S 2624 (2)TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
1...1...1..1— RUI DING-ELF.C'I'RICA I.
BUILDING DIVISION AmpucATIONmRRMIT
�a1lr� iSSM A� 15
ge1je-
LICENSIiD CONTRACIOR:S DECIARA'FION
I here'hy alBnn but I nm licemcd under Film...... of chapter 9
wish Section 700) aft' 13 of the livaincs apfl l' c inn ,1112
In hill f..crardrffccl. LJ (,
,tris n.r rl.a,s Lica
UACr11R'SNAGJIi: 110rsDvca� MIZ11,
O )RISS'.
10IJlU1/I JAI U7'leu- Ui—
❑ Consultant Fees Paid by Applicant (initial)
ITY ELECTRIC PERMIT PEI:
zO-,71z 1anderdandmy pl:A,s EhAl beusnl it, Pulite records 1
oz—a
F
�.j4 t n] License P1,1111rinnul
E; OWNER -BUILDER DECLARATION
C C Q I lar chy vffnn, bull I ren cxanpt from te hContractor's Licence I.aw for 'he X L U following mown. (Section 7031.5. Inwincs, and Prulessiom CMc: Ally city or county
W 3 LL y< which Icclnlrm b Fenlon Ie connlmet, laic, in,pn,se. demoli.q or elate any stiemarc
1—'u'OJ
PH 1. , e 1: y imappficautf ll permitI F1 g d.al nen
hal I Ip E I Ith C t t nl L (Chapter)
(courracencing x'IhSectii of u c„ JI I C'.10...
el X00
6 %o CL Wut h ,pl IAcrcf J tM nasls II yaea t n y violai nn of
LL• Section 7031.5 by any app Inn a pernj,4lIlASYIiJecls I app I n ,I
not more man five bumbesl'Au u
_ � p l nn p I,Env r Mo ' d ma l p. F s
k. w1ld m A Ire t , l 7
W andl I Cl �t�, I I of
pnd royPm h r, Co a l h nth 'h
his own employees. pro ded Lha, h air n all n E, offu ,
,x
sale. If. howl the building or improvers, I is sol within m,oy of nplais h
own
ci-huilJcr will have We but al Forcing Ihal hod'LEI not FuilA or ilnpn:vc IL
n 1 of so
❑ w
n`.
, es nw 'r nr,hc propcny, nm "xalucivcy cunpv 'Ih nwA cnnru"mn to
conwruct the project (Sec. III Hu.iwo ani f )The Cnmmeena Li-
cendc LIw does no, apply man::wncrolpmpcnYw w ,S Ih,reon, End QTY,
who contrensfnr such pmjccts wishan,mmmorts)liccsm am snt)p Co Imnur's
1 item" Low. /
I am exempt under Sec. V ufonhi(rea.
Owner
W(IRKIiR'S C(IMI'ENSA'rION DIifue t ry �
I hereby affirm under penalty of Ps jury one of tM1fell angM.k:m
I burs nnA will Inninmin a Ccr,ilicare of Cunncnun self-in.urc norr l n Sur
re
.alien, as provided for by Section 3701 of the Linn th
Crile, for e Icrform 1%
El keen wnly permit isi
❑ I have anid will maintain WorkrAer'. Cmnpcnvtinn Insurance. as ,cyuimJ by Sec,inn
3700 of me Labor Calc, lar the pull'onnuncc of the work ran whim Isis parmir i.v ismcJ.
My Workers Campcn.minn Imumnce clone, and Farcy no her brei
Carrier. PoI i"y No.:
CFR I JFIC3TF; OF 11XEMI1IHON FROM W ORKI?RS'
COMPENSATION INSURANCE
Th
(in rection nL r nw
oGcnn,plclL irlhc ps'rmit is his nnc hundnN dollar, (810)
c,v.1
I cendythin inure punburinu of,hework lin which,hls Fenlon is IswcJ, l Shull
nn cn0,loyany past un .oa
anyn ser.totecomcsablesmlhcWntr
rciCompen-
O'L option Wws of Caldomia. Oats
Z Appr"am .
h
NOTICE TO APPLICANT: II, uncr, making lois Cenifed. alF.cmpuon. you should
h Meoist, comply the Wmhcr'x Cnmpcnamie ermidinndof me lnhor Code. You mwst
W � fonhwim comply with such prvvisinns or lhi%pcnnil shall he dcunad rcvokeA,
a' Cuadher. sa,baN1.ENDINdinaAGENCY
L) Ihcreby allirm m:n,hcrc isacnnamc,into lending agency lin the perinrmanee of
U. —the work for which this permit is issued (Sec. 3007. Civ. C.)
C ULcndcrx Nit...
I<ndcr's AddresI _
(� I certify that 1 have read this application and state that the above inRlmenton is
u(n correct. I agree (I) comply with all city and County onlinbnao and Erne haws rclmingm QTY
U huildingamsruminn. and hereby amhorvc mpresenmrivesoflhi% city memer upmthe
a L...rmnioned property for inp,cadon ramuscs.
