22471 APPLICANTTO FILL IN INFORMATIOPd WITHIN RED LI
NES — USE BALL POIfVT PEM OWLY
eulldin Proce�demi(Icalion PIiN.WTNO.
Bullding Add�ce:^� �� �� � , Z 2 4 71
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wmre ame: onr. , p
� (,� CITY OF NPERTINO-BUILDINC DNISION � �1 � ^
� � co� ttm.H.�: _ c��.No: AppLICATION I PERMIT � ��1 ,'
:r?1t�/Fngiker, k o. B�LDINGF7.EC7AICAU7'LUMBMGMECFIAMCAL CA7EGORY CO �XO
Q7Y ELECTRICPERMIT �g BUILDINGPERMITINFO ''
Aadre..: - �
' I'F72h9i75SUANCB �T�Qu
LICENSED CONTRACfOR'S OCCLARATION
IM1ercbyaffirmthallamlkmecdunderprovlalon�alUapmr9(mmmrn API'I.IANC6SRF9DEM7AL ]OBDFSCItQ'170N
IngwltM1SeMon7000)of DiWdon3o(1heButlneseand Pm/eeslonoCode,and my
u«�k isi�r�u�o.�,,,a dr�. / rnxos / .� h}�p�.,C��•7
Lkenx Clam Llc p
Oale- CantnRor
ANCHITECI'SDECLARATION p�"�� �
p�+�7. Iunderehndmyplavelu116euecEapubllcrtwrtl� OVER1000AMI'S SQ.Ff.FLODRARFA 5/SQ.FI'.
k�Z LlcenxdPro(enlowl 9GNSELFf7RICAL � O C� D _ ��� �
� bWNCR-BNLDEX UECWRATION
�"n< ' SPFGIALCIItCU1T/MISC � �.OD '
zp.,�a Ihembya(firm/FutlameKempl(romtheConlnRorbLlcenxGwtmthe �
(ollowing rc+san.(Settlon 7m1S,Buelnese and Pm(enlona Code:Any tlty or
' O�F.� 1II.SP.MEfOtOR['OLEINS7.
rr,� cauntywh(chrtqulreeapermkfomvtruqalter,lmpmve,dertnlbh,orrtpalr
q anyetmctureptlorroltebs�ance.alwrtquimMeappllcvit(onuchpertNno �pWFRDEVICFS
P� � flle a elgned etatement that Fe V Ikeneed punuant to Ihe provblo�u a( the ��
�Dµy CantnctofeLkemelaw(Clupler9(romn�encingwltM1SecMon7000)otDlvl-
Q�+OJ slan3oflheBuelneeeendPro(embvCode)arlhatheleezempttFemlmmand SWP/h9NG7'OOLELLC7R[C . y0. A N
�0 5 tM baeb(or the alleged exemptWn. My Wolatlon of Senion 7Q71S by any OIJILETSSW1TCtIESFlXIURFS 3 � ��a
appilmnt(ara pertNt eubjMe Ihe app0ont loa dvil pevlty d nU rtnmtAan
A� !We hundred doihn(;5(1%.,
NEWR65IDEN17ALELECTR_SQ.FC. $'['ORI6 'fYPGCAN5fRUCTION I
� �I,ee mvrer o(tFe pmpeity,or rtry employcce wlth wagn u thclr eok
compeneaHw,w111do1heworka�dlhestruRurcbnoHntendedoro!lered(or� ' � � /�
�0 eale(See 70CA,Buelnco aM Pm(emlo�u Cade TM1e ConhaRor�Llceve Gw ��
$ docanolapplytoanawmro(pmpe�tywM6uildsorlmprovnthereoRand � ��
�5^ whodoeeeuchworkhlmeelfwthmughAlaownemplqeee,prwWedthatwch C S
improvemenb are not Intended oro((ertd(onale.If,Fmvever,lAebullding m 70TAL:
Impmvementle�old wltFln oneycam(cmnpletloqtheowner-bulldcrwlll Fave
tF�urdeno(pmvingthathedldnotbulldorimpmve(orpurpowotuleJ. Q'['y, PLCIMBINGPERMIT �' p�ppD I'
U L a�mvner o!Ihe Pmperty,em exclueively mntncHng wllh Ilmnsed PERMR LSSUANCE TE
mmntton ro mruwR the pmjeci($ee 7064,BueNm and Prolewloro Cade: ��
The CantnRar'e Llanee law doea nat apply m�n owner ot prope'ty wha qLTFR�DMIN k VFM-
Eu1Ws or Imp�oves tFueon,anA who mn<nm (w such p�okah wllh a WA��
rqfl{�actor(e711remed punuant ro Ne Contnctor'�Gcenm Law. FEE SUMMARY
LJ� �m evempt uMer Sec. B&P C (or Ih6 rcawn BAIX FLOW PROTFCT.DEl7CH
' Owner Dale DRAINSFI.00RROOP,ARCA,CONU. SAMTARY Y_ N_� �
RECFII'f N
� �WO0.1QdANCOMPF2�SAT10N�ECLARATION �,��5���.�� � $p{ppLTA% - Y N
PAereby aRlrm Ihat 1 Fave a rnrtlliate of coment to ee161nmre,or e . �� RFTE�7'M
