC NO: NIC CON TROL#
NO. ❑
11'11 1" iNGINIIeH: LIC NO. ADDRESS:
Z 2 �_
ONTA�C/T�j f BUILDING PERMIT INFO
�J� fGa ��" `/'� / /��,,�—(�/%/ ❑ Consultant Fees Paid By Applicant(initial) BIL�DG// ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEII JOB DESCRIPTION
1 herchy affirm thus I am limned under pmvisions of Chapter 9(commencing
MW�Z with Section 2000)of Division 3 of the Business and Professions Cade.and my license is RESIDENTIAL:
Iy in lull tinct and effect. PERMIT ISSUANCE: ❑SFDWL ❑KI'TCHEW REMODEL
aWV 1,ice.o,Chasse Lic.Is APPLIANCES-RBSIDEN'I']At, ❑ADDITION ❑PLUMBING 1EF-PIPIT
N z Wues Dam Comme nt
ARCHITECTS DECLARATION PANELS ❑MUI;Ph UNIT ❑S'TRUCILBAI.
Z p m Z I understand my plans shall be used as public records MODIFICATION
UPTO200AMPS El INTERIOR El CHIMNEY REPAIR
F¢.E2.F.; Licensed Prom,sonal 201-100I)AMPS IMPROVEMENT EJ SWIMMING POOLS
(OWNER-RUILDEB DIiCLARA'fION OVER IfNNt I ❑I3ATIREMODHIJREPAIR El DEMOLITION
IY C 6 I hcrcby affirm that I am exempt front the Carl...n ,License Law for the
aU fallowing reason.(Section 0113 L5.Business end Professions Csdc:Any citym county SIGNS ELECTRICAL ❑OTHI?R
Y]3 LL Nwhich requires a permit to amstrvn.neer,improve demafuh.or repair any structure
F�O� prior to its':suance.also requires the applicant fh anal to file a sighealsonvallid SPECIAL CIRCUITYMISC.
Fs�}
that he licensed Ptt they lth ( l I ,Liovan,L (Chapter9 COMMERCIAL:
�p0 (can ncuigwith Scsfos 90ygoflNv ii 3ofthe Bc,nc,,i 1IPmfi,,i,m COde)ar I'EMP�MISI'13k Dlt POLI31N5'T.
d L e C thus he Is cxcropt thcrclinm and the basin for mita olle6eJ exemption.AnY vinlmlan of ❑NI?W BLDG/AUUI'1lON (]DIiM01.1'CION
��NSection 90315 by any applicant for a permit subjecn eche applicant to a civil penally Of POWER DEVICES E]TENANT FOOD SERVICE
t m than five hundred dollars flu)(0). IMPROVEMENT
~=6 p1.as owner of the pmpery.or my employees with wages as their tele Compensation, SWIMMING POOL ELECTRIC
will do the work,aaddw,mi,num is nmmmudedur.ffered fa,saJ(1
le(See. 44,Business ❑0'I'HI3R
{>)3Oo and Padelonnr CIA-:11he Crane n ,IJacmc Law Jrcv nal apply man owner of OU'ILEI'S-SWITCHES-PIXTUBLS
property who builds e,improves thereon,and who docs such work himself or doo.1h
his awn employees,provided that such improvemmau am not intended or offered for NEW RfSIDENTIALF,LHC R SU I4.
salc.if.howeser,the building.,impmvemem is sold within am
line 1--f cpletion.the SQ.17.FLUOR AREA 5/Sparer'.
owner-hui Wer will have the harden of proving that he did not Wild or improve for pur-
,
� Issue.).
�I,o stun,of he pm sen am exd..mey common,with licensed e.um,oO,to
omWn the p,ojc,l(See.7(W.Businee and Pmfesi...CmIG)TO,Contmcwr'e Li-
s,Law docs Dol apply loan owner of da,dy who builds or improves themnq and QTY E FEE
who constricts for such pmjecn with a eommnm(s)licensed pursuam to the Commeor's
License W, S A
1:un cx t under Sec. ,B Rt P r
ER-1) N E VALUATION
.')wnvr Dan. :
KEW S MPENSATION DECLARATION 1T (J
I hcobym
unJee penalty of pe Jury one of the Rslhmwing dedvntio !/
❑ IM1meandwi aintain a Cerificumof Consent o self-imam for Wearkdk CI S R.ROOF ST RIES E
sdion,us pnwi for by Salton 39(x1 at the l.mWr Csdc,for the performance
week liar which mitts Permit Ls issued FI "S ER
1 have
an"
will maintain Worker's Compensation 1n.arance,as required by Seclinn S T I IUTLETS 3]IpofthclaWr Csde,fonhv,,k. naacrmgmw.rkfnr which this perm' - OCC.GROUPMy Workers Comensation Insurance carrier and Policy number are: SYSTEM OVER 4 WA)Camee Policy No.:
CERI'IFECATE OF EXEMPT ION FROM WORKERSGREASEIINDUS'I'RAL WAS 117 INTERCEI'rON
COMPENSASION INSURANCE
DIVISION IEdI1S
('E'hioection need not he completed if the permit is Tome hundred dollars($I00) GREASE IRAE'
PLAN'CIIIiCK LYE
or list.)
