99100102APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATIONMERMIT
679) %5- 4 1 ^-
LICENSED CONBAC ORS IIECLARAI ION
I hereby affirm mat 1 am licensed under pruviriuns of Chalner 9 (Commencing
web 9Cctimn ]Ilq)10(Divlslunl nl me Bnameuvant ops CtPde.andmyuceroP
in full farce and effect. �a ��i/(/�_
License�C�a%�f/ep�/�Y�� Lic. N
Uote / CommcCL
AR%h CFS ,CL iC reculN
I u . r�l ty pl�.h�.�i�lie rtemdc
Lie ,W mol
OWNER -BUILDER DECLARATION
ereby affirm teal I am exempt from the Comumb is License Law far the
following reason. (Section 7031.5. Business Card Professions Code: Any City or county
which requires a Permit to constrvct, alter, improve, demolish. or repair any structure
prior tons issuance, also require, the applicant far such hermit to file a signed statement
For h. is IiCHsed Pursuant ,, m. FoMmOn, of the Coni,minr's Lic... C Low (Chapter 9
(commencing with Sermon ]LAID) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a Civil Penalty of
not more than five hundred dollars (15W).
❑ [.as owner of the progeny, or my employeas with wage., as theirskconlracto
snuou,
will do the work, and the structure is not intended or offered for sale (See.us s
and Pmfes ions Cude. The Cun.me.mr's Limiue Law dues nm appref
pruprty who holds or improves thereom, and who dues such work hrough
his own employees, provided that such improvements am nut mienred for
sale. If. however, the building or intpmvement is sold within one yearn. the
wmerTuilder will have the hunlen of proving that he did not build on put-
'in
of sale.).
1, as Owner of the onpecy. nm exclusively contracting with licectothe project ($.,.70,14, Iluxina„ and Pri le,.,ions Code') ThP',1. -
aeLawdoesnotapplytannownerofmopertywhohnildsorimprovesihe d
who contract, for such projects with a cmmmmm(,)licensed onsuanuo the Cunt> ,
License Law.
D I am exempt under Sce. . B & P C for His ..an
PLUMBING - MECHANICAL
CONTROL as
BUILDING PROJECTIDENFIFICATION
ID
DPLUMBINGRE-PIPE
[I MULTI -UNIT
�NRACf/y N�y,F:
- per,
--1
AD[ SS
c; PeAtL F, I • Vie
HU ILDINGPEMIIT�F(S
❑ Consultant Fees Paid by Applicant (Initial)
BLDG/
QTY. ELECTR IC PERM IT
FEE
PERMIT ISSUANCE
❑ ❑
APPLIANCES - RESIDENTIAL.
PANELS
U P TO 210 AM PS
201-IDCO AMPS
OVER IMOAMPS
SIGNS ELECTRICAL
Owner Date
WORKER'S COMPENSATION DIiC1.ARATION
I hereby affirm ander penalty Of perjury one of me fallowing dcclura.imxs'.
I have and will maintain o Certificate of Consenno wll-imum for Worker' -
tion, as provided for by Sermon 37W of the Labs Code: forth.- rnance of the
w k for which this permit is issued.
I have and will maintain worker's Compensation Insurance, as required by Se
J ofthe Lobor Code, for the prouniance oflhc work aur which this perm it is is
MyWar )�py/��pt�+p Imunmc. cscrierand Polity
Comer:, UriN4+ Policy NO.;
CERTIFICATE OF EXEMPTION FROM WO RS'
COMPENSATION INSURANCE
(This ocooan need not be mmplmed tithe pc.it is forma, hundred dollars (SIM)
ar less.)
