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S 1723
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPEWFINO BUILDING,.BLECFRICAL PH IT NO BUILDING DIVISION APPLICA'1•ION/PERMIT PLUMBING.MECHANICAL 1723 BUILDING PROJECT IDI?N'1'IFICATION 1 JILDING ADDRESS: SAIR ARY No, APPLICAI ION SUIfEil DATE 2,04 1105 NAMI3: / PHONE: (IY(' ` CONTROLp �ARCHIECf/ENGINEER: LIC NO: )t S ✓ CON'1'AC`C PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) Loa EL.PCI' PLUMB M LICENSED CON'IRACfORS DECLARATION QTY. ELECTRIC PERMIT FEL' `,$�. I Hereby alarm mm 1 am Gamed ender P,uvisions of chapmr v fcommencins JOB DESCRIPTION GCZ tis Seaion]W01 of Division 3oDhe R.......unit Prvressions Cede.and my license ix RESIDENTIAL: -00 wt PF,RMI'f ISSUANCE 0.'W mfal lora and cffcc 7578 ❑SFDWI. El KITCHEN REMfIOEL dub Licenn tfly^ I'r, APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE. ti¢a D comma n '19:26Wr ARCIf1TECPS DECLARATION ❑MUI.TI-UNIT ❑STRUCTURAL I undemtand anhull be used io blie rcntdv PANELS MOD117ICNFION CZ=� Ypan., Pu . UP T0210 AM11 P$ El INTERIOR [I CHIMNEY REPAIR F.y.tw Licensed rosecvin is) 201-10(OAMPS IMPROVEMENT E]SWIMMING POOLS Sp OWNER-BUILDER UIiC1.ARATION OVER H00AhIi'Y ❑BATH REAAj)I)fil/R 11R J.J DF 01 ION 4"`6 1 hereby allimt that I notempt from the Contractor's License Law for the K rte' cc 3 LL U following reason.(Section 7031.5.Business and Professions Cod,Any city or county SIGNS 1:LECI RICAL ❑OTHER ','�{T--�— Oy which mitnims a permit to consaucL alter,imprnve,demolish,or repair any struetnm Re prior to its ia,ranee,also rcyuires the upplicant for such permit to file usigned.mtement SPECIALCIRCUIDMISC. 2�y'' that he is licensed pursuant to the Provisions of the Contractors License Use(Chapter9 9 p�'Q7 fcommendngwiN tixtion 7lNXp o[Ilivision 3olthe Pusinca and ProfessionsCode)nr TENIRMETERORPOLEINST COMMERCIAL: d pt m K shut he is exempt Fortran .and the basis for the illegal cxumption.Any vlolution of ❑NEW BLDG/ADDITION ElDEMOLITION W^mSection 7001.5 by any.pplicurt our permn.wbjects the applicant tau civil penahy,,f POWER DEVICES []TENANT ❑1'OOD SERVICE 4y of more than five hundred dollen,($51X1). IMPROVEMENT d 0 Lasowne,ofthe Pmpeny or my employee,w'uh wngas a, lar"sole emnpcnatima SWIMMI .fLEC'IRIC F� will Jo thewore.and,hesauctme isms intended orotRrcJ forsele(Ste.9044,Business ❑OTHER W and Professions Code:The Contassai License Use does not apply to an owner of OUTLIES- HES-FIXTURIS �'a property who builds er ided ile thereon,and was Joe.such work deed or tar tnxi our his own mvc ao.the provided that arch mens Id av t m not imcnded or e8'ered for NF.W RESIDEMfL\. :L "B SO ITL'. mIe.IL hnxrver.the builJin6 orimpmvemem is sold within one year of completion,the SQ.FT.BOOR AREA ESQ.IT. mt-bolderwill have the buMen of proving the,he did not build or improve for par. saarpp M P 1 D iwaele.). 0 I,as owner of the property,am exclusively contracting with licensed contractors;ti emtstraet the project Bee.9194,Business and Profession.Code:)Ile Contractor's U .c utwdoes nm apply in anowrp nar ompany who buldsor improves,haco..and m,mQTY. PLUMBING PERMIT FEE MAY 28 AMID who contracts for such projects with a c emr(s)license(pursuant to floe Coommoss License law. PERMIT ISSUANCE l.,it exempt node,Sec. ,B A,11 C for this wastm CI Owner Data ALTER-DRAIN Rr VENT-WATER CA) AL MON WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE ^ © vt— � I hereby alllna under penalty of perjury one of tiro following deciamtinns: L ❑phare