S3951APPLICANTTO FILL IN INFORMATION
BUILDING. DIVISION APPLICATIONIPERMIT
IILDING ADDRESS A • 111
112
USE BALL POINT PEN ONLY t
BUILDING - ELECTRICAL
�M_rs PLUMBING - MECHANICAL
6(,DL &4q Dom
❑ Conaultent Fetal Paid by Applkant (Initial)
1 herehy af! that I am licenved under prevision, of Chatter 9 (eoouriercing `
Qd'Z wiN Sztion ]V00)af Dir'aioo3 ofthe Busioc.0 Ptafcasiom Code, esd mYlianu is
11-� O ' full faro, ellen
aU i°
Ficen�. Ie '�tl u,.« B/
NQ1 Dule Cmtractm
crt ARCHITECTS DEC
F � Z I undmland my plan, shell W used ex M1li imm,
1oz O
r 14 F W Liaised Peofe.,tioml
Y f -i OWNER -BUILDER DECLARATION
IY C C 1 Merry affirm that I em cxcmv from Inc Contractors License Lew for the
LU rdhwing ra Prat, fS ram ]011.5. BelmeSI mal Pmfaa oar, Cda AnY city m ttatnty
3 LL which tryuites a permit to croodrun. altar, inipm,e. demolish, or mp any slNelule
0 )•im to its icesu
s., also regvim ih[applwva for ch Peron to Ek a. roW uat
Icy that he is liernre,d pwswnnu J¢Prnvisionx of the Cmlrecux's Licen ( PrerY
alp (cnmmancing with &pion ]1Mb)ollTvision3 nnle Busi dPiu (]Wc)a
E a e C thearSetr K u eumb any. li ad the bssLs ft Be aBaged� ny d'eaim M
"y a. ro a thand5 M1Y anncrev! cans far a pcmdt subjnts the evil peraliy of
a more that Bvo hunJrd drallen IS50).
Las,wrcrnf she Prny. or my cmploYeaV1h Iecampenwuan,
willdoe workrad aumiarbtimeodeJrak (Sc.]BYa-Businenasivn'Coda Conuacor s rnrort apply to an. of
y wW Wilds o impmvcs IIdars J work himself it Ihnaghhi, iwn rniployces,vide) that s h imp t inledd d oRend for
uk. If. boss ,3ildint or vcne,m e, ydar ofcdnp)nion. the
iia -builder will 'atheho i ofpm.'ing at he dal nal WiW«imprmefdpm-
❑Lmowre,r of th am exclusively conlrvcung inth heartiest cimut cora to
ermUuat tha project (Sea. . Bminess arW Prafentiom Cori The Connor, Ii-
cene,lAwdocanuapplylo ofPopmywhobuiWsorimprovcstnermn. QTY.
whocmtmetxforsuch pmjo, tha cnnloccluda) licensed pursuant o the Com selor'x
Line. Law.
I din caemlg uMn Sec. . B S P C far this tmsm
)wl¢r Lata
W'ORKER'S COMWFNSA1'ION DECLARATION
1 hvehy vffimt ache Penalty M perjury ore of de, following declnraiiom:
I have arta will mturia n a Cemfeale of Gxuenno xelf-insure fed Wrhrrs Cnmpen
."ion, us pmvlu4vl for by Semian 3]10 of the WWr Cale, ter the perfumterrce of the
k fur which Nis pemtil Is issued
have ad will mammonist Wohcrs Coni earvalion Inwra . n seyuitN by Senior
"fMl of de .r code. fur the pcRnnwda antic wed uliich this paanul i, iasa
My Wxk, QnmpyeMgin Insura¢c wrricr u%Jyajk
COMPENSATION INSURANCE
(Uhiexclionn d not tccnmpind ifmnc Prmnit is Praise hudid dnlWs(SInh
or EPs.)
I certify thvli Rich this Paton is issued. I shall
ax employ y pato, manna a W dkeri Cnmpen-
,'� radio Wws of Cd �' k
Z O Applicant
rA N(JI'ICE TO L efts muLiog this Ccrufcalc nl Escmpion, you rhwW
a^ hncm¢ svbja'I to WnA s Cnmpenxvtim pnrvitial, of tl¢ LeWr Caac. You nmst
� [ Rrihwilh cdnply with such prtwuuma �r ULv peTtil Uall W r4 me 1 revoked.