i:rtl(Iceleo(WorYen'CompereaHonl�uunncewecertl(Iedcopythemo!(Sec. GASEA.SYS'1'EM-1INC.60U7LEI'S PAWCFEE Y fY
3800,Iab CJ RFGDI'I M I
Ibllryi CAS£A.SYSfFM-0VFR I(FA)
Co�mp ny 6UIL1)INCDIVISIONFF.[S
�CertltledcopybFertby(umlehed. GREASH/INDU5IRLWASTEINTERCO'7OR PLANCHHCK�EE �
Cetlltled copy Lv(iled wilh the dty I'upeRlon dlvleion. ,,.�����,,. ,,,///��� i
CERi11lGTfOFIXEA1PfIDNFROMWORKENS' GREAS8IRAP �A'�'l�tC�4L �� �g�
COMPENSATION INSURANCE S�g-snMy.,�iwsrorsht En.lcpm�. Datc RCCCI �N
RM1laxtlion need nU be complMed if the perMt b(oro�hundred dollan
a10°>ar1�.� �yp�����y�����d�� LNGRCYFEE Y N �
ImrtlfythaHnlhepeAomanemf�hewmk(arwhlchtFlepertnlHebwM, — —
I aFall not employ any penon in any rtunner ao u 10 become eubfe t�o�he I W`��y�5�£At�7REAnNG ` D� PAID
Wwken'CompenutlonLweolGll(ornla.Date
Z Z NOTiCETOAPPLICAM:If,aftermaYinglhbCenlflaleofFsemp�bn,yw '�W�DFMIALPLMB. :OFf. DBfC �Zett'i tM
� � chwldbecomeaubpntalM1eWorken'Compe�uatbnprovblomoflheLabor TOTA •
ua
� N Code,youmustlortM1withmmplywltheuchpmvlelo�uorlhbpermibhalibe U N
W 7 deemed revoked.
a p coNsraurnoN�woinc ecwcv SEISMIC FL•B �
IherebyaRlrmlhatlherebam�ut�ucllonlendingagenryforlhepeAorrtr �O CLLC7'RIC[�.0
� Z anmo(thework/orwhlchtAbpermlthba�ed(Sec.3097.CIv.C.) TOTAL: 3 `•
(� O- liber'e Name PLUMBINC FEE
LL1= l.endcr'aAddrees QTY. MECHANICALPERMIT �C' MECHANICALIEE
OW Iwnifythatlluvcrcad�hieappllraHonandsmtethaltheaboveln(ormaHon �
a umrmct.lagrtelocomplywllhdlqtyandmuntya�divnmaandp�telawe I �'�RLSSUAKCE S• �'���/���:
} relalingmbulldingroroWcflon,andFcmbyauthatlurcprceenhlivnoltF� I C7
� Z tltytocntcrupontheahpvo-menllonedpmpe�tyfarLupectlonpurpuen. I AL7IItORA�D70MECH. (� �O nafC RCCC'1 �a
� — (We) ee�o eave,Iddemni(y an d kcep harmleea the Clty o(CLpeMlno
a abl0tlee a,m eandexpeneeawAlchrtuylnanywayacc'ue AIR}fANULINCUMTQOt0,000CPM) 'SUBTOTAL: S
Sgal teal Inro • n (thegranHngMlhbpermlt.
� �,q �1�!�p4 f�. n[xrurrouNcun�rrrovrxio,000crM� CONSTRUCTIONTAX
X Slgmturco(Ap �,�eico�n� . ' D.�m IXHAUS'fHOOD(W/DUCp CONSTRUCI'IONTAXPAID:
NA7ARDOUS MATCRIALS UISCLOSURE
Wllliheappllramor(umrebulldingorcupantemroorlundleFavrdow EIFATINGIIMT(71�1q1,00U6i1n n�fe {ZBCCIOI�
rtuterlal ae deMed by the Cvpertlno MuNtlpai Code,Ch�pter 9.17,�nd thc
fle�Ynd9fetyCodr,Sectl�on7553ZU)7 FIGATINGIJ�TT(OVFRIW.0009TIn TOTAL: Q
Illthcappllanto4turebuitdingaccupantueeequlpmenlordevices z ��nW770NFANlSINGLENES[D) , O ISSIQ'Qi1�ATG
whlch eMLhaz�rdaw nlr rontaminanb ee de(Ined by tFe 9ay Arca Alr '
Q,all�y Mamgement DlntdiYt BOILER-COMP pHP OR 100,IXq BT[n
i. �•o ❑No QFp G� �QQ�}
vercadlhehazarcTou�matcrlal+mquircmentsunderCM1apterG9iaf. 60fLEft�COMP(OVHR100,000B7i1) Y>r � V p7��•
�c Glllornla HmItF&Sa(ecyCode,Senlora 25505,25533 and 755k.t .
undenbMlhaH(thebulldingdcesnolcurrentlyhaveatenanq�hatitbmy N6WRF5lDEN77ALMIiGi. SQ.IT
resporeibility to ndlfy the occupant of lhe requircmenb whlch muel be met �����
prlor tu Lssuance M a CeNNn1e o(Occupanry.
r
Ownrronulhorlecd agmt , Dam ��'D a
7'OTnL: ISSUHD BY:,�,�
OFFICE COPY