S 0525 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,R'1'INO BUILDING-FLI CTRIGM. PERMIT'NO.
BUILDING DIVISION APPLICATION/PERMIT I'I.U1 PROJECT
lVeANIFIC C 05%25
ItU11.DLNG 1'RUJECT IDENI'I4'LCATIOy J v
SANITARY NO. APPLICATION SUHMI"(TAI.DATE
BUILDING AUURIiSS:
2-3
)W :R'S MIF PHONIF CON'IRACO S[JAMH: LI N
G�73uelG '7?-913 f� N/C CON'1xDLa . .
ARCIBITCI'/IiN NMZR'. LIC No ADDRESS ❑
CONTACT: 5 Ito BUILDING PERMITINFO
1:1Consultant Fees Paid by Applicant(initial) I- FLP PLUMB MECH
/Yl� '2 13 ❑ ❑
LICENSED CONTRACTORS UFCLARAITUN QTY ELECTRIC PERMIT FEE J013 DESCRIPTION
1 hereby affirm that 1 um licensed under previsions of Chapter 9(commencing
MZZZ with Section 7011)of Division 3 ohne Business and Profession.Code andmyhelmoris RESIDENTIAL
PERMITISSUANCF.
ffa--I- in bulli Cizand dick Lich ❑STOWS, ❑KITCH17N REh1ODFI.
<U ;iw;a
L'— Cammanr ^ APPLIANCES-RESIDENTIAL ❑ADD]TION ❑1'I.UM]HNG HE PII'li
ad on li ATIO ❑MULTI-UNIT ❑STRUCTURAL
PANELS MODIFICATION
OZNNu uhlicre UPT0200AMPS ❑INTERIOR ❑CHIMNEY RITAIR
Lroved Prnfcn.io for 201-I(X)o AMPS IMPROVEMpNT ❑SWIMNING PO(11S
Faa'Y ; OWNER-HUILDIiR UIiCLARATION OVI:R INX)AMPS ❑BATH RFMOUJi./REPAIR ❑DIiM01.i'1'ION
a:,=< 1 hereby affirm that I am exempt from the Contractor's License law fill the ❑OTHER
x L U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELI[CfRICAL
W 3 EL he which requires a permit to con',ho alter,improve,demolish,or repair any nmctme
FLL0 prior at its issuance,alto requires the applicant for such permit to file a signed smtemrnt SPECIAL CIRCUIT/M ISC.
Cy6� that he is I et,ove)pu(suam to the poreisaonxof the Comeremr's license I,.(Chapter 9 COMMERCIAL:
W.00 (commene:ng withgamia 17000)noDivisiontof(he lfusinessanl Ptofcsuonv Cade)or TEMP.METER OR IDLE(NST "W BLDG/ DDITION 4 �0,j I'I'ION
2 2 c C thm he is exempt therefrom end the naris 4rz the uBegW r,empdmn.Any violaann of ❑
W g y Section 7011.5 by any apFlicum for a permit subjects the applicant to a civil penalty of POWER DIiVIC6S AMT ❑I'UUD SFRvUF.
nm more thus live hundred dollorx($500). IMPROVIi
❑I,a%owner of the pmryny,or illy employees with wages as their sale comtpcnsmlan, SWIMMING,POOL FLFCTRIC OTFIIi{�T -
�'F'm will do the work.and the structure is not intended otufferW for sale(sec. Business OUT
a 3 Le anti Pmmxsinas Gale:The Canonical',Lice¢w Law does nm apply m an awmor of `
progeny woo builds or improves thcmun.and who dors such work hinaell at thnmgh
his own empinyaa,provided Ivor such ar
improvements e not intended or offered lot NIZW RESIDIi TIAL]iLEGI$ SG Pf.
sale.If however.the building or impovemem is sold within one yearnfcompletiao,the SR FT.FL(%)R ARIiA SISQ.PI'.
rbuilder will have the burden of moving that he did out build or Improve for oput-
rysxnLwne
❑ ass ale). L
1, of the Prnpcny,nm exclusively contracting licensed ctmtmctnm o
rename(the pojeet(Sec.7H44,Business nnA Profcxsiom Code)TTe Commeou's Li-
no Law don not apply to an owner of Pmpc,who builds or improves thereon,and QTY. PLUM BI, 'Piz IT ! F'
who connate%for such projects with a commeter(s)licensed pursuant to the Contractors
Liccnvc law. PFRMIT ISSUANCH
❑1 nm exempt under Sec. .H&P C for this rcmon
ALTER-DRAIN&VENT-WATER I. 'VALUATION
Owner D l.O �w
WORnder PCOM PENSA'ryON UP CLARATION BACK FLOW PHIITI?CP.DI!VICP.