�Z CONSTRUCTION'LENDING AGENCY
U O Iherehy uffrm Mel them ise uxuvuni�n lending sycmy[anhe perfuminieud
V. — the work for which lois pcmtil is issued (Sec. 3897. Civ. C.)
O F" Lanai Naha
LUtI I<Ncrs Addrtax
1 cenify lhnl l dove mad lois opplicatinn dust stele dun me.Nova mforderi it is
LLn mirth. 1 store to comply whb all city and coumy oNlwrcex and slue laws mEaling to QTy,
U Z Wildin cmmlaimtioo. wid haradyaudmria representative, of this city to env span the
^ abnvc-nese e,3 Property Rr inspection par,sta .
(We) agree m wve, idemnify anal hep bumdecs the Cay ofCupeninse against
IiaM1ilitics.jdrne,ms,curls u W cxpcnsc.v %'Each may In any way accma ugair st old City
n emoted. of the, ,amimia of inis pemJl
APPI.I(j DS AND WILL COMPLY WITH ALIjNON/POINT
Signtluteraf ApplicanaEdnI.u, r a Due
HAZARDOUS MAI2RIAI.S DISCLOSURE
W II applicant sr fulurt ipilding occupant 4ort 2r lwndk luunhans muttivl
res dela y the,
im MwicilW Coe. Chapter 9.12, rain We HcaIN and—slyCade, a3532(a)?
E]Yet,
Will the applicw or for= huili iog arca cuum use equipment ce devias which
emit haurdw.v air condominiums as defined by the Bey Area Air Quality Management
Dielnn? ,.,'/
E] Yes, Dim
1 have «ad Ilio hamrddss matmels iryuimrcnis omdn CTapn 6,95 of de Cnli-
knonu;16j�I h &Sof s 25515, 2593 vd 25.4 W. 1 udlastadl that If the
Wn�(gal.(yl cynranay nave a teat , it is my respmibilo, m'limy tv ne.,ead
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RISI DENTIAL
PANICS
UP TO 2(0 ANN
11I-1000AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUMMI.SC. 1
TEMP. NIETER OR POLE INSf.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SW'ITCIIES - FIXTURES
NEW RISIDEN'1'IAL ELECTR SQ PT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN AVFl4'I'- WATER EA)
BACK FLOW PROFIECT DEVICE
DRAINS - F.00R, ROOF, AREA, CONE).
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INCA OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA,)
GREASIMNDUSTRI. WASTE. INTERCEI'NR
GREASETRAP
SEWER - SANITARY - STORM EA. 2200 FT
WATER IIEATER W/VEN-UT ECI'R
WATER SYSTEM/IREATING .
WAFER SERVICE
NEW RESIDENTIAL. PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (GVER 10.000 CPM)
EXHAUST HOOD (W0)UCT)
HEATING UNIT (TO 100.000 BN)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP LIMP OR 100.000 BTU)
BOILER - COME(OVER IOU.(MM BTU)
AIR CONDITIONER
NEW RESIDENTIAL MF.CI L SQ. PT.
OFFICE
3951
M
u
OMM .R IA
❑NEWBLDG/ADDTTION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. .F AREA /SQ. FE
D JUN 1 4 1999 D
FEE
Byp J
VALUATION Oy
�IiJJ pJ' v
STORIES TYPECONSTRUC
--
OCC. GROUP APN
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY Il?BI
GRADING FEE
SOILS ME
PAID
a Receipt A
TOTAL
BUILDING FT ,
FEE SEISMIC
i?LECfRIG
PLUMBING
MECHANICAL & -
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dale RadeidN
ISSUANCE 1) TE n P
❑ or ❑ � ❑
FEE
JOB DESCRIPTION
RESIDENTIAL
0 SFDWI, ❑ KITCHEN REMODEE
❑ADDITION ❑PLUMBING R&PIPE
❑MULTI -UNIT C3 STRUCTURAL
MODIFICATION
❑ IMERIOR ❑ CHNINEY REPAIR
IMRROVEMENf EISWIMMINGPOOIS
❑ BATH REMODEL REPAIR ❑ DEMOLITION
❑ OTHER
OMM .R IA
❑NEWBLDG/ADDTTION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. .F AREA /SQ. FE
D JUN 1 4 1999 D
FEE
Byp J
VALUATION Oy
�IiJJ pJ' v
STORIES TYPECONSTRUC
--
OCC. GROUP APN
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY Il?BI
GRADING FEE
SOILS ME
PAID
a Receipt A
TOTAL
BUILDING FT ,
FEE SEISMIC
i?LECfRIG
PLUMBING
MECHANICAL & -
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dale RadeidN
ISSUANCE 1) TE n P