27819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF i.r.ixcrRICAI PPIrtNO, 27819 p q n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL L O 1.J
BUILDING PROJECT IIIENTIEICAI']ON
BUILDING ADDRESS: w SANITARY NO. APRJGITIONSUBMfITALDATE
0 "CA 1Q ,Fi k Y '/UNIT- LOT# 1 S
OW IRS NIA�ME: PHONE CONTRACTOR'S NAME: LICNO.
O D 0. e1. " \ A] CONTROL 0
•ARCHTfECf/FNGINEIiR: LICNO: ADO _ _ I ❑
�vrC 1 •n 2�!
CONTACT': PHONE ` BUILDING PERMIT INFO
6',p �� QTY. ELECTRIC PERMIT FEE
6 9 - i3 PFRNHTISSUANCE ELECT PLUMB MECH
El El E]LICENSED CONTRACT'OR'S DECLARATION
OWZ Iherehy affirm thm l am flamed cod, reocioro.f CK"a 9(an do,with APPLIANCES-RESIDENTIAL JOB DESCRIPTION
u1 �
00 tfomea mud ff iviain lof the Daum.and Rofeaau Code,and eme
mY licuin PANELS
IFFQ-y� Bann Cid c a L# SZ Z Rq Z UPTO2(X0AMPS
y Qp Date $/SQ,FT.
C C'PS Dr DECLALII-100)AMPS S FT.FLOOR AREA
ZOy� ARCHI'TECT'S RATION OVER 1000 AMPS Q
1 unde+suM my ft desill thin used sa public renxrLL
FyF-w SIGNS ELECTRICAL
Qy SJ Lioemd PmficzdK l
E:a�U OWNER BUILDER DECLARATION SPECIAL CTRNR/MISC.
RnOa I hmoby affirm that I am exanpt from the Conuactor'a Licame Law for me
fdlowing rcntoo.(Smfmo7031.5,[Lumeta end Pofwiau Cab:Any city m county TEMP.METIER OR POLE IN ST.
E' which vequha a permit to carunvc6 dotes,improve,demolish,or repair a ry taactufe - / �f cc w
y'u�a� Prior to let isatuari Jso reyuirn dteapplicwt fee such parmit to Be a aigeol vannera POWER DEVICES GI\-9 —`(xJ
oc
C pK 9 tha he is licensed peruunt,o the Tro mm.of the Comranor's Ucenae Isw(Charm.
a LL mmmencingwith Seemso 7000)of Uivuion 3 ofde Basinw ad Rocesina Codc)foSWIMMING POOL ELECTRIC VALUATION
E., m that he is exempt therefrom arm the hssisfor the alleged exemption.My vldafon of
�ZQ Sec,ion 7031.5 by anyapplicam for. arrom aubjecu deappli.to it civil paultyof OUTLETS-sWITCTIFS-FIX'IVRFS
mt mme then rva hundred dollar ISM).
F� ❑ I.aaowrterofthelmoparty,nmyaoployeawithwgnndeiraokcarlpcaatin, NEW RESIDENDAL EIECfR SQ.FT. STORIES TYPE CONSTRUCTION
uuto will&the wocic' otie wuclmc is.aterdcd wMfacd faadi 70,M,Buai.
ad Pofasinc Code The Cantrecu,ra L.iccmc Isw dura oo,eptly to en owrc or
property who builds nr impmves thttam,end wb does such woh himaa f m through hla
nwnaoploym,pToviddthetsucbu,pmv uacretint moffmmfaa e.If, R P RFS.UNITS
howcvv,the Wildin8 m improvement u add within arc yaro(amrpledon,de owner- TOTAL:
buiWar will have the burden of,moving tha bradid rout baid of inmm.e fm pmpeae of
sale.). QTY, PLUMBING PERM I'r FEE FLOOD ZONE MIN
❑ I,nownerofdelmofeny,mnexdusivelyro trwtingwithlicemdcontnctonto
abinet the pmjee,(Sec.9(P14.Bruheas ao Profcaioru Code:)The ConwebrY
tissue lawdmret applymanowrcrof paapcny whobdlda rt'vnprwadeen,ad PERMIT ISSUANCE
Ix,en.Isw,recu fm suchpojecbwithecntnetm(a)Ixenrd PviwnHOlBe Conuacmr'a ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
0 1c
❑ 1 mn exempt under Sm. .B&P C fu this reason BACK lIAW PROTECT.DEVICE OUUsdDE }I
SANITARY YN
Ownec DXT DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT-
