00010058TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
•......,....+�.
BUILDING
BuuJnNG DIVISION APPLICATIONIPERMIT
I/
COMPENSATION INSURANCE
(This section all not M completed if the permit is lot "a hundreddollX
or less.)
Ico l y thin in the formar ercenflae work l'ar which thlspmmit is issu
not employ any person in any manner so as to thecrnt¢ dabber m the Worker' 0 z cation laws nl CA bore. Date
z Q Applicant 1
Ir y NO] C17 TO APPLICANT: If, niter ranking this Ccnific to or Esemptim you should
h" becon a subject m the Workels Compenmtion rani ens of the Labor , you must
forthwith mntply with such pmvlsionxnr this permit shill hedccmed r yoked, I
Q
CONSTRUCTION LENDING AGENCY
V Thar thitfimuhanbere isacnnswcti30oCo. agencyf the performance of
LL lac work far which this permit ie issued (Sec. J09], Clv. CJ
U Lenders Name
4SI hander's Address -
0.1 I cenify that 1 have real this y and coon and state a at Ste starve information Is
slyW bildingagrectoennply with erlldhortodeertebardin of and state laws reaminge
L) z buildingcnmswetiri any, hcrehy auttionparramxnmtivcs o( Ibis city menlerugm the
uMrve- mentionedpropcny for inspection keephs.
(We) agree hP save, Indemnify and keep hay in an the City m e against s against
liabilities, judgments, costs and expenses which may in any way aceme against said City
I n ennveyuence of the gro of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicanUConwctor Data
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or fumbe building recupent store orhondle hazardous mamrial
as defined by the CUperlion Municipal Ctic, Chupmr, 9.12, ants[ the Health and Safety
Code. Section 2553260?
[1] Yet No
} Will the applicant or futum building occupant use equipment or devices which
iii hurardaus air ... mdmnants as defined by the Ray Area Air Quality Management
'ar c'I'I
i ❑Yes El No ,
I have read the h venial materials rcgairearenur under Chapter 6,95 of the Cali -
fnmin Health as Safety Cade Sedians 25505, 25533 and 25534. 1 understand that if the
building does not curronlly have a tenant, that it Ivory re,consiblllly to notify the vacupanl
of the requirements which must he met prior In issuance or Certificate of Occupancy.
Is,,� PELrq RIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPI 02N)AMPS
OVI7R 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUILMISC.
TEMP. METER OR P0112 INST.
POWER DEVICES
SWIMMING POLL ELECTRIC
OU I'LETS —SWITC ES -1+1$1
SQ tT
ox"S1 'g, %„ PX1NIRfNG PERMIT; LP..
PERIOD
A 1, 1'H DRAIN& VEN f— WA'I'F.R 11 ?A
BA PhOW I'ROI'ECT. DEVICE
NNS — FLOOR, ROOF, AREA. COND.
FIXTURES — PER TRAP
GAS —EA. SYSTEM -I INC. 4 OUTI.H.IS
GAS - IiA. SYSTF.M.OVER 41HA)
GREAMU NDUSTRL WASTE INTERCEPTOR
GREASHTRAP
SEWER — SANITARY — S'FORM PA. 20D PL
WA I'ER IIEA I'BR WNEN'I'IELEC'TN
WATER SYS'I'Hil RHATING
WATER SERVICE
N17W RESIDENTIAL PI.MB. SQ, IT.
PERMIT ISSUANCE
ALTER OR ADD IV) MF.CH.
AIR HANDLING UNIT' (TO 10.OW CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST 11001) DGIDUC T)
HEATING UNIT' ('IO 1101,001 BTU)
HEATING UNIT (OVER 100,1111) It I'U)
VEN1 I.A'1'ION FAN (SINGLE RESIU)
BOILER— COMP (3HP OR 1101000 IiTU)
BOILER — COMP (OVER 100,000 8'I'U)
AIR CONDI'I'ION17R
OFFICE
SQ. ET
FEE11.
El
BUILDING PERMIT INFO -
BLDG ELECT PLUMB SUCH
❑ ❑ C5., ❑
JOB DESCRIPTION
corvsncr. + +�•.
