20551 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'M Idendfkaan. TNO.
Building Address: 20551
�
JOIJ3,,,,5 int Tan�au
. tee. AG DA IL
Tand-th) P'� • CITY OF DIVISION /
l.o
Contracter'.Name' L if Lac N u APPLICATION I PERMIT
�VO B(1MNGELECTRK-AL-nUMBINGMECHAMCAL CATEGORY CONTROL
Amin /Engineer. Glc Na
1 Q ELECTRIC PERMFT FEE
BUILDING PERMIT INFO
Add. 570 C 1 E1 CSm�nD 'Rf'a I�RMRn$uAN� ZpD El ❑ IMT
CONTRACTOR'S DECLARATION
I hereby aRErmtlut l amlkensed under pmvisonaofChapter9(tvnmen APPIIANChSRE-91DFM1Al JOB
ingwlth Senbn7MOMot Div m3oftheBud andllrofeWCodpandnry '
license le In full force and dfd PANELS
anerue n ClaLal..
D
rte GOmdradcr 701-1000A.MPS
ACT5 DECLARATION
�2 I understand my pk..h.11 aluB be used as record.recoa OVER 1000 AMPS SQ.FT.FLOOR AREA
O SIGNSELD,IRICAL
Lin."«d]Mmdessloal
<� ONINER-BUILDER DECLARATION S'ECIALCIRCIIIT/MQSC
therebyafilmothatlamexemptbomUeCdb L
ardraorkenae Lawtmlhe
z
following reason.LSealm 7MI-S,Businessand liba
ofessCode:Any city or
F TEMP.METER OR POLE INST.
Mceuntywhlchrequbnapemato oarWr Malter,Mpmv demolbh,ormpalr
Stm=mprbrmlbbsuame,aborequl theapphl tfw Suchper to POWER DEVICES
a. file a sigml statement that he b licensed Pursuant m the provhbru of the -
3 Contraciors License Law(Chapter 9(commendng with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O;} sion3ofthe Bustnessand ProfetimuCode)orthat he b exempt thenfromaM
f3< line baab for the Mleged..cmption. Any vlolalon of Section 7MI.S by any
appbcantforapemdtwbjectetheapplkanit..ciAlpenagydnalmorethan Oim•EfSSWnn USFIXCIIRES 'V
Bve hundred dollars(f50y. NEW RESIDENTIAL ELFG7R
�n ❑I,as owar o!the Property,lir my employers with wagn ant theirsok SQ'7' TYPE CONSIRUCTON
compemwaion,w01 do the work and thestructure b rot Intended or offered for
Mak(Sec 7014,Buslrus.M Prdosbro Code:The Communes Ucema Law _
� 59 doesoatapplytoanownerofpropertywho buildsorimprotltthereon,and
S^ whodonwchworkhlmselforthraghhiaownemplcyn,provldedthatwch _WC.COLfP RESUNITS
tmprwcmenbarenatintendedoroffemedfor le.If,hownver,thebuildinger TOTAL
Improvementbeold wilhinomeyearofcampletbm�theowner-bullderwlll Tuve
Uryt.¢�rarnofprovingthethedld wt baud or Improve for purpose ofvkJ. QTY. PLUMBING PERMIT FEE
"L as owner of the property,am exclusively mber
ntactlng with IuM / APN
contract.to mrtMwd the project(Sm 7011,BuMness ant Proferbru Code: PERMIT ISSUANCE
The Comrsdari Llcerue Law don not apply to an owner a(property who
Wilds or tmpnwn thereon,ant who mmnm for such p,"with a ALTER-DRAIN&VENT-WATER ff-V
-wateeoris)BcenaN pursuant to the Contntlmi License Law. BACK FLOW PROTECT.DEVICE FE ARY
U ec 1 am exempt under SB &P C for fhb recon
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
f Owner Dae RECFIPr
WORKMAN RECEIPT
COMPENSATION DECLARATION
Orm ve
❑I hereby afthat I haa certERna te of consent to self-insure, a PSS'PER TRAP SCI100L TA% Y_ N
Ne
artNadeofwcalum'Comperuatlon I...,or.amBkd copy thneaf6ec GAS E.A.SYSfFAf-1 WC40IfILEIS PARK MY N
350Q lab CJ RECEDT 0
I olEy I GAS EA.SYSTSd-0VFR!(Et)
Cany BUILDING DIVISION FEES
I Certified copy b hereby furobnee. GREWSE/INDUSRL WASTE INTERCEPTOR PLANCHECK FEE
LpJ�CertNed copy is tiled with the dty inspection dIAMon.