(WE) agree to.nve, indemnify and keep hamticss the City of Cmenlno against
Bibi liticnjmlgmenls,.Das and cxpeme, whish Inuy In any wary accrue agam.l said City
in o:i¢nce of the ¬ing of lois permi,�
APP W NO UNUERAANDS AND SV11.. C'UMI'I$ WI ill ALL, NON -POINT
HAZARDOUS MA'DiR1A1S DISCLOSURE
Will me upPllcanl Ir Ilam, building ollupanl our, or bundle heiarJom' material
a, defined by the Cupenino Municipal Calc, Chapter 9.12, and the Health bbd Safety
Calc, Scctinn 255321:5!
❑ Yes
Will ,hc applicant or fmure building scc.PxLE, u.w cyui,,ncnt or devices which
ni, hmardous in conunninamd as de inod by dw key Ara, Air QIm1'ny ManllEment
toric,'!
� Vcs Lyre,
bb",rad hcI rloot m;nerinI rcq brubt,olds,Chapter 6.95ofthe Cull -
fn 1 cahh & Sofq� f $,"tions 255115, 5533 and 25530. I un stand ,hu, 11 ,hc
IJ,A noesnmcle,IuficaNilan,ahmi�,ru,mspml�.ibil ,ifYlhcrcnyryq
PERMIT ISSUANCE
e `L
APPLIANCILS — RESIDENTIAL
PANELS
Oil 10 200 AMPS
❑SFDWI,
201-1000AMPS
❑ADDITION
OVER 1000AMPS
MULTI -UNIT
SIGNS ELECTRICAL
SPECIALCIRCUI'F/MISC. ZY
INTERIOR
'I 12Nlr MLI'ER OR POLE INS "F.
ISIPROVI!IL
Pf)WERE DEVICES
❑ FA'I'I I RPMODFLgUEPAIR ❑DFL OLITION
1 NIL ELFRIC
IH TS-. 11HEL IIXTURES
2
NE ESLD IAL IA f CIR
SQ CC
PLUMBING PERMIT
FEE
PER Nt T ISSUANCE
N.TG — AIN&VENF—WATIiR(EN
BAC1/ v 'R(yfF;CT. DEVICE
,'RiAusl—IL .. Rf✓iI'. AREA. COND.
'GA.'LF,4. TENNI INC. J OUTLl'. IS
GAS -CA..' SFEISOVER J(A)
GRIASF INDUSTRL W'AS'TE IN'1'ERClzvl OR
GREASE IRAP
SEWER -SANITARY -S,ORM HA. 210 FI'.
WATER ljF I'Ilk W/VENT/IiI.I:CFR
WAI'CR SY$'1Iimri k[ W ING
N'AI I;R SI[RVIC13
NFWRESIDENTALP1.1,16. SQ. PI'.
M RCI IA NICAL PERMIT
PERMIT' ISSUANCE
AUI'ER OR AODTO MECH
AIR HANDLING UNIT CIO 10.001 CFM)
AIR HANDLING UNIT (OVER 10.11X1 CFM)
EXHAUSTHOOD1W/DUC )
HEATING UNIT (TO L00.001 RTU)
HEATING UNIT (OVER 100,00b RID)
VENTILATEON FAN (SINGLE MID)
RUILER-CONIP Lu IPOR 1111.000 RTU)
BOILER-COMPIOVIIR I00,000BOD
AIR CONDITIONER
NEW RESIDIRS FIAL MECII. SJ
l�
DING PERMIT U,
I EryCI'/ PLUhIR
LJ ❑
J013 DESCRIPTION
RESIDENTIAL;
❑SFDWI,
❑ KITCHEN REMODEL.
❑ADDITION
❑ VIJAIBING RL.F[PE
MULTI -UNIT
❑STRUMIRAL
MODIFICATION
INTERIOR
El CHIMNEY REPAIR
ISIPROVI!IL
C]SWIMMING POOLS
❑ FA'I'I I RPMODFLgUEPAIR ❑DFL OLITION
❑ OTIII3!
COMMERCIAL:
❑ Nine BLDG/ADDU'ION ❑ DEMOLITION
I Iil`AN9 ❑POOL)SERVICE
1
INIPROVI:LL
❑ Ol'IRLR
SQ. lel. FLOOR AREA ae/SQ. FP.
F
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V� ;C.
Y sD RI ILS TYPECO STRUCI
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w
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ILOING DIVISION FEES
PLANCHE' Ai r
N lt( 2—
nun i Plitt
PAID
Date Nccciplp
N C THE,
I°EF: SIi1SM IC VVE.
,I EC'FR1 P.li 3 0
_ PLAN VC :
M Ill 193E
C NS ll1CF1()N TAX
110 .1N6MI'1'IGAIFON 193E
PAID
Date Receipt x
ISSUANC17 DATE
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