I card ly tem In the p itmnnanre ul'me work for which this Penni. is-ssucd, ),hall
sun employ any Pcroon in any nnnmer so as u+h,v .PC umjcn to me Worker,' Cumpci+
C)Zsaran Lnwsml Cnllfom.. Data
Z O Applicant
IZINOTICE. TO APPLICANT: If, afmr making this Cenilicate of Exemption, you should
F become zubject m the Workers Compensation provisions of the Labor Cede, you masa
W ti
forthwith comply withsuch mwOions or this pemdt a hull be deemed revoked.
d
CONSTRUCTION LENDING AGENCY
U O l herebywhich hi that Lwued FSCnian lending agency for the perfinntance Of
� F' the work for which this pemril in issued (Sec. 3097. Civ. C.)
C ULander. Name
W Lender', Address
a 1 Certify that I have ream this application and slate that the above information is
nh c sect. 1 agree m Comply with all city and county ordinances and state laws rnaa ig to QT Y,
U Z lambing Ctnsvnel P, ad herd,finhorc,rjue,cnml se, A this city to enter upon the
above-mentioned progeny for inspection Puapo,es.
(We) agree to Five, indemnify and keep harmless the City of Cupcnina against
liebilities.judgmenu. Cass and expenses which may in any way accrue again said City
in asequence of the granting of .his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCE: RBOIII-' INS.
SigSlgroar fApdica VConlmcun O tCVCmm7i O tc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or (marc building Occupant store Or handle h tiaNmu, material
as defined by the Cupenina Municipal Code, Chapter 9.12, and he Health and Safety
C. ee Se, +n 255]2(o)?
Yes [-1 No
I Will the applicant m future building eccupin use egHi,.CPt or devices which
Put hanNnus air contaminant, as defined by the Buy Arca Air Quality Management
INYe, Fl No
I have read the ea,nnlnus materials nequimnaenPo under Chapter 6.95 Of the Cala
Icahh & Safety Cede, Sections 25505. 25533 ..it 25534.1 understand that if the
(hx�z nut ^curre'ntly hat tenant. that it is my.%Ponibility to notify the recupant
-r1U'Y9R'"`Mice �t suet pdonoissuance ofa CcrigSuRbf Ofes.
SPECIAL CIRCUS VMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWI FCHES - FIX'] ORES
NEW RESIDENTIAL ELEC R
PLUMBING PERM I FEE
NRMIT ISSUANCE
ALTER - DRAIN & SENT - WATER (EA)
BACK FLOW PI OI'ECT. DEVICE:
DRAINS- FLUOR, ROOF.
WATER SERVICE
NEW RESIDES '1'IAL PL.MB, SQ, FT.
TOTAL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 103100 CFM)
AIR HAS DLING UNIT (OV ER I This) CFM)
EXHAUST li(X)D (W/DUCT)
HEATING UNIT ITO 100.000 BTU)
HEATING LNI'r (OVER 100,000 B U)
VENTILAI [ON PAN (SINGLE RESID)
BOILER - COME' OHP OR IRLOM 1,TU)
BOILER - COMP (OVER 100.000 BTU)
AIR CONDI 'IPOSER
NEW RESIDENTIAL MECH. SQ. FT.
d - La r -QF
NIC``//((//��
CONTROL as
OKFICHENREMODEL
ID
DPLUMBINGRE-PIPE
[I MULTI -UNIT
❑STRUCTURAL
MODIFICATION
HU ILDINGPEMIIT�F(S
[I CHIMNEY REPAIR
BLDG/
ELECT PLUMB
MECH
L�
❑ ❑
❑
JOB DESCRIPTION
RESIDENTIAL:
D SFDWL
OKFICHENREMODEL
❑AUDITION
DPLUMBINGRE-PIPE
[I MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
[I CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
D BATH REMODELIREPAIR D DEMOLITION
❑OTHER
COMMERCIAL
D NEW BLDG/ADDITION [IDEMOLITION
¢'F$fANI' DFOOD SERVICE
IMPROVEMENT
OOTHER
SQ. FT. FLOOR AREA
v 0
3110 olo -o?I
BUILDING DIVISION FEES
PIANCHECK FEE
Dane
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION V
ROUSING `(NGA
PAID
I UTAL:I ISSUED
OFFICE
ISSUANCE DATE