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99090158 (2)I. „ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING DIVISION APYLICA'PION/PERMIT IILDIN--ADDRESS.69 IvIar—le11a r71 11111" A CON'1'ACn rnOnt:: ❑ Consultant Fees Paid by Applicant (Initial) }iA9ARDOUS MA'T'ERIALS DISCLOSURE Will the applicant nr none building cel -Pant mora nr handle haentdoun mmerild as defined by the Culrcnino Municipal Code. Chapter 9.12, and the Health and Safety Cooke. Section 2553200! 0Ya EJ No Will the applicant or future building occupant use equipment or devices which Oil humrdon, air ammmimon us defined by the Bay Area Air Quality Managnnent DistricR C] Yo ElNo I hove mud The bnmrdmts asocials mquircmmab under Chapter 6.95 of the Cull - Corona health & Safety Code. Seeriono 25505. 25531 and 25530.1 understand that if the buildingo�grymneunendyham.1mnthatt iis my rtspnnsibiliry mnmify rhe srccupmt of The mWnts which efly °ne66 io/lWt issuance of a Cenificate of Occupancy. ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP10200AMPS OVER 1000 AMPS SIGNS ELECI'RICAI. SPECIAL CIRCUUUMISC. TEMP. ME11:R OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - 171X I ORES NEW RRSID1INI'IAl. ELECT R SQ FT. I a O 0C) atU U F ZIt1 LICENSED CONTRACTORS DECLARATION I hereby union that I am licenced under provisions of Chapter 9 (commencing with Section 7000)of luoloon 3 of the Iuoum,sandl'ruf csinns Code, sad my lieensc is in full force and effect. License Class Lie. p Date Carlin r QTY BLDG ELECT PLUMB MECH ❑ ❑ ❑ BACK FLOW PROTECT. DEVICE W ZOyZ ARCHITFLT'S DECLARATION IwJecamdmyplansnhall bcusMo Twblie records JOB DESCRIPTION RESIDENTIAL, O SFDWL D KITCHEN REMODEL OADDITION EI PLUMBING RE -PIPE ❑MULTIUNIT ❑STRUCTURAL MODIFICATION D INTERIOR DCHIMNEY REPAIR IMPROVEMENT EJ SWIMMING POOLS D BATH REMODEDREPAIR ❑DEMOLITION D OTHER OZ -a GAS - EA. SYSTEM -I INC. Y OUTLETS OCC. GROUP F F W Licensed Professin ed GREASMNDUS'rRL WASTE INTERCEPTOR QZ,YB; OWNER -BUILDER DECLARATION PLANCHECK FEE C a Q XpCil.: y W 3 a T- 1"u'0Q } wQQ d e e• I hereby affirthat I am exempt from the Contractor's License Law for the affirm that fullowing wston. (Section 90315, Bovines and 11 lcssiuns Code, Any city orcounty which requires a permit hr consumer, alter, improve, demolish, or repair any structure prior to its issuance. alm¢quires the applicant for such permit to File a signed statement that he is licensed pursuant to the provisions of the Contractors ctors License law (Chap,,,, 9 (commencing with Section 7")of Di vision 3 of the Business and Professions Code)or Ibat he is cxmnpt lwmtnnm nod the boas Err the alleged exemphmn. Any violation art Section 9031.5 by any applicant for a permit subjects the applicant in a civil penalty of ENERGY FEE WATER HEATER WNENFUELECfR GRADING FEE F Z } = 0 p. w a., mme Than five hundred dollars 651X)). D I, as Owner of the progeny, or any employees with wages as their sole compensation, will do the work, andthe structure