28793 (2) .' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.CITY OF CUPFRTIIVO BUILDING-1?LBCPNICAI. - N PIiRMI'1'NO. w ^ a�
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL Lj7 {CJI3
BUILDING PROJECIADENDFICA'11ON
BUILDING ADDRESS: a SANITARY NO. APPLICATION SUBMITTAL DATE
WI
OWNER:$ AMEN PI ONE: CQ��RryG I'OI2:5 LIC t>'O: - i
•/ '—I S /vl/.-:(J' . . " Wr),�y�• .A':_l lv.�(� N/c cocrrl[ol.w
ARCHTI LCI'/ENGINELIi: LIC NO: - - ADDRESS /�-1� /� //'' t ❑
CONTACT. - PHONE: - - BUILDING PERMIT INFO
-1n „� ',
El Consultant Fees Paid by AppliCant(Initial)' BLUG 'ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
n„�Z -
I hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
, withS i ]OW)ofDivision 3 oDhc Burnes dlime �onCJ day license RESIDENTIAL
��+ O nhall f I d fft 1'CRMI I ISSUANCE
yUZ� Lcd. u.s {� C-S S- Lep 3tr 1 6 � ❑SFDWL � ❑ ITCHEN Rf MODF:f.
6d Duo Com actor�� J API'LIANCHS-'RESIDF.NTIA1. ❑ADDITION MBING RF I'll'E
ARCHITECTS DECLARATION PANIIIS
Fpm - ❑MULTI-UNIT `_ ❑S'fk UCTURAI.
I understand my plans shall be usedaspublicrecnrds ' - MODIFICATION ,
OZ..� .+ UP"1'02(KAMPS ❑INTERIOR [I CHIMNEY REPAIR
H�f'41 Licensed Professional - - 2111-1(Ng1AMP5 IMPROVEMENT
OW,
OWNER-BUILDERDEC
LARATION OVER 1011 AMPS ❑BATHkEMODEIIREPAIR ❑DEMOLITION
Q 1 lot affirm that 1 mal from
thee omC,m n r 1 L for me
K 36 VF
following .(Section 7031S,Holmes,and Pmf C vl A y ty aunty SIGNS ELECTRICAL ❑OTHER
F�OJ wbch 1a pe n a t ipa p de I'd is ysame
t cure
Aron _
m l I requires Ill ppf tf such a 11 signed statement SI'hCIAI.CIRNIT/MISC. .
p. dp u n n p faf C -I I” l I [Chd '1' COMMERCIAL:t„
Cl
((e can,nt g with d ]1NNB 10 ':' i fth B . Old 11 Coded I n: or I:MI'MCTI:R OR POLE INS'I'.
6 o CG
that ho is exempt therefirear und the basis fit the alleged ex,aption A y I fon of ❑NEW BLDG/ADDITION ❑DHMOLI'TION
^„
m oSu n TOILS by any applcanl for a peumisub/eats the apphcunl In a civil dually of POW12R DEVICES ❑TENANT ❑FOOD SERVICE
tmnre than five hundred dollars($501).
Q I,as toner ofrhe prupeny,is employees with wiles as their sole cam IMPROVEMENT
still do the wark.and mesaucom isms mtendcdmnffered for sale Is..]MJ Business SWIMMING POOL ELF.CI'RIC ❑0IDER
3 uad Professions CWe:The Contractor's License law ones not apply to an owner of OUTLIH;S-SWITCHES-FIXTURES
property who builds or improves thereon,and whe does such work himself or through
his own employees,provided that such improvements an not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however.the building or improvement is.sold within one year ufcomplaionthe SQ.Ff. K H $/SQ.Fr..
owner.huilder will have the burden of proving that he did not build s improve for par-'
ansa
❑I mowne,of the p p ty x I -' ely counted, 11 b true(.....m - TOTAL: - 'JUL-
construct1f
il project(Sec.704411 : df f:' c,d )n CnW lr:Li- n U
adult,Law does not imply m,tnwnerrdpmpeny who builds or npnoes thereon,and QTY, PI-UMAINO PERMIT FEE
whocontmets farsuch Nn,11x with a commomr(s)li,rnsedpmocunuotho C.donvr's /S ITV UI„ `(�r CHIN .
