S 0196 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO RUU.UINC.-ELECTRICAL P' IT NO
BUILDING DIVISION APPLICATIONIPERMIT PING PROB NG-MECEN riFic, J 0196
BUILDING PROJECT[UEN'I'IfICA'1'ION
SANITARY NO. APPLICATION SUHMII'1'A1.DATE
BUILDING ADDRESS:
ieh � G 2
WNER'SN MIo PHONE: CON" AMOR'SNAME: LIC NO: NIC CONI ROLN
r• RCHITECTMNGINEER: LIC NO: A )KESS:
CONTACT: PHONE;:
BUII,DING PERMIT INTO
wet ❑ Consultant Fees[laidbyApplicant(Initial) BL❑uG I PLOM liC
LICENSED CO RACIOft'S DECLARATION QTY ELECTRIC PERMIT FEF, JOB DESCRIPTION
I hereby affirm am,I am license,under provisions of Chapter 9(commencing
WOZ web Section WM)0)of DivisionJo(the Business and Pmfe..inaw Cade vnd my license is PERMIT ISSUANCE. RESIDENTIAL
CW in toll foe d effect. 2 ❑SFDW'L ❑KITCHE RIiMODF.I.
aUkJ License Clu,' _ Lit.p _ AI'PLIANCCS-R1iSID1iNTIAL ❑ADDITION ❑PLUMBING RE-PIPE:
yZuj Dam Coramcmr ❑MULTI-UNIT' ❑STRUCTURAL
ARCHITEGT:S DIiCI,ARATION PANELS MOUIIICATION
pzyz Iun,crsmml my plans shall be.,do,publi,mcmds UPTO200AMPS
[I INTERIOR ❑SWCHIMNEY
NG POOL
F on E'W LianseJ Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Cyd; OWNER-BUILDER DECLARATION OVER InDO AMPS ❑BATH REM ?I/REPAI U'
C C 6 1 hereby affirm that I am exempt from the Contents License law for the [I OTHER fLx O L U following reason(Session 963 L5.Business and Hufes,ioas Code Any city or county SIGNS ELECTRICAL.
W 3 LL y which regvims a Penson to conswn.alter.mtprove.demolish,or mpair any cwemrc
F�Oyy� prix t t .til y ' fl p,l tf :uhpc tett 11 'b.rd....cteem SPECIAL CIRCUD MISC.
hEi!!�y yi
bar he.f Ipurs'mlt thep stn ' r l Contractor L Law(chapter9 COMMERCIAL'
(cn 8 'Ih Seat 91KIU) fD'vls I I'tl lines II f :'Tin CalO or II:MP MITI ER OR POLE I NSK
tY a o e' LI HON
that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDGIAUDITION ❑FOOD S17RVI
Section 1031.5 by any applicam for. eaf subjeco,he applicant to a civil pcnahy of POWER DEVICES ❑TENANT ❑FOOD SIiRVICE
m more than five hundred dollars 155018. IMPROVEMENT
Q 01.as ownerofthe property,..my employer'with wngcs as lheinole compensation. SWIMMING POOLIihECB[C ❑OTHER
p. will do the work,and lbesuucmre is not intended orofered for sale(See NEW,Business OUTLETS-SWITCIIliS-FIXTURE
a m and Professions Code:The Common.'.Licence Law docs nm vpply e+an owner of
property who Wildx nr iinprovcs thereon,and who does such work hanwil or through
his own employees,provided that such Impo tetacros am not intended or offered far NIIW RESIDEN'DAI.ELIITR SQ FI'.
sale.if.however the building or improvement issadd within one Year al'completion,theownSQ,17.pP]L��f10R Aft1iA 9SQ.4T
•olatilder will have the burden of proving that he did not Wild or improve for Pur- Y' A ,
,maxof sols.). TOTAL: !J
O 1,as owner of the prnpcny,am exclusively m amadog with licensed cona.nars 1. 1 ���
consume the project(Sec.70,1,1.Business and Pm fe,sions Codm
Code:)The COmcmPLUMBING PERMIT
Li- FEE p
cense Law Jots not apply to an owner of property who builds or improves thereon.and Y.
who contracts for such projects with o onlowtotts)lIterood pursuannth
tome Contractors CilTII[4
Lmcnec Law. ,H&PCIbr In"reason PERMIT ISSUANCE YIJr (/Uf P
I]I am exempt under Sec.
