9665OFFICE
PROJECT [DEN 'I'] FICAI ION
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nUUILDING
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SANI1'ARV NO
ON SUyAI L DATE
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CHI1'F. /ENG) RSR: LI /NO: Q DURESS
N . W. VI 944
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BUILDING PPEERMIT INFO
'jo`p, ("dJj(p �/✓ 335-/990 D
❑Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION
I Hereby nrprnt nim nm Bc.nted airier provisr.n, or coaster 9 (commenans
fe,,auo Cnnndm,haculets
%uh Section 9fxx➢ ofDivicion Sol the Ba,ma,J de
inlu0 fiauc.vnd after 5815
Licens Lm. #
Dnlc a Conlmclm
QTY
ELECTR IC PERMIT FEE
1'ERA11T ISSUANCE
APPLIANCES-kESIDEN I'lAl.
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
0pDDIT10N El PLUMBING RE-PIPE
❑MULTI-UNIT ❑ STRUCI'URAf.
MODIFICATION
0INTERIOR LJ CHIMNEY REPAIR
IMPROVEMENT OSWIMMING POOLS
❑ BATH REAIODEIAEPAIR EDDEMOLITION
❑OTHER
ARCIiIT IiCrS DECLARATION
PANELS
phc records
UP IO2WAMPS
P fc,elon.1 201-10I)RAMPS
OWNER-BUILDERDECLARATION V S
I hereby affirm Thal 1 ant exempt from the Convector's License Law for
following tartan, (Section 903 L5, Business' and Professions Code Any dry or co IG
which reyulrc, n permit to c.num.0 ahcq imprnrI. dao.11sh, m rcpan any time
primunt,i.cunn¢..1..require,the applicant for inch permit lllc a signed uummcit SPECIAL CIRCUIT/MISE.
mal M1c in l¢enecd pur.uar,;h, the pnaiowo a!thc L'anexmis license Lary (ChaNer9
COMMERCEAL:
❑NEW RLDG/ADDITION ❑ DI?MOLITION
[.}T{,ippNT [I FOOD SERVICE
IMPROVEMENT
❑GTHER
��<Q
IL y C
0
N
F'Z'Y
E Q
W3 m
'
..minenciagwith Seavioa]tkxtl of Dts;xlna3ornhe Business and Proce.tinn.v codelor
)hal he is exempt maYcfr.m and the bna, for the alleged c uratptien. Any violation of
Section 90315 by any applicant tura pencil subject the applicant to v civil penalty of
m mom Chun Glc hundred dollar (55 W).
Lns townor of the pmpcny..r my employeex with wages mlhnrsnle ntmpemu
wdleMlhewnrk.andthe,moomre isnnImonrOrdoroflived facda!Se,, 91144. Bus
and Profession. Code: The Contractor's Liecns Law does nor apply can awn, e
property who hudds or improves thereon, and who docs such work himeulf or Inn
his town employees, provided that such imprnvmncros arc not intended or offered or
wlc.11;However. the M1uilding err lnmmvctncnl is sold within one year tofwmplcuon.Ihe
I' ,TL 1
E E
A G( 1
' W RFSIDBN' PAI. ELECTR SQ PT.
SQ. FT FLOORAREA
S/SQ.FC.
er-builder, will have the haden of proving IhaI IN did sol bwld or improve farpur-
pnsc uEwlct
dra.. i
1, rs owner of Inc pi-open,aro exclusively enmradm, wah In, emad... t.e
TOTAL:
instruct the pro ci (See 7044. If rsiness and Pmlessions Code) Hot Contractors I.
nee Law doer not apply to an uwrcr of property who builds or improves thereon and
QTY.
PLUMBING PERM fT FE 10
who contracts or such projects won a urnnucwr(.) licensed pursaum to the Cmnmctm's
License I,—
O 1 am cont, mahr.Sec. . R d P C lis this reason
PERM) P ISSUANCE
'O
Owner Data
ALTER -D AIN&VENT-WATER (EA)
VALUXI'ION
WORKERS COMPENSA'T'ION DECLARATION
I hcrehyaffirm under penalty of perjury one of the li,llowins declarations:
BACKFLOW T, DEVICE
•�
•J �O no 0
Ilmv, and . 111 inaitramn a Ceni Gcamt.f Consent card(-amore for Worker', Cicar
wean, as prtrvidcJ rc. Ay Scmu+n }p)0 of the Lnbnr Code, fur the performance tot the
DRAINS- 00 ,ROOF, AREA. COND.
S'rORI S
TYPE CDNSIRUCTION
wu for which this permit is ieuul.
