99100070 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I 1 0b
CITY OF CUM—RTINO BUILDING-ELECTRICAL. N .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENOnfiCATION S0001
BUILDING ADDRESS: SANITARY NO. APP LICATIONSURMI3TALDATE
NER'S NAME: PHONE: CONTRACTOR'S NAME: IAC NO. 10-13—P7
l N/C COM'ROLIf
ARUDOECT/ENGIN R: LIC NO: ADDRESS: J ❑
CONTwC1': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ;z, ❑ ❑
QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 nm licensed undo provisions of Chapter 9 my license
SOB DESCRIPTION
��2 withSection
eade tf Diviaion3 of'M1e Rosiness and Professions Ode,and my licensees RESIDENTIAL
FWD in full force and effec{�1�k� PERMIT ISSUANCE
a U V License flosg Lic.x ❑SFDW L ❑KITCHEN REMODEL
vFiGi Dam S�"�—Comraclnr APPLIANCES-RESIDHNTIAL Cl ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION
r ti Zzs 1 understand my plans shall be awaits reco
s public records PANELS ❑MULTI-UNIT ❑STRUCTURAL
UPTO200AMPS MODIFICATION
F 4,F.,� Ltaensed Professtonnlff ❑INTERIOR ❑CHIMNEY REPAIR
6 `J OWNER-BUILDER DECLARATION 2111-I WO AMPS IMPROVEMENT (]SWIMMING POOLS
1 Q I hereby arn that I am exempt from the Cameroon's License Law for the OVER 1000 AMPS 11 BATH REMODEUREPAIR El DEMOLITION
3 d F fallowing reason.(Section 703 L5,Business and Professions Cada.Any city or county SIGNS ELECTRICAL ❑AOT'HER
which requires n Permit to eonsurct,alter,improve,demolish,or repair any svecture /�
Prior to its issuance,also requires lheapplorgt for such permit In flea signeJmamment SPECIAL CIRCUIT/MISC. t�r"
Ilial he is licensed pursuant m the previsions of the Contractor's License Law(Chapter 9 /y Mtn
00..00 (commencing with Section]000)of Division 3.t the Holiness and Prnrexsions Code)or - -
TF.MP.MGfER OR POLE INST COMMERCIAL'
d y M C
that he Is exempt mercfmm ane the bathed
basis far e allegexemption.Any violation of E]NEW BLDG/ADDITION EI DEMOLITION
Section]03 LS by any applicant fora pemtil wbjects the applirnm macivil penaltyef POWER DEV ICES
yy n more than five handfed dollars($500), El TENANT ❑FOOD SERVICE
G ❑1,as owner of me property,or my employees with wages as'M1cirsnle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not imended oroffered forsele(Sec.7044,Business ❑OTHL'R
W and Professions Cada:The Comment,',License Law does not apply la can owner of OUTLETS-SWITCHES-FIXTURES
property who builds or impmvrs thereon end who docs such work himself ar through
his own employees,provided that such improvements and,not intended or offered for NEW RESIDENTIAL ELF.CTR
aide.If.however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA 5/SQ.IT
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors In 'TOTAL:
constata the pe jest(Sec.7044,Business and Professions Cade;)The Cantr..... Li-
censeLowdoesnotapplytoanownerofpartially who builds or improves throne,and QTY, PLUMBING PERMIT FEE
who contracts for such Projects with a emaraceu(x)licensed persona m the Contractors
License I.tw. PERMIT ISSUANCE
❑I ora exempt build,Sea ,B&P C fm this reason
AuerALTER-DRAIN&VENT-WATER CA)
Date VALUATION
WORKER'S COMPENSATION
an DECLARATION BACK FLOW PROTECT.DEVICE
I herebylloffinin
useunder penahyte perjuryoneofthefollowing orkerJon:
❑om a,and will for b, ection 3 me ofConsent a self-iCode,f tfor Worker's Comfce of the
pRA1NS STORIES TYPB CONSTRUCTION
sereno,os provided for by Swann 3900 of the Labor Coda for the performance of'M1a
ark fordh this permit is issued.
El 1 have and will maintain Worker's Compensation Insurance,as require
a
3700 of me Labor Code,farthe pertbrmanee of the work for which this pe %0.WAkM-IINC.4O S OCC GROUP APN
My Wnrkers Compensation Instmnce currier and Policy number xre: �\����
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE PA 1 I A ;PfOR
(This se,tinn need no'be complawli[the permit is forone bundtW dollar(E HrILDING'DIVI9ION FEES
ar less] G .ETRAP -
as" .PUANC I�HCK rf0
toy any metro the Isaftarreamdaymardo,10 stobekfor subjectla to the osissued,Ishall
not employ any Interim ony rnenner so as m bocomb subject m the Wnrkers AR
'NFR�Y FEF. � .
,Z. Applianwe of California Dote T E /ELF,CTR / t {{t
O O Applicant I 6t
7 GRADING FF:E 6
q y N(]TICF.TO APPLICANT.If,afmr making this Certificate of F.xem tion,y hoe '4
P WATER SYSTEMITREA'fING
become subject to the Worker's Compensation Provisions of the Labor Code,you muss e,13ALs 'E
Liz `-t forthwith comply wish sbch provision or this penult shall be Deemed revoked. WATER SERVICE
0
:Dz CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.IT PAID
I hereby affirm lhnuhere is aconswciun lndingagencyfortheperftermanceof D Hie 1pl#
O ethe work for which this permit is iasued(Sao 309].Civ,C.)
U O Lender's Name V] TOTAL:
� W Lenders Address TOTAL:
" Fy 1 certify that i have read This application and state that the above information is BUILDING FEE
N correct.)agree to comply wilttall city and county on inances and state laws relating to QTY, MECHANICAL.PERMIT FEE
L) Z hada muniNrepresentatives of hereby author..representativof this city to enmr upon the SEISMIC FEE
above-mentioned properly for inspection purposes. _
(We)a a to save,ancient p yo pe againstPERMIT ISSUANCE gre y and which
harmless the Cit of a nine i ELECTRIC PEC
liabili'ies,juire ofts,costmid,expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in con.ceyuence of'he graining of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT SOURCE.WiG�TIONS.. AIR HANDLING UNIT(TO IO.Ofp CPM)
SOURCE REG TIONS. MECHANICAL FEE
A AIR HANDLING UNIT(OVER 10,Wt1 CFM)
CONSTRUCTION TAX
Signature of ApplsanV on ctor 1,1� Da EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume,building ocebparn station,handle hafarma,material HEATING UNI'f(TO I up,nod Bq'U)
as defined by the Cupeaimt Municipal Cale,Chapter 9.12,and the Health and Safety
Come,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes 7 N
VENTILATION PAN(SINGLE RESID) PAID -
Will the applicant ar future building occupant use equipment or devices which Dam Receipt If
emit haaanlous air 000mmi...is ax daflned by the Bay Area All Quality Management BOILER-COMP(3HP OR 100,000 BTIp fol
District TOTAL
❑Yes EINo BOILER-COME(OVER 100.000 BTU)
1 have read the anomalous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomiu Health&Safety Code,Sections 2550.5,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building fres not currently have a tenant,thin it is my responsibility to notify the occupant
of the royuir meats which mus'be of prior m issuance of a Certificate of Occupancy.
Owner ur ainhori.d agent Ua'e TOTAL: ISSUED BY:
OFFICE