31127W
'BUILDING DIVISION
APPLICATION/PERMIT
1(3201 -TORS AvENue
IWNER;S NAME: PI
ONLY
olou R
❑ Consultant Fees Paid by Applicant (Initial)
I hereby affirm Nat I am licensed muck, Provisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Business and Professions Cade, and my license is
in full force and effect.
License Class Lic. p
Date Contractor
ARCHITECTS DECLARATION
I understand my plans .shall he used as public retards
Licensed l'rofessimed
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License law for the
fallowing reason. (Section 7031.5, Horsiness and Pmfessinns Gyle: Any city or county
which rectums a permit to construct. alter, improve, demolish, or repair any structure
prior m its issuance, also requires the applicant for such Permit file a signed statement
that he is licensed pub manno me provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
that he is exa npt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of
net marc than five hardest dollars (5500).
0 I, as owner of me property, or my employees with wages as their sole compensation.
will do the work, and the creature is not intended or offered for sale (Sec. Business 1
and Professions Code: The Contractor's License Law does num apply ,, mm owner or
property who builds or improves Hereon, and who does such work himself or through
hisemployees, provsuch ided that ch immc
ms,%i nts are nm intended m offered for
sale. If. however, use building or impowemcrt is.sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
El I, as owner of One propeny, on exclusively contracting with licensed conduction to
construct he project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense law dors not apply to as owner of propeny who builds or improves thereon, and QTY.
who contracts for such projects with a contraour') licensed pursuant to the Comracmea
License Law,
D 1 am esemp)ypyr�ec,/ , B & P C for this mason
I herebycorm under penalty of perjury one of the following contortionist
❑ Iheveandw I maintain a Cenificam of Consent to self-insumfor WorkdsCompen-
sation, ms provided for by Section 3700 of the Laher Coco, for the performance of the
work for which this, permit is issuW.
❑ I have and will maintain Workers Compensation Insurance, as commit by Section
37M of the Iahar Code. for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance canner and Policy number are:
Cancer: ' Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
('Iris section need net be rompleted ifthe pemdt is forum hundreddollan ($1 100)
or less.)
I certify that in the performance of the work for which this permit is issued, l shall
not employ any peram in any manner on as or become .bj., m the Workers' Catalan -
infirm Laws of California. Orae
OO Applicant
F7 NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
hencenrom subject to the We Compensation provisions m the Labor Cole, yon muss
forthwith comply with such provisions or this permit shall be deemed revoked.
0
CONSTRUCTION LENDING AGENCY
U O (hereby affirm that hem is it construction lending agency for performance of
Da F
the work for which this permit is issued (Sec. 3097, Civ. C.)
Q U Lender's Name
Lenders Address
f.., 1 terrify that I have mad this application and state Nm the above information is
F -I (A corerl agree to comply with all city and county ordinances and state laws reaming to QTY.
Cl ,Z building conservation. and hereby emharire representatives of this city to came uWn the
above-mentioned propeny for inspection purposes,
(We) agree to save, indemnify and keep hnmticss the City of Cottonton against
liabilities, judgments, colo d eapvtseswhich may in anyway accrue against said City
in consequence of the n Mlhis mit.
APPLI "' UN T S , D r I ITE ALL NON -POINT
�S ce G
�
am of ahcmo Cantm xr Data
Wil he applicant or future building occupant store or handle hazardous material
as definedy the Chinaman Municipal Code, Chapter 9.12, and the Health and Safety
C e, Sec , n 25532m)+
❑Yn SIN.
Will the applicant or future building occupant use equipment or devices which
mit haza,daus air contaminants as defined by the Bay Area Air Quality Management
District?
C] Yea
1 have mad the har Nous tamarisk tnquirements under Chapter 6,95 of be Calm
forma Health & Safety Cade, Sections 255(45.25533 and 25534. 1 understand that if the
building docs not currently have a mount, that no, my re,,senhility to nmify the e..Paul
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS
SWIMM INGTOOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS SQ lT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALPER - DRAIN & VENT- WATER
BACK FLOW PROTECT. DEVICE 7
DRAINS- FLOOR, ROOF. AREA. CONE.
PINTURFS - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEW13R - SANITARY -STORM PA. 210 FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMU SQ. IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT DO MOM CFM)
AIR HANDLING UNIT (OVER to,=) CFM)
IMIAUST HOOD 1W/DUCT)
HEATING UNIT(TO I00.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. PT.
TOTAL:
OFFICE
C
3112
TION SUBMI'FTAL
LS—
DNTROL#
_ j—
DNTROL#
V l I
IIT INFO
.UMB MECH
❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
.E3SFDWL
D KITCHEN REMODEL
DADDITION
OPLUMBING RE -PIPE.
D MULTI -UNIT
OSTRUCTURAL
MODIFICATION
S�INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODRUREPAIR D DEMOLITION
D OTHER
D�IEW BLDG/ADDITION C1 DEMOLITION
TENANT El FOOD SERVICE
PROVEMENT
❑OTHER
SQ. FT. FLOOR AREA
PAID
FEE MAR 25 RECD
CffY Ur uuml-11INO
5/SQ. FT.
STORIES TYPF.CONS
OCC. GROUP APt
B 'rDItISION FERS
PLANCHECK FF NV
ENERGY FE
GRADING E11
SOILS I iE
PAID
D e Receipmp
TOTAL:
BUILDIN FEE �
FEE SEISM FEE C
ELEC RICFEP. l
PL BING FEE
MI HANICAL FEE
Cl UCTION TAX
HOUSING IGATION FEE
PAID
Date Receipt p
L:
�fIISSSLI,ANCC DATE