99080160 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
E
P6RTIN0 Bill] )ING-ELEICHKICAL ?RM1 f
AP PLICATIONmERMI'1' rl.ummur..Au:cnnmau.
IVISION BUILDING PROIF,CT IDI:N'TIFICATH)N
\/l0I V�. ���� I ^ tiANI'IARY NU, nl'I'LICnI'I<)N ti11nMIl'I'AL Dnf
GSS /OL jl.%-� 2 3LIC NO:WNR '110NE; COM'RACfOR'S NAME: NIC CONIR06N
aCIII'I'ECDENGINEEK: LIC NO: ADDRE\ti:�,^ �f ❑
O\kms BUILDING PERMIT INFO
CONTACT: ✓I' Ga: PHONryE: �1 G
I / (y"'7- ❑ C(nmuIImrt Fees paid by Applicant(Initial) RI.OGELLC'I' PLUMB MECII
Sb�! SO) S CO✓ 0 ❑ ❑ ❑
LICENSED CON I KACfOR$LaEi LARATION QTY ELECTRIC PERMIT FF• JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing R• F TI -1
SC�1C%Z lh Smtlon7Wf,I'Ulvision3nl'Ihu ltusinass and i'm[ansi.ns Calc,anal mylseenxu is pl?HMI'T ISSUANCE Sppgrl, ❑KT'I'CHEN REMODEL
1cc) .full Tante anal coact. C f
IQF--UV Li¢nw Cla l I-1a.It APPLIANCES []ADDITION
❑I'hUMBING RI'rl'il'li
InZW Date Cammam ❑MULTI-UNIT ❑SI'RDCfHRAI,
ARCHITECT'S DECLARATION PANI71-9 MODIFICATION
zonz (undersand at,plans shall he used as public records UPT02(X)AMPS C1 INTERIOR YICIHMNEY REPAIR
Z Licensed E'm&wiood 201-INX)ANIPS IMI'ROVF?ML'NT ❑SWIMMING POLLS
OWNER-BUILDFR DECLARATION OVER la10 AMT'S ❑BA'T'H RF,MOI1? REPAIR 4DEMOLITION
l`
C 9, I hereby off..Inas 1 am exempt from the Contractor's License Law for the ❑OTHi
X O 6 U billowing maNA) w f w { -ffa�4f
1+13 W y whim rcquirts a pannii ,,construct,alter,improve.demolish.m repair any snucture
�, plot u,.I,i"amose.aborequims heappEcam Wr.uchixrmit to Glc:aignca Immanent SPECIAL CIRCUI I lMISC �Jy n •^". •.VJ<
> that he is limned Punuam to the provisions of Ne Contractor's License Law(Chapt'r9 COMMERCIAL,:
==D 2O (commencin -th Section 7")of Division 3 of the Business and Professions Code TEMBMETERORPOL NST. El NEW BLDG/ADDITION CI DEMOLITION
LyeW that he is exempt I manam and the basis for Ne alleged exemption.Any violation of ❑TENANT ❑FOOD SERVICE
w Seariun 7()31.5 by any applicant fnr a permit subjects the applicant to a civil penalty of POWER DEVICES
W
I mnry than five I..ndral dollar.($MXE. IMPROVEMENT
a WIMMINGH OL1?LECI'RIC
will
Lmhe work.the the Car inemyot intended with cared for sale
S ❑OTIBiH
p., will Jn the work.and the nmttum is not intended oroRcnN 4a sole lSecA(Hd.Business OUThET -SWI I'CHFS-FI%TURPS
W 3 m and Prof."mu Cock The Conlmcmrs License Law it.,na upply w an owner of
p..;oy woo builds Cir improves tberenn,and can.does such work himself or through NE FSIDENTIAL ELECTR SO IT.
his awn em pl.Yces,'"Molad thin such homnvm,arl,are ant imarded n,offered it r SQ FT.FLOOR AREA SISQ.IT.
sole IL bnmo the building or improvement is sold within one Year Cil completion the
awnerbuilder will have the burden of proving Nat he did nal build or improve for pit,
poise of sale.). TOTAL
Or
an owner of the pmpcny.i m emlu,nely ma mating with licensed commuch rs m
tnsaun the prnjsat(Sec.]Oad.eusines<and Prnfossions Code:)Tre Contractor'I PI.UMBING PC•RM IT FEE
......Law does nm up ply u,an owner of property who milds or Improves theresn,and QTY,
who coca.,for suchpCmjectx with u enmmemo,)he coned pmsuom tu the C.nlmetur'S
License Low. PERMIT ISSUANCE
l o.,mar i mpta Sec. .B&P C fonhis mason
ALTER-DRAIN&VENT-WXF17R(EA) VALUATION
' ON DI?CI,ARATI(1N BACK IIAW PR(YILCI(DHDEVICEWORK(?RS COMI'17NSATI
ni. IncrehyaRam undo pertiiYteof urynneo Cap
following deelarei or. STORIES 'I YI'Ii CONSfRUCI'I
' ❑Ihwc and will maimainaCcnifcmc.f Consenuo wlNinsum for Workers Compere DRAINS-FLWR.ROOP,ARBA,CONO.
s:nion,as provided for by Section 3700 of the L lax Call for the performance of the FIXTURES-PER TRAP
work fnr which its 1.1tit is issued. ��
33
37Ihave andwillcele,to,Worker's
....a or
and,
n:nsrapairasby Section (TAS-EA.SYS'I'HM-IINC.JOU' .I?TS OCC.GROUP PN
3]W of the Lthor Cide,for Ne Fenton wnce of the worA for which This permit is Issu W.