1 hand w aRmt under penally teperjury one of the following W rker s ns
❑Ibuvc Inti willmmmuinaCcnificme of Consent to sdf-insure for Worker's Cnmpen- DRAINS-FLOOR.R(DOF,AREA,COND. STDRIIiS '1'YI'E CONSTRUCTION
sation,as provided for by Station 1100 of the Labor Code.lin the perknoun r of"the
work far which this permit is i...ra Il%TURES-PER'1'µAP
C)I have and will maintain Worker's Compcnsmion Insurance,as required by Section
1700of the Labor Cale,firth, minrmanmoldic work It), Ns
which this latit is ueGAS-EA.SY$TIiM-I INCA Of1TLld1'S
d. OCC.GROUP ANN
My Worker'sC pen�Y Jwa na currier and Policy number am: GAS-EA.SYSTIiMOVFR4(F.A)
Camicc�{-l�A�-n Policy No.
CF;RTII'ICATF 111EXEMITIONIROM WO KERS GHBASI%INUUSI'Rh WASI'Ii INTIiNCIiP1Y)H
COMPIiNSAIlON INSURANCH Hllll-DING IIIVI, ON PFi?S
(TM1issatinn neW not beatmpleted ifthe pcnnit is for one hundmlJollam 15100) GREASC'1'µAP
PLANCfIECK PIiIi !
or less)
I cenify thou perfnrmuna of the work for which lhie permil is ismnl,IshaH GFWER-SANITARY-STORM IiA.]1111 PI'' I?NIiRCY I'CH
not employ any y manner o a M1jat m the}py ke Glm}}yya
O Z nmian ornfi.DAP. B WATER IIIiATEN W/VENTRiLECfR (1HADING FEE
ti NOTICE TO APPLICANT:IL a ter m mg thm Crn(Rcam of FxemPuon.You snnuld WATER SYSTEM/TREATING SOUS THE
F become svbjat et the Workers Compcnsminn pmvisinns of the lads CWe,you mon
LYt � fonhwi(h annoy with shah pruvisionsorthie pcnnit.zhull be dccmW revoked WATBR SIiRVICI?
IIJ 0
a
CONSTRUCTION LENDING AGIiNCY NEW RESIDENTIAL PLMB, SQ.I PAID
m RactptM
V zI hemhy atTnm thigjai ixaemtnmetion lending agency forthe IF to mancell
the work for which thi.v Extent is issued(Sec.30U.Civ.C. 'I'U'I'AL:
Q U Lenders Name TOTAL
r H.1 Lender's Address BUILDING FEE
CE. I eenily that 1 have read Ibis apPlicmion and state thm the aMwon i
e inlitmwtis
.Fn ZI correct.l agree pt comply with all city and county ordinances and state laws Mating to QTY. MECHANICAL PERMIT FEE SI71SMLC ITE
U z huilding construction,and hereby uvthmiec repesemanivnvofthis city arenmr.,orme
oMrvennentioned properly lar inspection pillows. PIiRMI F ISSUANCH FI EC'I'RIC F'
(We)agree tut rove.indemnify and kap harmless the City of C.,cnmo against
lahifiiesjudgnmms,encs and expenses which may many way acerae agaitmtsaid City ALTER OR ADD TO MECH. PLUMBING EE
in nsequenee of the granting lot this Perini(.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING U NIT U U I(toigh CI'M) MFCIIANK LITH
SOURCE REGULATIONS.
AIR HANDLING UNIT DOVER I0,I100 CFM( CONSTHII TION TAX
Sign amts of App]irma/Commnor Dam EXHAUST HUGE)UV/DUCT) HOUSING N iAT10N 1':
HAZARDOUS MATIiR1AL S DISCLOSURE
Will thcapplicant or future building txupa .a
ntme or handle M1mardous malarial HIiATING UNIT ITO l(mf)00 BTU)
c
as defined by the Cupenina Muni iPal CWe,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 101.00)BTU)
Cuda
Coal,Sdu l L55321:p'f
❑Yen No VENT]LATION FAN(SING LE RES I U) PAID
Date Rcaipt b
Will the applicant or future building acupam use equipment or devices which BUB ER-COME'OHP OR BELOW BTU)
emit havardous air contaminants its defined by the Bay Arca Air Quality Management TOl'AL:
District? BOILER-COMP(OVER 101.000 BTU)
❑Yea Nn
AIR CONDITIONFR ISSUANCE DATE
1 have read the(Code,S s mans 2S5 5,2553 a umler ,1 mor 6.95 ill We Call. -
lomdan." h sty CWe,lection%25505.25531 anti 25534.1 umlervmndnoccu the NEW RCSIDENTIALM111iC11. SQ.FT.
building) .not rrundy haven ane tha(I +nsXul coactoo ufy the Poor
none stn w ' n or t � of enmrme of Gr pates.
)w c uombuui ',ngcm
Ilam TOTAL: ISSUED BY:
OFFICE