B 0165 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF VPERTINO BUILDING.ELFIC'I'RICM. PERhtI No
rtUILI)IN6 DIVISION APPLICATION/PERMIT TING pRoj Fcr ICRANICM, S0001
Illlll.l)ING 1'H(1J F;CT IDEN'TlFll'ATIUN
SANITARY NO. AI'1'LIC61'ION S1JItMl'I'I'AI.DA'I If
BUIL 1N ( lHESS: O
)WNER:S NAME: I IONL: C ACTOR'S NAM r: LIC NO: NIC /l/YnCONTROL p
i1�r / Co ❑
CI TF, d:NGINFEH:Aghnnyd I.IC NU:TQ AU�SS ./
CONTACT' PHONE:T /V lLJi•K• BYILDING PERXIIT INFO
/� _ /)r) 200 0 ❑ Consultant Fees Paid by Applicant(Initial) IfLDG 1:1.1:(:1' PLUME MIRCH
�.Q OJ!—/ I ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMPT FEE
I hereby dlina 0u.].,,I licensed under pmveliom of Chapter 9(commencing JOB DESCRIPTION
Z with Senior7000).f Dskionlof.he Inninessand Polf atone Crde.and my liecomis PERMIT ISSUANCE RESIDENTIAL'
W In full force mnd,tlent. O ��¢Z,� ❑SPDWL ❑KITCIIEN kIiVOUIiL
a U[) Liccnw Class O Lie.a APPLIANCES-RESIOCNTIAL ❑ADDITION ❑PLUMBING RE-PIP17
NQ W hale Contractor
le. ARCH[TEC'S DECLARATION El MULTI-UNIT El STRUCTURAL
F''z I understand my plans shall he used as public records PANELS MODIFICATION
ZOyn UPTO200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
OZ—O
Fly.-~.Tal Lic,nseJ Professional 201-IIN0IAMI'S IMPROVEMENT C1SWMOLINGPOQIS
�YF j
OWNER-BUILDER DECLARATION OVER IWOAMPS ❑BA'TH k1iMOUEUR1a'AIR ❑DI:MUI,ITIDN
y 6 I M1crehY nffim,the film exmnpt from the Contractor's License Law for the ❑OTHER
x O�O following reason.(Section 70.11.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL
ID
A.N which starless permit to ronmram,.he,improve.demolish,or repair any saucmre
C' pit on.....ia.arce.als"nosairen theapplicaut for such permit o rile a signed statement SPECIAL CIRCUIT/MISC.
E Y that he is licensed Pursuant to the provisions(if the Conecmr.License Law(Chapter 9 COMMERCIAL;
u1�00lennouncing with Seninn 7000)(if Division l of.he Business and l'mfcssioas Code)or TEMP.MM-RORPOLEINST.
a m e C .nut he is exempt theorist.and the basis for the alleged exnnp.ion.Any violation of ❑NI:W BLDG/ADDITION ❑DEMOLITION
Section 1011.5 by anyapplicant fora permit subjects the applicant civil penalty of PDWI:R DEVICES ❑TI!NAN'IC1 FOOD SERVICI:
n more than rive hundred dollars(S5(Np. IMPROVFMENT
SSC ❑ I.us owner of the Propury.or my employees will,wages as their vote compensation, SW IM M INC,POOL ELEC1R IC
F, ❑DI HI.R
will do the work,ouldir,accure is not intended or offered forsade(See.AW,Business
teal e'm end Profc.si'm'Code:'I he Contractor's License Law Joss not apply pr an owner of OUTI.BTS-SWITCHF,S-FIXTURES
property who builds or improves thereon,and who dims such work himself or.hn ugh
ills own employees,provided that such improvements am nm rymedcd nr off NE E 1, r
sale.ILhorever.the building or improvement is sold within one year nlamnpla. SQ.Irf.FLOOR ARIA SISQ.I•I'.
owner-builderoks
will haw the burden of solving that he did not build nr improve pur-
Pnm oLaOe').
he
poli Ne pm.70,4 am exclusively contracting will,hcco.md canto zit`
msec.theses not apply
Ou44.Business mp Professions ds crit T roves dram - nd
scLaw dreor such p eject, all aofpropeny woosedporimpnsthe Corsi�unJ QT - PI,UMBI MIT
who amtma for such pmjats with a commnor(s)licensed pursuant m the Com "
License).are PERMIT ISSUANCIi
I am exempt under Sas ,B&P C It,,this reason
ALTER-DRAIN&VENT-WATPR(HA) VAhUATION
Duro
WORKER'S COMPENSATION DECLARATION RACK FLOW PRULECT.DIivlCli
I berchy affirm under penalty of Feder,one of the billowing declarations'.