snot intended nrnffcred forsale(Sec. 7I Rusineus and Prof comers Code. ]he Contomor'c lieensc lanes dews nm apply lie air tnvner of property who builds or hnprovex thereon, and who dna such work himself or through $❑Itis PFIi WATER SERVICE PAID his own employees, provided that such imP+Ovmnen6 art not intended no offered fill NEW RESIDENTIAL PLMB. SQ. I7 Date ReceiptN sale. It, however the building of improvement is sold within one year orf completion, the TOTAL: owner visit have the burden of moving that he did not build or improve for pur- TDTAL BUILDING FEE e - Of lade.). ❑ I, as towner of property, am ewe toively colo ing with lmcased contractors w SEISMIC 17EE nmurel the project (Sec. 7GI Business and Podisslons Cade:) The Contracnnr's Li- PERMIT ISSUANCE ELECTRIC FEE ne law dome not apply or an ownerf property who builds or improves Hereon, and QTY. PLUMBING FEE who contracts for such projects with a contmmor(s) licensed pummun to the Contractor's AIR I IANDLING UNIT (10 10,IX0 CFM) MECHANICALPEE License Law. ❑Imoo eacrofo^See 1 B k P C fill nils ecuson I �/�TT� AIR HANDLING UNIT (OVER TO." CFM) CONSTRUCTION TAX D 17XIIAUSI HOODOI HOUSING MIT IGATION FEE 4— Ihlaid a0innun er Cena ryone of the foo ingdedecr,Coons. hcnte HEATING UNIT (OVER 100.000 BTU) Thew laid forbineCcnl ofCe Labor Cook. sure oPerfodsCOmpcn- smion, as d lin Section 391X0 of the labor Cook. for rbc Performance of the -- VENTILATION PAN (SINGLE RESID) en work for which Nis mannan is isued. hick BOILER -COMP (3HP OR W.000 B'IG) D 1 have and will maintain Compensation ce, as requirtd by Section BOILER -COMP (OVER 100.0010 BTU) w rk to, Qrde,rot themcrfor,aarwml the work forwhich This permit is loved. ofthe he Performance AIR CONDI 'ITONER ISSUANCE DA Ii 7 sp — F ,CLabor My wmkcra ctompemxtmton Insmmnea ear;er sen rauoy nnnnber aro, My Caner: Pnliey No.'. CERTIPICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('Iris section need oat be cmmplecd'dlim .no, is for one hundreddollars(SI()) u Iczs.) that in the performance illthe work for whijM1this pentonis Issued, shall z Z '�r N a� 5Z `41" (:) >^ D.7 tL N ay torn , Lay Conan imy manner will, m become subject to the Workers' Cnmpen- seninr olowyany of Culihomoa. Data Applicant NOTICE TO APPLICANT'. If, altar making this Cefficate of Exsorption, you should become subject to the Wodery C'nntpcusation provisions of the Luba Code. you must fonhwill, comply with such provisions or this permit .shall ce deemed revoked. CONS I'RUCI[ON LENUINGAGENCY 1 hereby off ran that there is it construction lending agency liar the performance of rhe work or which this permit is issued (Sec. 3099, Ctv. C.) Isnote', Name Lcndcr's Address 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating m QTY, U C..) Z M1uilAing annswetinn. unJ hereby umhmiw rcprucntative. otthis city to enter upon The ahnaenmcntimmol property for inspection purposes. (We) agree t0 save, indemnify and keep harmless The City of CuCenino against liabilities, judgmems, costs and expenses which may in any way accrue aFaimt sail City in consequence of the granting of into permit. APPLICANT UNDERSTANDS AND n1LL COMPLY WITH ALL NON -POINT SOURCE dj.GU1.A'1'ION }iA9ARDOUS MA'T'ERIALS DISCLOSURE Will the applicant nr none building cel -Pant mora nr handle haentdoun mmerild as defined by the Culrcnino Municipal Code. Chapter 9.12, and the Health and Safety Cooke. Section 2553200! 