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dice
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury one Of the following declarations:
[have and will maintain.Crodicatcof Comenl lm self-insure for Workers Compete DRAINS-FLOOR.ROOF.AREA.CON0. Sl'ORIES TYPE CONSTRUCTION
sation,as provided for by Section U W of the Latin Code,for the performance Of the
work for which this permit is issued. FIXTURES-PIER IRAE'
1 have sad will maintain WarIme,Cninpaneation Insurance.as rcyuired by Ser ion GAS-F.A.SYSI'IiM-1 INC Y DID LIF
310e of the Latae Code.fin the performance of the work for which this permit is issued OCC.GROUP AI'N
My Workers Compensation Insurance caner and Policy number are: CAS-EA.SYSTEM-OVERY(EA)
Caries Policy No.:
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASEIINDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING DIVISION Plifti
(Thisuationnecdnnt W completed ifthcpemat is forone hundred dallae($10f) GREASETRAP PLANCHECK FEE
7 or Is—)
1',omlythnl in tla"erfannanccol'the w'orkforwhich th'j,Iwoat is Issued,I shall SEWER-SANI'IANY-SIORM EA.21X10 ENERGY FEE
mm employ nay penton a.any manse w as) b me su 9 to the Walken Compcn-
Z sodium lawsu(���l '- WATER HEATER W/VI?NT/ELECfR GRADING FITE
Z Applicant Y+r zd
NOTICE TO APPLICANT:If.a ter making this Certificate of Exemption,you should WATER SYS'17-M/TREATING SOILS FEE
a > become subject to the Worker's Compensation Provisions of the Iahar Code-you most
� ry forthwith comply with such pmm
provisions permit shall be deemed revoked. WATER SERVICE
QPAID
a
GONSTRUCTIONLENDINGAGENCY NEW RESIDEN'DAI.1'LME. SQ.IT. DOW Reseda#
VQ l hereby al0nn thin there is a aonstnlction lending a,tam,foo the E,form are of
IA the work for which this permit is Issued(Sec.3097,Civ.C.) 'RUAL:
C) Leiner',Name 'rGI'AL'.
Lender,Address I BUILDING FE
r D. FEE
(L 1 certify the I base read thi,application and same the the-have information is
th co.,.I agree to comply with all city and county ordinances and stela laws relining to QTY. MECIIANICAL PERMIT FiiF, SEISMIC FET:
U building I I n and hereby math ile repoo,matike,of tM1:etly to c.lc'spends,
stn 1 p peny in,unpe,00n pumplaoss. PERMIT ISSUANCE ELECTRIC FEE
J if,mudk p hot let,11'.C"y fCPenin gmnsl
I'aM1lte.s,judgmtnts.costs and expenses whet atty in any Y bm.w dCq ALTERORADD'IOM1IECH. PLUMBING LITE
in ema nuance of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITIi LL NON-POINT AIR HANDLING UNIT('10 10,(10,0 CPM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.001)CEM) CONSTRUCTION TAX
L J�
5lgnuw¢of APPll vntlCumm-�— Utile EXHAUST HOOD(WIWCq I10USING MITIGA'T'ION PEE
HAZARDOUS MAT IiRIAIS DISCLOSURE
Will the applicant or lvmre taidJingoccupant.,ma,nr h:nMlc hvaNaus mammal HEATING ON II'('10 I I0AXI B 11
am defined by the Cupenitn Municipal Code,Chapter 9.12,and the IIcahn and Solely IIEATING UNI I'(OVER IIX4000 BTU)
Cade,Stenon 2553200?
❑ TYes ❑No VENTILAION PAN(SINGLE RESID) PAID
—Dam Receipt N
Willme applicant or future building occupant use equipment or device,which BOILER-COMP(IHP OR U00.W0 HTU)
crait har dour sir contaminants as defined by the Bay Are.Air Quality Management TOTAL:
1)Imim'I HOILER-COMP(OVER 100,000 B'I'U)
❑Vex E]No
AIR CONDI'1'IONICR ISSUANCE DATE
I have mad the hamrdom mamnals requirements under Chapter 6.95 of the Cali-
fomla Health&Safety Code.Sectians 25505,25533 and 25531.L mdcomal that if the NEW RESIDENTIAL MECH. SQ.14.
building docs not currently have a tenant,that it I%my responsibility to notify the Occupant
of the v;nircncros which most be met pear to issuance Of a Certificate of Occupatmy.
� m
Owner or amhon ,men,gc
Dee TOTAL: ISSUED BY:
OFFICE