WORKMANCOMPGISATIONDECLARATJON SCHOOL TA% YN
e'5 M1,C self-ineare,ca Lab C)which FIXTURES-PIR TRAP RECEIPTa
M'vrkcrx'Gvn setirm Inco macatifM mpy thcrmflSea lPgl,Lab C)which PARK IrIl Y N
coven Wl cm tuA 40 n GAS-G.SYSTEM-I INC.4CUTLLTS RECEIPT'#
Policy Y _V l A - - BUILDING DIVISION
Coo�Pe^Y un 111 111_�pq pqn'4--1a
GAS-F.S.SYSIFM-OVERd(EA) PLANCIIECK FEL'
❑ Cmin apyn by fumisMd
❑ Cmifid aPy in fled with the city impect em division. a,.. GRHAS N US'IRI.r &STI:INTERCEPTOR GRADING FFE
CFRTHICATE OF EXEMPTION FROM WORKERS G E SOILS FZE
COMPENSATION INSURANCE Vk
(This accdan rad mtbc mnplacd if the permit uforaoeh ) WLR SAIVITA 1:"M EA.g00FT
or .`I EN
lm.) r
IanifYthetintle FerfmrwtaoftheworkfoTwhkhtoa Pemdl tau�r�ailWl� 'WATER + /li,ECIR r
cit employ it,Penn in my owner so to to bttvrre subject t Wbteia r PAID
Canprnaanm l�wa of Cdiforoia Da< V �d/IRF.aTNG Due Rcaip0
Q1CF:TD APPLICANT:If,eller making That CeadBweof E,,corptlaa,yollftdd N RPSIDEMIAL PISIB -c21rSQ.IT. TOTAL:
p VJ 1acome..abject to 0e Worker's Caru
nleuin pociumcc of the Ubbyprr Coe,you must
� forthwith cai with such provums or tour Pascal atoll be deerte5rre2kM BUILDING
0. Q CONSTRUCTION L.F1,1DWG AGENCY. �,,.?' SEISMIC FEE
U O IM1ertby aRrm thnt thvc iaecanrmedn lrndiry egoey far the perfmmrra of TOTAL: ELECTRIC FEE
the work for ec
which thin permit is immi(S .3097,Civ.C.)
Lender's Nem.
U' F I<Mcr'a Address QTY. MECHANICAL PERMIT FE PLUMBING PER
U 1 cmif cooler rod thu ygliarin aM qae that the above hot- :__is MECIIANIGII,FFE
carte,. to com 1,with dl city and county or .and sate laws relmnpto PERMIT ISSUANCE
_ V) huildin vn,ad hereby eutharite reprvcngtira ofthie city to enter upm the
() Z abd pr
above and for lm oetioi pu,swat. ALTER OR ADD TO MECH. CONSTRUCTION TAX
egra to sere,'u,danily and keep hafmlaa doe City of Caputin agvnu
lisbi d ,Judgmmu,cmuaoapamewhichyinary yacvreagaiv4aaW Ciry AIR H,,NDLING UNIT(T010.D(XCFM)
oa
mof the e ofJh oemat/Jru /�J
7 zOFC HANDLING UNIT HAUNIT(OVER 10,000 CFM)
Sigtulureof AppliLooCntrctar �V Ihtc-/ 1 E%IIAUST GOOD(W/DUCD PAID
HAT RDOUS MATERIALS DISCLOSURE HEATING UNDUCIO 100000 HTU) Date Rocaiq#
Will tharr,icamorfuture building occupant nme or hardle huadwa messier HEATING UNIT(OVER 100.(100 BTU) TOTAL:
as defied by Ile Cuanin Municipal Coe,C ptcr 9,12,arm Be Health end Safety
Code.Sectio 2553300? VENTILATION I7AN(SINGLE RISID)
❑Ya EDNo
BOILER-COMP DHP OR 100,(108 BTU) 1S5IJAN1 FyQATE
Will Neepplican,orfuturtbuildingnccul.�tuucquipnentmdevica which emit P Au
dee air ammnineoty a def d by me Bay Aro Air Qudlty Maragcmcnt BOILER-COMP(OV iR I00.0W BTU)
4Mt?
is ❑Yea ❑No NEW RESIDENTIAL MECH_ SQ.FT. MAY 2 31995
1 have Tad the h....doun mmcnac code Crofter 6.95 of me
Cxlifanio Hcahh&Sefcty Cade.Se tiems 25585,25533 aM 25534. 1 midermend that
Bde building does mt curremly have a termor,Chad it is my rapumlolhy to notify de CIIYyUr to U
occ.,eim of de regoiemrnb which mon be met Poorto inueree of a Cenne a(
if
OttvWacy.
Ownermauthaira,la" l Doc TOTAL ISSUEDB
OFFICE