❑Ihavemel.illearnalna Cenilicwc of Canxnnn sell:inwrefor Worker'.Ganpen- DRAINS-FLOOR,ROOD,AREA,GDND' S'I'ORU:S TYPE:CONSTRUCTION
cation,as provided for by Section 1100 of the Labor Code,for the performance of the
work for which this pcnnn o Issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance.as reevireJ by Section OUTLET'S
31(NI or the Labor Code.for the performance of the work for which this premot is issued. GAS-EA.SYSTEM-I INC.a DCC.GROUP APN
My Workers soon In....coe,.,lett and Pon,'am nW WVP] — 7 GAS-HA.SYSTEM-OVER 4(EA)
Cartier: �JK D, ,J7
CEHI'IPI'A'IMPENSATION1INN FROM WORKERS' GREASI%INUIIlIAh WASTIidNTERCI:IHOR
COMPHNSATION INSURANCIi BUILDING DIVISION PECS
(Phis weiion need nut be completed!fine panni.ie Income hundred dollars(SI00) rr
or Iuss.) GREASE TRAP PLANCHRCK Flai
I verify that in the performance orthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM EA.21X1 FT. ENERGY 142E
nut mnploy any season in any Tanner so as.,become subject o the Workers'Compem
Z cation laws of California.Date WATER HEATER W/V tF;CTR GRADING PEE
z0 AI'plicam 1
.N-i NOTICIi TO APPLICANT':II:e.hr mak.ng this Cenihcntc of Lsmnp0on,you Q old WAI'FR SYS'ITM/1'RE ING SOILS Flili
Mconm.mbject to the Nbrkvh Compensation provisions of the labor Coda you meet
tiIl of comply wish such pmvisirna ar.his perind shall b,decmod revoked WATER SERVICE \s"
7Z CONSTRUCTION LENDING AGENCY NEW RMIUEIJDAL PLMIL SQZ$1'. a PAID
hale Receipts
I hereby affirm that there rs a coneecJnn landing agency tat the perfocntanct,of
WtM work car which this Pe,mit is iwucJ(See.1891.civ.C.) TO h:
O L) lender's Mone V
LemlcAAJJress T 1 x\\\
BUILDING PGI2
I cenify that 1 have craft this application and state that the above information is
t�A ccome,Iagree utcoinply with all city and annintyordinunces and state haws relating it, QTY. MECHANICAL PERMI'P ,)`)FIiE SI71SMIC ITH
C.) Z building connotation.and hereby authorim representatives ofthi.s city to enter upon the
nowtonnedioned pmperry for allocution purpnme. PERMIT ISSUANCE '\\ BhEC'fHIC FET!
(We)agree....cava indnnnlI and Ace Innmines the C'ny of Cupenlno neem.
Iinbiliticz,juJgments.toys and expense rnsyina wayaccmeagainsuaiJCity ALTER OR ADD TO MECH. PLUMBING FEE
in cnn.uWucnce of lit,6'anOng"Di r t
APPLICANT UNlotiHSTAN ND\ ILL .Y W' TALL NON-POIN'P AIR HANDLING UNIT(IO I0000CFM) MI:CHANICAI.119;
SOURCE REGULATION /�
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCfION'TAX
Slgnummot APPlicmrVCunuamor Uwe P,XHAUSTH000 IW/D(1CT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hcIardous material HHATIN'G UNIT(TO 100.000 BTU)
as dchnel by the Common)Municipal Code,Chapter 9 12,and.he Health and Safety HFA'I'ING UNIT(OVER 104.00)BTU)
Cate.Section 25512(x)?
E]Yes E]No V HN'FILA'OON FANS I NGLH R ESID) PAID
awe Receipt.
Will the applicant or futon building«',Baal use equipment or devices which BOILE.R-COMP(1H1.OR 100.00011F
ILD
.it hamnlou.a air conlaminanR us Jdined by Ne Bay Arca A'u Quality Managcmen TO
District? BOILER-COMP(OVI:R t00,(XIBBTGJ
❑Yes ❑Nn
AIR CONUI'HONIlk ISSUANCE DATE
I:ha real fee h ore.Sec mwmal.,rqui.emean under Chapter 6,95 of the B Cali
hrmiu Iluhh&Safety Croda Scnlnns 25505.25513 and 255',Id.l understand.hm if mile ryhW RCSIIII?N'I'IAL MECII, SQ.FT.
building Jrros box curently have a tenant,the it i.my resgmsibility m nrnify the sxcupam
ofthe requirements which anus,M met pnorm issuance oft Certificate'!O<cupamy. a /X
Owner or uuthoriaeJ ager Uwe TOTAL: ISSUED BY:�-��1 Iy _ T D
OFFICE
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