L-so z 98 &�9y
❑
SOD
Uz V
Ada
LICENSE) CONTRACTOR'S DECLARATION
I hereby kffirn that I am licensed under provisions of Chapter 9 (manmencing
wila Section Jlx1P10f Division3 of the Business and l'rnlessinns Clxle, anti myliceax is
in full runaround cBect.
License Class Lie g
Dam Cente
QTY
❑ PLUMBING RE-PIPE
❑oslum -UNIT
Zy Z
ARCM '(ECT'S DECLARATION
1 understand my plans shall be used as public records
MODIFICATION
�.F'. W
Licensed 11 mf ssionot
IMPROVEMENT
i-�
OWNER- BUILDER DECLARATION
❑DEMOLITION
<
6 U
Oy
nu that 1 am exempt mn the Commur's License Low on the
I hereby million to
following rcal ( Secion 7031.5, Business and Professions Code: Any city or county
which requires a pencil to construct, Sue r....mown, demolish, or repair any 911nenne
prier to its issuance, also requires the applicant for such permit to file u signed statement
�e,
((��1a
gpri
XQ
sit
Way
F Q
firllte is I'll Personal h+ the provisiunsol'it" C....o m's l,ieenxa Law (Chapter 9
(mntmencingwith Section 9W()of Division 3ofthc Businessland Privessionr Oulc)or
lhm he is exengn thmefron+ unit tic harts for the illegal exemption. Any violation o[
Section 7031.5 by any applicant flat a permit subjects the applicant to u civil penalty of
notmore hat Eve hundred AWlnrx(5510).
❑ Las ownerofthe propl or myelogica es with wages as lhcirsolecompensatinn,
will do Inc work, and the swctum is not intended or offered for sale (Sec.]044, Business
COMMERCIAL;
;
❑ NEW BI,DGIADDITION
❑DEMOLITION
_
W 3 R
and IPrafersions Cole: The Comrderoh License Law tines not apply to an owner of
property who builds err improves thereon, and who tines such work himself or through
IMPROVEMENT
❑ OTHER
his own employees, provided Ilmt such improvements are col intended or offered for
sale. IL however, the building or improvement is sold within one year of completion, the
nor - builder will have Be burden of proving, last he did not build or improve for put-
Eric
❑ 1, err owner of the properly, am exclusively contracting with licensed enntrac cis to
,newer the project (Sec. 7014. Business and Profusion. Cold) The Cot Radial Li-
sse Law does not apply man owner ofpropcnywho hold sor box mvcst -r J
who commas for such projects with amnlrecnsr (s)IicenxJ pursuant to the C+ wet
Tl
License law.
❑ I am exempt under Sec. , 11 & P C for this as err
Owner I Data Six
WORKER'S COMPENSATION DECI.All
thereby offinn antler penalty of Perjury one of the following dedarauo
I nave unit will maintain of Consent to sell- insure for Workers Campo
a Lion Seam
as provided fnr Section JJ W of the Labor CoJC, for the perfolmunce of Be
woink,
en
work for which laic pertain is issued '
Compensation as required by $actin.
I have and will maintain Wnrkedtemore
is fo
fhe work It hi permit is issued.
3700 aflac Lahur Q+ ,(nnthe e e fthewark for�ywbhai�c�h
•o
Jody and Policy INpis�
My Worker'. ranee
7/S �/
Gmicc Policy Nu.:�b �/
COMPENSATION INSURANCE
(This section all not M completed if the permit is lot "a hundreddollX
or less.)
Ico l y thin in the formar ercenflae work l'ar which thlspmmit is issu
not employ any person in any manner so as to thecrnt¢ dabber m the Worker' 0 z cation laws nl CA bore. Date
z Q Applicant 1
Ir y NO] C17 TO APPLICANT: If, niter ranking this Ccnific to or Esemptim you should
h" becon a subject m the Workels Compenmtion rani ens of the Labor , you must
forthwith mntply with such pmvlsionxnr this permit shill hedccmed r yoked, I
Q
CONSTRUCTION LENDING AGENCY
V Thar thitfimuhanbere isacnnswcti30oCo. agencyf the performance of
LL lac work far which this permit ie issued (Sec. J09], Clv. CJ
U Lenders Name
4SI hander's Address -
0.1 I cenify that 1 have real this y and coon and state a at Ste starve information Is
slyW bildingagrectoennply with erlldhortodeertebardin of and state laws reaminge
L) z buildingcnmswetiri any, hcrehy auttionparramxnmtivcs o( Ibis city menlerugm the
uMrve- mentionedpropcny for inspection keephs.