FIXTURES
1 nava and will muinmin Wida is Conymwmum I.,comer. at rcynired by See,i.n
37 )nfinei.uhor Code, for the frerformvnm of the work for cancan Uis pump......ed,
GAS -EA. SYSTEM- .40V .f;
OCC. GROUP
APN
MyWta��/r �}1�1 yW Liu Inwrance cosier and PolicyyjYl�1 TTL�yy ,h'L
Cnnfer:3. 71Yi�iLl� Policy No.:6/ M,10
GAS-EA. SYSrEM.OVER
'/(���/•b77
CER I IFICATE OF ENEMPII ON FROM WORKERS'
COMPENSATION INSURANCE
GREASEANDIISTRL WAS INTE(EPTOR
BUILDING DIVISION FEES
(Chis carton need nut hr o0mplc¢d if the peh
rmit is [Drone udredndalurs (Slip)
or lass.)
CREASE TRAP .-•-••"""""'�-� �1-1 I
PLANCHF.CK FEE
OZ
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O ULmtder's
W
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Cog
Uz
Iwni[y lha in the serfnmtanec t.fthework for whicM1 this permit is isxued.lvtrll
not employ any Person in any manner ser asmiwernm sibjemwihc N'nrkcrs'Compen-
Dam
t
SEWER - SANITARj' _STORM F.A �Hp Fr.
-t U ��
ENERGY FEE
canon Luw.nf Caldarnin. WA'I ER HEATER W/VENT/ELECTR
Appl e m
GRADING FEE
NOTICE TO APPLICANT: 11, aper neaking has CeNficate of Exemplar, you shoWd WATER SYSTENiah T
baso.. subject to the Worker's Compensation pmvi...m.f IM1c Labor Code, you must
t'anhwithcorTI, wahsuch pito mons or this prinuh ,,hull he dcemrdmv.kcd. WATER SERVICjI
CON.STRUC:ION LENDING AGENCY NEW'NESIDF.NTIAL PhM1iB. SQ. FT
Ihaner, of rot that era corm.,,u, lending agemm
ncy fur the Perforec of ... _�.•_ _N ���
mework fur which this Irennit i, mucd (See, 3099, Cb. C) l--f--^
Name
SOILS FEB
PAID
Um. Rcnipt>
TOTAL:
Lender's Address TOTAL:
BUILDING FEE
7
I amEyIhm I have rendibis.,pliwlinn and ,at, that the aMrvuarddmullnn is
c nect.iaga,ai...rupiau'nhaO.it, and! o,.myo.Nmanecwnd one hwsminung lto QTY MECHANICAL PERMIT FEE
building construction, and hereby immunize representatives of tots city to enter upon the
SEISMIC FEE
ELECTRIC PEE
uMvenncnunned prupeny far utpection Frorl
(We) afire, to cavo, Iadevmify and keep Fail the City of Cupeninu against
PERMIT ISSUANCE
PLUMBING FEE
IlvM1ilities,judgmenl,,exaas andvxpen... whuntmay many way erxmmgainsuuid City
an nmyucna of the Panting tot this ..miss
ALTER OR ADD TOMECT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON-POINT
SOURCI: RE .0 il/fl ONS. /�
AIIONIUit/JI/
.AIR HANDLING UNIT TO VyHC0 CFAU
CONSTRUCTION TAX
CONST UCTIONT
/ AIR HANDLING UNIT (OVER 10,111x1 CFM)
^�(/x�n
Sig taw. "I Applinmt/Cmnrnnnr 1);; —
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD r W/VUC1)
HOUSING MII'IGATION FEE
Will the""'limn,,,foam M1u0dingtamupnnl+are err handlehezallou. material HEATING UNI')'(TO PxxfCI BTU)
ns dahncd by the Cupcnino Munrcipal Coda. Chuplu 9.12, and Ilse Health and Safety
Ccdc,��' a25532w),
I( EATING UNIT LOVER 100,1100 IF I U)
$Yes ❑Nn N
VENTILATION CAN (SINGLE RESIU)
PAID
-
Date Kaoipt #
Will m, aI, nousu or fmure bur ad by :he B use equipment or device, which
nit AanNuuwir ainteimmnt a, der ad by me Buy Area Air Qnnlily Munngcmmn
BUILGR-COMP 1?HP OR 1001X)0 BTU)
TOTAL
gS1(]Nn
HGB.ER-COMp(UVER IIp,txxl BTU)
7-,
hYca
'' I vave read the hmard.u, maNnals rc yuvrmenu under Chapter 6.95.dme C.nll.
AIR CONDITIONER
ISSUANCE DATE G
,mi: H 1 h l S-f Iy C I Sections 25505 255» J 25534 J .t d that A IM1c
' lyh / t Inn y p ..brvt al)th sraryorfine
NEW RE.S'IDEN'I'I AL MECH. SQ. FT
I �nmjfuly Q.hy J�at prior to is fa cen fly��Ocyc
/ff/ oiDi`m
ISSUED BY:
u.huri dagent TOTAL:
OFFICE