S 1224 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CU]aERT]NO IIIIILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATION/PERMIT 1'I.IG PROJECT ID11ANIFIC 1224
BUILDING 1'R(s.IRCT tUls I'II+KATION
11111LDING ADDRESS: - SANITARY NO, APPLICATION SUBMI'ITAI.HATE
as v CLue,,.,,µ.�.� G',� �� -L (0,0
OW IfS NAME: PHONE: C R IOR'. AME: LIC NO:
NIC COWROL0
,AKCI 1iCl/1 'GINI?F.R: Tor.NO1 ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACD)R;q DECLARATION QTY ELECTRIC PERMIT' FEE
I hemny.from that Turn licensed under provisions of Chupmr 9 wounmencing JOB DESCRIPTION
Qain full larcenist effect.Z with Section 701Xdol Div m.3oflnes
he Bueisand Prou(nfessiCavn
lwdmylicomois RFSIDENTIAS
T--ca 1'I?RMII'ISSUANCI?
WF ❑SFDWL ❑KITCHY:N REMODEL
�UULicense Class hic.N
7APPLIANCES-RESIDE;N'TIAL ❑AUDITION [I PLUMBING RE-PIPE
rF�TW Datc Canlmclnr
LL ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCfURAI.
F.7y PANH S MODIFICATION
Z O r2 Z I understand my plans shall be used as public records
OZ—m UP TO 20OAMPS [I INTERIOR ❑CHIMNEY REPAIR
r- nt'.W Licensed Prafessirml 201-1000AMPS IMPROVEMENT SWIMMING POOIS
OWNER-IIUILDP.R DECLARATION OVER INTO AMPS El BATH :MOUIiIJREPNR [I DEMOLITION
1 hereby affirm Thal I am exempt fmm the Combat Liceme I,aw for the
NiyyiS5OyU following reason.(Section 7031.5,Business and Professions
Code:Any cityor county SIGNS ELECTRICAL ❑OTHF
a in which requires a permit to construct,alter,improve,demolish,or repair any stmeture
I"=co prior to its issuance.A.so requires me applicant[arsncb perminolle a signed statement SPECIAL CIRCUITIMISC.
� y -1 mmheis B[ensedparsm.nn.the pmviviansmfthe amtmemrx Litems L.w(ampter9
W 1:1 (commencing with Section 7001)of Division 3 ofihe Business and Professions Code)or TEMP.MITI!R OR POLE INSr. COMMERCIAL:
E a�X m C that he is exempt therefrom an I the bais far the surged smmpti.n.Any violminn Of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by imyapplicval car.permit subjects the applicant toe civil penanyof POWERDEVICES ❑'TENANT ❑FWD SERVICE
not more than five hundred dolbtrs 145 W).
(-Z P IMPROVEMENT
Spa ❑1.as owner of the pummoy,or my mmpinyecs with wages as their suit annpensation. SWIMMING POOL ELECTRIC
p., will do m
the work,and lhennicm is not intended Or offered hsr.sale(See 7014,ausiness. [I OTHER
and Professions Cale:The Contractor's License law does not apply to an Owner of OUTI,17S—SWITCHES—FIXTURES
propeny who builds Or improves thereon,and who dress such work himself or through
his own employees,pmvided(bat .,It Improvements ore not intended or uttered for NEW RES ID17N'I IAL ELECfR SQ IT
sale lf,howeven(lie building Or improvement is sold within One year ofcomplellon,the SQ.FC FLOOR AREA VSQ.PT.
neebuilder will have the hunden of proving that he did not build Or improve Tortoni. P A B D
pox Of sale.).
i] I,as owner of the properly,um exclusively contracting with bounced enntmemrs to TOTAL
onsnuct the pnhjed Sec.71034.Business and Prof sions Code:)The C'ontractor's Li. FEE FEB 1 D ANS'D
toe Law does mol.poly em an owlnr of propcny woo n��Rdx ar in,provc.,mercun,and QTY. PLUMBING PERMIT'
who contract for such psojeons with acon(mearno licensed parsunnl to the Contmnnr's
License La, PERMIT ISSUANCE
❑ I ant escmp(under Sec. ,B&P C far this mason CITY Ur our Cn Iim.