and will mainuin aCcnificam of ConunuoseiGinsurc lar Workers Comlzm DRAINS-MOOR,ROOF,AR G.GOND. SI'ORIIiS .1'YPECONSTRUCI'ION .motion,as fares idiot Jar by Section 3710 of the Labor Code,for the performance of the w a k fir which fits permit is issued IgXTUR HS_PERI RAV ❑I have and will maintain Worker's Cmaiso a non Inmrance,as required by Section 3]00 of theWMr CtNe,for the perrmmance of the mood far which thispermit .issued. GAS-IiA.SYSTIiA1-1 INCA OUTLETS OCC.GROUP AFN My Workers Comlamsattom Insurance curler and policy number no, Carrier: Policy No.: GAS-F.A.SYSTEM OVER 4(EA) CERTIFICATE OF EX EMPfION FROM WORKERS' COMPENSATION INSURANCE ❑RF.ASIIINDUSTHL WASTE INTERCEPTOR 0'his section need not he completed Bite pemmi,is tor one hundred dal lan($I(XB BUILDING DIVISION REBS or less.( GRFSE TRAP I'LANCHI[CK FEE � ——_— Iccnifythas inthePerformanceof,he work fir which this panni,is i,suvJ,IshalI SEWER-SANfI'ARY-STORM HA,200 FE not employ any peoaon in y t rte to the WorkerK Compvn- ENERGY FEE O z suntan Lasyg�L�alif.,tl'fD'F an ea_y.p�yce 'gl WATER III:ATF.R WNEM'IELECI'R Applicant' N 11 3Y7�'� O GRADING FEE h NOFTCE'IO APPLICANT:ILafte,ardim,dr,CeniGctc of Exemption,yoeehmi1il WATER SYSTEM/I'REA'I'INC, hecome subject to the Worker Compensation provisions of the Labor Code,you most SOILS FEE lafonhwithenmply with such provismoserthis prmi et shall Ex deemed revoked WATER SERVICE Q CONST is aconstruction NLENDINGng agency NEW RESIDENT AL PLMP. SQ.FII PAID L)Qkherebyfwhich thi thatpermit i is a (See3 lending agency for the pednmtance of UmKA R eipt p the work for which this permit u issue)19ec.)(197.Civ.C.) 0 (~ Lenders Name TOTAL.: WLenders Address L: el G 1 certify that 1 have read this application and smm that the above inpomtetion is BUILDING FE res eormil.I agree to comply with all city:tad c...y on inance,and x[at.laws relating m QTY. MECHANICAL PERMIT FEE V z hnilJing mmswction.and hereby authorize representatives of this city memo upon the SEISMICPEE ab ve-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agreemsave, Juntoly,tad keep harmless the City of Coperino agalnat ELECTRIC PP IJimi,ies,judgmeor m' nJ expenses which murinary way acemc against said City ACI'GR OR ADD TO MECH. in cmnseyuenceo mgr ng of this Permit. PLUh1BINf tEE APPLICA DE 'ANDS AND WILL COMPLY WIT I ALL NP I AIR HANDLING UNIT(TO 111,0011 CITM) 9DURC [C IA S. \/L/V� (/l/b] JE AIR HANDLING UNITfOVHR IB,IXX)CFh1) X Signaturcof Ppl' nJContracmr Data EXHAUS'I'HOOD(W/DUCT) ON FEE. HAZARDOUS MATERIALS DISCL09 RE H511 toe applicant m forum building occupum entree,handle humrJous material BEATING UNIT GD 1)JXXI BTU) as Earned by the Ctmenino Municipal Code,Ch,aer 9.12,and the HeAh and Safety Cole,Section 25532(a)'1 HEATING UNIT(OVER 100010 BTU) ❑Yes ❑Nn VI3NTILAIION PAN(SINGLIi RESID)Will thea licant or future buildin Deco m use equipment tar device,which Itcaa:iP,p PP d PurQuBOILER-COMP(311P OR IW,000IFTI) emit District, nus air atmammams u defined by the Ray Arca Air Quality Management T(ll'AI District? ❑Ya No BOILER VFIt I0f1,(IOfI BTU) I have real the harsrdnus materials requirements under Chapter CONDITIONER 6.95 of the Cali- ISS NCE DAT' lin'nia HedO at Safety Core,Serious 25505,2553,1 nod 25534.I mWcsmnd nisi,if the N'W RESIDENTIAL ME F. SE fT. building dres no,"hardly have a tenant,that it is my respmsibilay to notify the accup of of the reyuim nsid,which most he met Four to isuance of a Cumficme of Coo npanry. Ownermramnoroad.,car lyum TOTAL ISSUED BY: OFFICE