(We) agree hP save, Indemnify and keep hay in an the City m e against s against
liabilities, judgments, costs and expenses which may in any way aceme against said City
I n ennveyuence of the gro of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicanUConwctor Data
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or fumbe building recupent store orhondle hazardous mamrial
as defined by the CUperlion Municipal Ctic, Chupmr, 9.12, ants[ the Health and Safety
Code. Section 2553260?
[1] Yet No
} Will the applicant or futum building occupant use equipment or devices which
iii hurardaus air ... mdmnants as defined by the Ray Area Air Quality Management
'ar c'I'I
i ❑Yes El No ,
I have read the h venial materials rcgairearenur under Chapter 6,95 of the Cali -
fnmin Health as Safety Cade Sedians 25505, 25533 and 25534. 1 understand that if the
building does not curronlly have a tenant, that it Ivory re,consiblllly to notify the vacupanl
of the requirements which must he met prior In issuance or Certificate of Occupancy.
Is,,� PELrq RIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPI 02N)AMPS
OVI7R 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUILMISC.
TEMP. METER OR P0112 INST.
POWER DEVICES
SWIMMING POLL ELECTRIC
OU I'LETS —SWITC ES -1+1$1
SQ tT
ox"S1 'g, %„ PX1NIRfNG PERMIT; LP..
PERIOD
A 1, 1'H DRAIN& VEN f— WA'I'F.R 11 ?A
BA PhOW I'ROI'ECT. DEVICE
NNS — FLOOR, ROOF, AREA. COND.
FIXTURES — PER TRAP
GAS —EA. SYSTEM -I INC. 4 OUTI.H.IS
GAS - IiA. SYSTF.M.OVER 41HA)
GREAMU NDUSTRL WASTE INTERCEPTOR
GREASHTRAP
SEWER — SANITARY — S'FORM PA. 20D PL
WA I'ER IIEA I'BR WNEN'I'IELEC'TN
WATER SYS'I'Hil RHATING
WATER SERVICE
N17W RESIDENTIAL PI.MB. SQ, IT.
PERMIT ISSUANCE
ALTER OR ADD IV) MF.CH.
AIR HANDLING UNIT' (TO 10.OW CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST 11001) DGIDUC T)
HEATING UNIT' ('IO 1101,001 BTU)
HEATING UNIT (OVER 100,1111) It I'U)
VEN1 I.A'1'ION FAN (SINGLE RESIU)
BOILER— COMP (3HP OR 1101000 IiTU)
BOILER — COMP (OVER 100,000 8'I'U)
AIR CONDI'I'ION17R
OFFICE
SQ. ET
FEE11.
El
BUILDING PERMIT INFO -
BLDG ELECT PLUMB SUCH
❑ ❑ C5., ❑
JOB DESCRIPTION
RFSIDENTIAL:
❑SFDWL
❑ Kll'CHEN R EMODEL
El ADDITION
❑ PLUMBING RE-PIPE
❑oslum -UNIT
❑STRUCTURAL
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
El SWIMMING POOLS
❑ BATH REMODEUREPA1R
❑DEMOLITION
❑(TfIIFR
�e,
COMMERCIAL;
;
❑ NEW BI,DGIADDITION
❑DEMOLITION
❑TENANT
E] 17001) SERVICE
IMPROVEMENT
❑ OTHER
SISQ. IT.
s ao
PLANCHECK PEE
ENERGY THE
GRADING PILE
SOILS PEE
PAID
Duet Rcccipl4
1 OTAI.:
BUILDING FEE
•
FEE SEISMIC Fill
ELECTRIC FEE
PLUMBING FEE.
MECHANICAL FEE
CONS'TRUC ION TAX
ROUSING MITIGATION FEE
PAID
Data Rsold k
TOTAL(���