ACT ER—DRAIN&VENT—WATER THAT VALUATION
mer U:ee
)RKER'S COMPHNSAT N 1)f I.ARATION BACK ROW PROrIiCT.DEVICE
Ihr yafl nunder pen.hy of perjury one the following Jalamtions:
I have and will maintain a Certificate of Conse(n(o self-imme for Worker's Campton- DRAINS—BOOR,R")EARHA,COND. STORIES TYPECONSTRUCTION
su(inn,ns provided fur by Section 371X1 of We L.tn Cale,lin We perfarmvnce of the
work for which this permit is is,ucd ITX'I'URP_S—PER TRAP
1 have and will maintain Worksts Compen.antion Insurance,as required by Section
370X1 of the lahor Cale,far the performance ofthe work for which this perit is issued GAS—IiA.SYS!fFM-I INC.40V1'LErs OCC GROUP APN
My Worker'.Compensation Insurance carrier and Policy number are:
C...or: Policy No.: GAS—EA.SYSTEM.OVF:R 4(EA)
CERTIFICAT'It Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS[ONDOSTRI,WASTE INTERCEPTOR
BUILDING DIVISION PEGS
(This section need not he completed if the peril is forme hundred dollars(SI(10)
or kss 7 GRIiASE'fRAP PLANCII[CK PI:P.
I cenily(hut in the perlisranceofthe work tinwhichthisperi(ixisarJ,INUB SEWER—SANITARY—ti'FORMEA.2(R)Irr.
oat employ nny person in nny inonnm sn ns w become.enbjed to the Wodem'Cnmpen- ENERGY FEB
O ,� salon Laws of C.1ifomi..Date WATER HEADER W/VENTiELECfR GRADING FEB
Z Applicant
fA
NO)ICH 10 APPLICAN I':It,afte,makin,this Certificate of Exmptinm,you should WA'1'I7R SYSTI?M/FBEAT'INC,
become subject to the Worker's Compensation provisions at the Labor Code,you must SOILS FI:E
kK � forthwith comply with such provisions Or This pcoml 0.11 he deemed revnkcd. WATER SERVICE
Q
UO
CONSTRUCTION LENDING AGENCY NEW RESIOF.NTIAI.I'LMR. SQ,FF. PAID
r
I hereby offthatnt them rotor isvemstrvnian lending agency fnnhe perfnraOce of Dam keccipt#
time work for which this permit is ismed(Sec.9097,CW.C.)
Lender's Name AI.:
L) Lender's Address 'TO'TAL:
'� "I 1 unify that I have rend on,applicalian and smm that the.lune information is BUILDING FEE
Cis
C4.1Z) correct.las=to comply with all city and county mdinvncrs and smhe laws relating to QTy.. MECHANICAL PERMIT FEE
UZ hoilding[umauctiomand hereby umhonzercn,...btivesofffikeity mentor Upon the SEISMIC FEB
above-IOen(io.ed properly Ior Inspection purposes
(We)eg.to save,indemnify and keep hnmdcss the City A Cu"ano againstPERMD ISSUANCEL'LECTRIC FIiP
liabilities,judgments,costand expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in ronsequence Of the granting Of this permit PLUMBING 'E
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AT R I IANDLING I)NIT M)10,01X1 Most
SOAR EGULATIONS. �^' MECHANICAL FL•E
/p AIR HANDLING UNIT(OVER IB,M)CFM) CONSTRUCTION AX
Slgnamr A, ciatoCruntralmar Date F,XHAuS r HOLD(W/)UC) HOUSING MITIG FEE
HAZARDOUS MATERIALS VISCI. IRE
ill the applicant mlbmm building m[uparra onto or handle unudous material 177 HEATING UNIT(TO 100.1t BTU)
as defined by The Culxd ims Municipal Code,Chapter 9.12,and the Houldi and Safety
Cale,Section 25532(a)7 1WATINO UNIT'(OVER I000H)[IT[))
❑Yes 0 No
VI?NTIIATION PAN IS]NGLI?RI?SID) PAID
Bat Re[eip
Will the
us air applicant or furore holding by die B use ea Air Qu m devices which BOILER—COMP(3HP OR 100,0(X)BTU)
emit District?
ous tar ninmminonts as Defined try We Buy Area Air Quality Management TU'AI
Dislncl7
C]yes 0N BOILER—COMP(OVER I00,M)BTU)
I have read(he Incomaus mammals reptummems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE:DATE
fomia luelth&Safety Cde.Sections 25505,^_5533 unit 25534.1 understand That il'tho NEW RESIDI?NTIAL MECIL SQ.FF.
huilding dwv not comity haven tenant that it is my rcxpnnsibility m nosily the pan,,m
of the nts requiremeshish mon ba nm(prior m issuunec of a Ccnillcmo of Ouupuncy.
Owner or authumved agent Date TOTAL: ISSUED BY:
OFFICE