Littnse L.W. PERMIT ISSUANCE V I ,
❑1 em exempt under Sec. ,B&I;C for this rcuon - - -
ALTER-DRAIN&VENT-WATER(RA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under Finally of perjury one of the following declmankno: - - . '
❑I love and will maintain u Certificate ofCousentto self-inave for Worker's Compur- DRAINS-FLOOR,ROOF,AREA COND. ,
anion,n
s provided for by Section 3700 of the Labor Codd far the performance of the STORIES TVI'B CONSTRUCTION
-
r inwhich lhls permit is iasucd, FIXTURES-ICER TRAP - an
wo l to m,d will maintain Worker's Co n,mooian Insunmce,nr respond by Section
3700 ofthe labor Codd,for the perforotunce of me work for which this permit is issued. GAS-'HA.SYSTEM-1 INC.4 OUTLETS
My WorAer' ,mpensnot)rt lnsur ¢e cerrierend Policy numberarc: - _ OCC GROUP APN
Currier. ems. - Policy'No.:�J--��'aThh�: GAS-IiA.SYSTEM-OVER 4IEA)
'RTIFICATE OP HXEMPIION FROM WORKERS' GRL'ASFJINUUSTRL WASTC If4TfiRCIT1'ICOR
COMPENSATION INSURANCE. ) BUILDING DIVISION HES
(This section need nm he cumplmeJ if me pennil ix for ane humlrN Jolla..(81 W
mless.) - .. GREASE TRAP
PLANCHECK FEE
Toy any thaumh adurnym ane Dh stuckfwhichili .error.'. Coddle . SEWER SANITARY STORM EA.21X1 FT.
m employ any Person in any as to interlard.ubJe�n m Workers Coddled. BNERCY FEE -
liana laws of Cvhfomv Date -
_ O 1 WAI'1R HEATER WNENVELECIR f r 0
O Appl'ud : - - - 'GRADINGFEE .
yNNOTICE TO APPLICANT If after caking this Cerhfevte of E ...tion you should WAI fill SVSTIIM/TREATING
a become subject m the Workers Conp,ensation previsions of the Labe Cade,ynu
must 5: ,. SOILS FEE
131rzfanhwith comply with such provisions or this permit shallM deemed revoked. W'ATIIRSERVICE ,.
0.
CONSTR1ICTION LENDING AGENCY
U0 NEW kPSIDEN"1'IALPIJdB. SQ.Pit PAID -
U O Lha by which
mm them issued((Sed.3W7,
agency for performance of Date Receiptw
� H the work far which mil permit is issue)(Sec.J09],Civ.C.)
O U Lenders Name - TOTAL:
Lenders Address T
GI candy the fha e mail th': pl fedi nand.tate fill--th h T nations BUILDING FEE t
r
0
U-�
it gQTY MECHANICAL PERMITFEE
h, ld',g construction ant]hereby authorize morountativesofthis u
cityt calerial,on the SHISMICHE - -
ahave-n,enuoned property for inspection pur.u.ce' PEItMI'1'ISSUANCE
(We)agree m save.inJannify and keep harmless the Ci1,ol Cupanim,agaiou HLECI RIC FLEE
a.
hihilih,,jud,ohms,musing expenses which may in any way accrue aguins said City ALTAR OR ADO TO MECH.
in ronsequcnce of mee granting of Ibis detain. PLUMBING FEE _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10.0110 CFM)
SOURCE REGULATIONS. I MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCIIONTAX ,
Signature of Applieant/Conuarda Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
- Will then hero,or Ionic holding us"upanl,on io,handl,anionic!.....material HEATING UNI'I(TO[00,000 BTU) -
m defined by the Cupenin l Meni,yd Code,Chapter 9.)2,and Ilse Health and Safety
.Cede,Section 25532m)'I IIFNI INC,UNIT(OVER 1009011)BTU) - t
❑Yes 71No -
VLNI'l1.AT10NPAN(SINGLE RES ID) PAID
Datil Receipt w
Will the applicant infntum building ceche Biose cyuiil Quality
M..agwhich BOILER-COMP 3HP OR 100.000 BTU)
emit hamNous air comaminams as dotal by the Bay Arca Air Quality Mvnagemem
DiaricB - BOILER-COMP 10 VER 1009 �I BTU) "TOTAL:
❑Yes C]No -
I have lead the hamnkar,materials mtudemenrs under Chafer 6.95 of me Cali- AIR CONDITIONER
l Fl _ ISSUANCE DATE
faroafl dlh n Safety dy, Sa :255(1525531 and 255141 1 I' th hat NRW RESIDENTIAL MECH; SQ FT.
ht IJ' g 'cu nay hu 1St t II I t my q b'llyt tfy tl tpvnf t .
ofTho no 1t , nnp�t ameantaCtn'fct oTO y,encY. - 4' `
O ner or authorized agent Ilam TOTAL ISSUED BY:
OFFICE