0Ya EJ No Will the applicant or future building occupant use equipment or devices which Oil humrdon, air ammmimon us defined by the Bay Area Air Quality Managnnent DistricR C] Yo ElNo I hove mud The bnmrdmts asocials mquircmmab under Chapter 6.95 of the Cull - Corona health & Safety Code. Seeriono 25505. 25531 and 25530.1 understand that if the buildingo�grymneunendyham.1mnthatt iis my rtspnnsibiliry mnmify rhe srccupmt of The mWnts which efly °ne66 io/lWt issuance of a Cenificate of Occupancy. ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP10200AMPS OVER 1000 AMPS SIGNS ELECI'RICAI. SPECIAL CIRCUUUMISC. TEMP. ME11:R OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - 171X I ORES NEW RRSID1INI'IAl. ELECT R SQ FT. I WO FI'. TOTAL a O PLUMBING PERMIT FEE BUILDING PERMIT INFO ALTER - DRAIN for VENT- WATER (EA) BLDG ELECT PLUMB MECH ❑ ❑ ❑ BACK FLOW PROTECT. DEVICE DRAINS- FLOOR. ROOF, AREA, COND. FEE JOB DESCRIPTION RESIDENTIAL, O SFDWL D KITCHEN REMODEL OADDITION EI PLUMBING RE -PIPE ❑MULTIUNIT ❑STRUCTURAL MODIFICATION D INTERIOR DCHIMNEY REPAIR IMPROVEMENT EJ SWIMMING POOLS D BATH REMODEDREPAIR ❑DEMOLITION D OTHER FIXTURES-PERTRAP GAS - EA. SYSTEM -I INC. Y OUTLETS OCC. GROUP APN Z GAS -EA. SYSTEM -OVER q (EA) GREASMNDUS'rRL WASTE INTERCEPTOR BUILDING DIVISION FEES �a-Pr1( OR PLANCHECK FEE COMMERCIAL' ONEWBLDGIADDITION El DEMOLITION ❑TENANT DFOOD SERVICE IMPROVEMENT OOTHER SEWER -SANITARY -STORM EA. 200 IT ENERGY FEE WO FI'. TOTAL a O PLUMBING PERMIT FEE PERMIT ISSUANCE ALTER - DRAIN for VENT- WATER (EA) VALUATION 2 . ,SO Q BACK FLOW PROTECT. DEVICE DRAINS- FLOOR. ROOF, AREA, COND. STORIES TYPH CONSTI FIXTURES-PERTRAP GAS - EA. SYSTEM -I INC. Y OUTLETS OCC. GROUP APN Z GAS -EA. SYSTEM -OVER q (EA) GREASMNDUS'rRL WASTE INTERCEPTOR BUILDING DIVISION FEES GREASETRAP PLANCHECK FEE SEWER -SANITARY -STORM EA. 200 IT ENERGY FEE WATER HEATER WNENFUELECfR GRADING FEE WATER SYSTEM?REAPING $❑Itis PFIi WATER SERVICE PAID NEW RESIDENTIAL PLMB. SQ. I7 Date ReceiptN TOTAL: TDTAL BUILDING FEE MECHANICAL PERMIT FEE SEISMIC 17EE PERMIT ISSUANCE ELECTRIC FEE ALTER OR ADD TO MECH. PLUMBING FEE AIR I IANDLING UNIT (10 10,IX0 CFM) MECHANICALPEE AIR HANDLING UNIT (OVER TO." CFM) CONSTRUCTION TAX 17XIIAUSI HOODOI HOUSING MIT IGATION FEE HEATING UNITTO I 00.000 FIT) HEATING UNIT (OVER 100.000 BTU) PAID -- VENTILATION PAN (SINGLE RESID) Dam Receipt or BOILER -COMP (3HP OR W.000 B'IG) TOTAL: BOILER -COMP (OVER 100.0010 BTU) AIR CONDI 'ITONER ISSUANCE DA Ii 7 sp — F NEW RESIDEW AL MECH. SQ. FT. OFFICE I OTA L.I I ISSUED BY. 0