lo,any thatnn in anymamanceo its
work for which this the W is iss'Campr- SEWER-SANITARY-STORM EA.200 FT.
i Dol employ any person in any manner nn nx w become ehjceun the Workers'C.mpen- F.NEHCY ELF.
Z cation Laws of Calderon.Date WATER HEATER WNENq:1.FCTR GRADING FEE
zQ A,pheanl t
H h
NOTCH 10 APPLICANT:If after making this Cri i'imle of Excmpeon,you should WATER SYS'ILMOTREATING SOILS PEE
become subject to the Workers Comped-tion Provisions of the Labor Code,you most
� ,•.r foolosahconidy with such pmvisionsul us, .it shall be deemed invoked. WATER SERVICE.
Q
Q'
CONSTRUCTION LENDING AGENCY N[W'RESIDIiNIAI.PLMB. SQ.FT. PAID
� Z Duro Itcempt p
G O IherehY a'Brm Orem there hacomwctinn lending agency fonM1e pedbnnanec of
LL r 'he work 4r,which III rmi Isis,S
sissue (S.30g2.Ci C) TOTAL:
Q Lendcis Name TOTAL:
U
Lender's Addms, BUILDING PEE.
y I verity that I m c read this application sad own tWt the abar<mf
.. tZ) correct.Ingres to comply with"it dty and county orllnnnees and nam laws mlating to QTY. MECHANICAL PERMIT FEF: SEISMIC FEE
L)Z buildingis.nsnumion,recd hereby-Olhnrimm,vesednlives.fthiachy On enter.pm the
aM e-aratinned pmpeny Poli inspcehon surfaces,_ PERMIT ISSUANCE ELECTRIC FEE
(we)agmc m eve,indemnify and keep hemJcss the City Of Callao against
Iiabilities.judgmeos.cons and expenses which may in any way aces,against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the grunting of this pernit.
APPLICANT UNDHkS'1'ANDS AN 1)WILI.COM PLY WETI I ALL NON.PONF AIR HANDLING UNIT(TO 100DO CFM) MECHANICAL FIi1i
SOURE REGULATIONS,
AIR HANDLING UNIT IOVIiH IILINNI CFMI CON S'TRUCTION'I'A%
Sig awmofA It •E/Commctar Date EXHAUST FOOD(WIDUCI') HOUSING ME N
HAZARDOUS VINF 3RIALS DISCLOSURE
Willi pplii i..Innate huiWiagoccupum xtnrc ar handle haeurdnunmmerial BEATING(1NI'P(TO I(NI,(XNI I3'Tl])
us Jtlimed by the Cowin o Municipal Code,Chapter 9.12,and the Hcahh unit Safety BEATING UNIT(OVER 1011,0110 BTU)
ate
Scotian 25532(-19
EE
�A'cs ❑NoVENTILA'T'ION PAN(SINGLE RESIDE PAID
kmcist
Will the applicant or future Wilding Occupied tae egmpmeat ne devices which BOILER-COMP(3HP OR IIN),fNlO BTU)
emit haruMs air ear mminauts as defined by the Bary Area Air Quality Management L.
District? BOILER-COMP(OVER 1011.00d 13 FU)
pKres ❑Nn
AIR CONDITIONER ISSUANCE DATE
have read the Call,
Su tion.2ls 5.2553 ease under Chapin understand
of the Cali- _ 4
Timm,Hchilh& e.,ry Ill a Sceionx 259115.2s my and 25531.1 to many
the
that if the NEW kESIDEiNTIAh MCC]1. S0.FT. s� 7 i
huih tJ.crr nalcu[r't ¢yam Mhyl til ix my fCvpnneihifyln nattily lhC nccupnnl
of O 1 're vhi ae�Ti mLl+li'r to issuance,,''a Ccnifcide nI(kenp-nay.
Owner nr am o zcl agentv6e
Uate T(ITAL: ISSUED BY:
OFFICE