My Worlo, or Ctsini,phistabou cartierand Policy. oR: CAS-EA.SYSTHMOVERJ ?A)
Cartier:�f- Policy Na:
CE IIFICATEOr H,EMPT[ON FROM WORKERS' '�t GREASFIINDGSTRI,W F,INTERCEPTOR BUILDING DIVISION FEES
COMPI?NSA'I'ION INSURANCE
(This section need not be cmnpleted ifthe permit is for one hundred whan 0 Its), GREASETRAP PLANCIIECK FEE
or le".)
lemony lb,,,a in pmfpmm.,,,r, workut,subjforhichect
this permitika,'ed.I,mIICanaan- gEWEH-SANT Y-STORM EA.200 FI'.
nnt employ any at an in any manner so m m become subjen to the Workeri Compen-
z smion Lnws of Cnlilitmin.Date WATER HE ' :N WNENC/ELIiCTR AD 'FEE �'I
Z O Applicant l p should t
N N(I I&TO APPLICAN I':If,after making this Cendicme of Exent lion,you s WAI12 SFFMO REAPING Solus Il?In
Fbecome subject a,the Workers Compensation provisions of the IrM,r Code,you must V U
W? forthwith comply with such provisions or this permit shall he deemed mvokea W B SERVICE
Q IoW RFSIDENI'IAI.PLMN. SUET. PATI) c
CONSI'RUCI'VON LENDING AGENCY Date ' a
�s[1�.]t I hereby affirm Chat there is o construction lending agency for thu urfommnec of
0 the weak for which this permit is issued(Scc.3097.Co.C.) 'OI'A
Lenders Name TOTAL:
US] Lender's Address BUILDING FEE
[
1 0. sanity that 1 have trial Ibis xppliemion and%tam that the above information is FE'
LL'I mrncl.l agreemcoinplywiEallcityz I...City.rdlnances anJ.tato laws calming to QTY. MBCHANICAI.PIiRMIT SEISMIC ITH
U2. buildingcmmmnion,and hereby m4anzenque cnmtiva'of this city 11)enterupon the
abiwamearooned pntpeny for inspection Purposes. PERMIT ISSUANCE ELECTRIC FF,Ii
(We)agree to save Indemnify and keep humdcss the City of CuCaarom against
linhi Cities judgments.costs and expenses which may in any woy.caucogam....id City ALTER OR ADD'TO MECH. PLUM RING FEE
in annsuyuence of tha grunting ot'thi%permit.
WI'TII ALL NON-110 AIR IIANOLING UNIT(TO III,INII)CFM) MGCIIANICAh F11E
APPLICANT UNDERS'CANDS AND WILL COMPLY
SOURCE REGULATIONS.`-r AIR HANDLING UNI'IF(OVER 111.0110 1 CONSTRUCTION'I'AX
Signannaofnpplleam/Coulm,lua Data H%1IAUST In(D(W/DUCT) IIUIISING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theappllaant or future beildingoccupant stun or handle haaaNaus mmarial It 'IN UNI
'I'('10111 TU)
as defined by the Cupenino Municipal Coach.Chapter 9.12.and the Health and Solely DEATING UNIT COVE W,00011TU)
Code,Section 25532tu)] PAID
Ej yes LCJI" VENTILATION (SINGLE RESID) Dmc Raciptp
Will Lha applicant or future building ipcupanl use eyuipmm,t n.device which ROLLER-C P(3HP OR 100.000111 U) 'IOCAL'
emit b t,,um era air.nompapanb as calmed by the Bay Area Air(}utility Management
Dlhtnsa? EOILE -COMI'IOVER I(XLlNN1 BTU)
❑Yes No
V Cil 'ONDIIIONI?K ^IStiUANCC DATE q ,•r
I hod,mamma hams.Sections
5505,155.13 an it,.25534.1 pe,mat 6.95 al thathet
if
V y o 1 ('
' b,mia Health&Sulay Civic.$eCll.ns 25505.25577 and 2553x.1 uniMrslanJ that if the CW RE.SIDI?NTIAL MECII. St).I•C
building dines not currently have a Cerunl.that it is my mslam ihillly m notify the occupant
mthemquiremmt: icbmust,e ext normissuance oft Cenifcam fIxcu rxy.
TOTAL: ISSIII?D fly:
Ovine clittilvnved gen Dam
OFFICE