CERTIFICATE OF FI(EMPHON FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA D'MFI' Date Reoei [#
ffMa aectbn need not be completed lithe permit b ferom hundred dollars
atm)a IevJ WATER xEArRw/vFNr/TIF Tx ENERGY FEE Y N
I oertuytnat in the performance of the work forwhIch thio peb b
mut ared.
1 Shall not employ any pemen ue any manner an,as to become subject to the WATER SYSTEMt TREATING
W«ken Campmmws
ean laof Gmk
lifo .Dae PAID
O Z Applicant NEWR®DFNTIALPLMB 50}7 Date Remi t#
Z O NDTICE TO APPLICANT:ILaXer maktna thio Certificate of ExemptbR you
Fshould become wbkd to the Warkers'Compenalon provisions ofthe Labor TOTAL:
N
Code,you.0 forthwXh comply with wch provbbm or Chia permit Shall be UILDIN
LU ] deemed mroked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby afgrmthat there b a mmtmetion lending agency for the perform,
Z TOTAL: P� E
ELECTRIC FEE
ennufthewnrkforwhkhthbperm bbated(See3097,CEv.C)
U O lenders Name - PLUMBING FEE
LL t LendersAddress QTY. MECHANICAL PERMIT MECHANICAL FEE
O W leertitythatl hawreadthbappllote
llonand mathatthe aemfonnetion
M bcomed.IagreetocomplywnhaudtyaMc ntyoMd net anaetaelawa PERMIT ISSUANCE FEES PAID:
minting to building construction,and hereby authomlre repmnamtatN of this
00 m to entero Pon the abcv rnrntbad for Ens ion ALTERORADDTOMFGH.
~ Z Siwe).gree to .T,indemni an d property
to city oi iw Date Recel t#
I..I agamatI d nand expense which myln,nyw.yamve ADS}1ANDLING UNIT f1O 10 SUBTOTAL: 'eO
.gal dthe granting dthb pemdt. AIRHANDLINGtRTf(OvFR1o.Wo CFM) CONSTRUCTIONTAX
X ti—13 ��
o cant or Date EXHAUST HOOD(W/DI1Cn CONSTRUCTION TAX PAID:
xAlAR SM ATERIALSDISCLOSURE
Will the applicant or futumbutidingocevpant More or hendk h rdous HEATING UNIT(TO I COODO BTU) Date Recei t#
material..dell and by the Cu per ino Mumddpal CMe,Chapter 9.17,and the
Hex lth a M Safety CM a Son I=75537(a)7 BEATING UNIT(OVER IW,000 RTU) TOTAL:
❑ Yn No VENTILATION FAN 61WLE RESID)
WWthe apaa rd t a tontannldingomfine use the Bay re.device ISSUANCE DATE
Falb end.hagement W rontandmmsatede0ned by the Bay Arca Ab
Q�jality htaraganent D❑lMrbt7 ROn cc-NMP OTB'OR 100{AU BTUI PAID
haw
and No
havereadiealth ort material,Sect In.
25 05,under Chapter 6.95 of BONER-NMP(OVER 100,000 BTU)
the GlBamt Hefth&Safety CMe,$soba25505,wa nand,that. I
uMnstaM that if the building eon not currently have atean4 that It is KEW RESIDENTIAL MECH. SQFT
responsbBey,to notify the occupant of the raqulmmeas which.0 be and
prlartotx .cceof.Cemllflcateafoccuparuy. ^,j''f Ot Cupem,n0
Owner or authorized agent Date iSSUEDBY: Rl�
TOTAL —
OFFICE COPY