S 2144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWFINO 'BUILDING-ELECTRICAL PHSITN0. ^�� ser
BUILBING HI V[SION APPLICATIONAERMIT PLUMBING-MECHANICAL J L 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPI,ICAT]ON SUBM/IE�E[ALL DATE
OWNS 'S is I L PHONE: CONTE
1'V.. NIC CONT LN
�ARCHITECTIENGINMIR; IC.O: IAD]R'SS. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
-3 -7q ❑ Consultant Fees Paid by Applicant(Initial) BL❑ID, ELECT PLUMB M H
LICENSED CONTRACTOR'S DECLARATI`ON Q'TY RLECTRICPHRMIT FEE
1 hereby,fern thin I am licensed under pmvi ens of chapter,9(commencing JOB DESCRIPTION
WOClot:Z hhis 1 7000)nl Dvhlon9 onhellin -and Pintos- n.vende,ondtnylicenseis );E$IDENTIAL
610 w q I'UItMI'T ISSl1ANCli
C W in full lion snit c0 t kZFDWL ❑KITCHEN REMODEL
aUU LiccnscC N
, Lic. �O APPLIANCES—RESIDENTIAL. ❑AUDI TION ❑PLUMBING RE-PIPIT
P•7z-W�
'D. AItCI111'HC'I"S DECLARATION I'ANI11.5. ❑MUIJ -UNIT ❑STRUCTURAL
w I nndecewnd my glens shell be ovula,Public records MODIFICATION
Z'O m, UI '10WAMI'S
CZ-,Zt-q 2 ❑INTIiIUOR El CHIMNEY REPAIR
N15LL1
Linnscd Profcsein tal 201-10N)AMPS IMPROVEMIiN'T E]SWIMMING POOLS
FogJ OWNER-BUILDER DECLARATION OVER I(Nl0AM1'S ❑I1AT1{kIiMODEIIREPAIR ❑DHMGLITIDN
C Y, 1 hereby vffinn that I ata exempt from the Contractors License Low tor the
kO L U following reason.(Section]1131 5,Business rind Professions Code:Any city nr county SIGNS ELECTRICAL ❑ariluR
W 3 0.N which requires a permit m construct,alter.improve,demolish,or repairany umemr,
,E„•6d�g
prior to issuance,also requires the applicant for such permit to rile a signed smtemem S 19iC1 At.Cl RCUITIMISC.
that he is I nerved Personal it)the provisions of the Contmeort,License Los,(Chapter 9
w IY 000 (commencing with Section 900)of Division 3 of the Ruviness and Professions Code)or 'FEMR ME*rHR OR IDLE INST, COMMERCIAL:
a y o IY that be is exempt therefrom vol the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
W to Section 9031.5 by any applicant for a promL subjects the applicant to a evil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE,
=Q not more than five hundred dollars 1$51101. IMPROVEMENT
C]1,as osier.of the pn,pony,or my employceswith wagesmtheirsole romPen,vion, SWIMMING POOL ELECTRIC
%F will de lac work.and the structure is not intended comforted for sale(Sm.IBM,Business ❑OTHER
W m and Profession,Ctde:111e Commerce,L.icenw Law does not apply to an owner of OUTLETT S—SWITCHES—FIXTURES
progeny whir build,or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements arc not intended or nBered for NEW RIIS IDENTIAL ELECI'R SQ PT.
sale.I L howeveq the buildi ng or improvement is sold within one year of completion.the SQ .1`1 RAREA $/SQ.FT.
ser builder will have me burden of proving that he did not build or improve for pur.
pm of )
E] 1.as owner ftl p gent exclusively contracting with licensed tutn+ 'IDEAL
: /
constructth project(S 7144 business dl f: Cd )l'h C t o I'. i///
c 1.a.does maniptp,t tPnpny who hid-a impriwe,therein, d Q9'Y. PLUMBING PERMIT FEE
whectaturactsLI' ,Jog leets vi th enol ulo0.$)Iwmed pnrsuunu th C I 's /
License Low. 1'I;I,MI'I'ISSUANCE
Inlncitenipi under See. ,B&P C for thlsesnn
ALTER—DRAIN VENT—WR'I'ER(EA) VALUATION
Owner Dam
WORKER'S COM 1117NSNI'[ON DECLARATION RACK FLOW( TCT. E
1 hereby affirm under penalry nr perjury one of the following declarations:
0 I have and will mainmin aCenithracorConvent to self-insure forWorker's Compem DRAINS—F ROOF 'ON STORIES TYPE CONSTRUCTION
tritium,as provided for by Sectio 3900 of the Labm Code.for the performance of the
wprk for which this permit is issued. FIXTURE: TR P
have and will maintain Workees Compensation Insurance,as required by Section
.2 tthe Labor Code,far the performanncce(ovftthhe woe f r which this pemoit is issned GAS—E. STL �6( LETS OCC.GROUT' APN
My rr'no vagpx_ ii��alnsumttys .t"e '�/I� t —
Carver. _^ a V illicy No: 71J GAS— 'YSTEM OVER4(EA
CERTIPICAfE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREA$F LWASTE INTERCEPTOR BUILDING DIVE. ON TEES
This section meednot he c it,lemd if he permit is furonchumashollars(SI(N))
or lesc.l GRIiASE'DtAV 1'LANCIIIiCK Rli
I cenify shat in the performance oftac work for which this Permit is issned,Isha0 SF.WI?R—SAN ITARY—STORM[A._
not employ tiny Person in any manner so as to becnme subject to the Workers'Camper. ENERGY ITC
0Z ,inion laws of Califcmia.Dam WATER HEATER WNF..YT/F.LECTR
2 APPIie nt GRADING FEE
N NOLICR 10 APPLICAM:If,alter making this Certificate of Exemption,yen should WATER SYS'I 1:10 REATINC SOILS THE
Feiner,,,subject ,,the Worker's Cumpensauon provision,of the I.abor Code,you must
forthwith comply witbsucL pn:visior-o this permit shall he deemed revoked. WATER SERVICH
Q
as CONS'TRUCT'ION LEiNDINGAGENCY NI7W RIiSIDEN'HAL PLMB. SQ,EL PAID
U 'Z Ihercb rfioa hatnoee ixnccmlmctica renals fur that performance of Date Receipt% .
ya s.gm,er
V� Tho wosk Inr which Oliv punnit lx i,�neA(Sea 909],Cie C.)
w Lender's th is ' TOTAL
U Lender',Addre,,. TOTAL:
'Js W BUILDING lBili
I worry(hut I have rwA This up�Ileallnn ansl cute that the above inrnnnulinn s
C6yr TWA correct l agre,Iocony,Iy wimnll city mal,raryoninance,and seen,I.ws rclving to QTY MECIIANICAL PERMIT FEE,
U Z building mmstnwtioncane herehyma orivee'resemmtives of this city to emr,imm the SEISMIC ILII
abovo<nentioned property in inspection puTows' PERMH ISSUANCE D
(We)agr 'save,Indemnify unit keep harmless the City of CuNnino vguinst IiLHCfRIC PER u
liabilities,judgments,case,and expenses which may in any way wane againsls.id City ALTER OR A DD TO MUCH.
in ctmxequere,of the,..ming of this permit. I'LUMIIING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNITT(To IQ010 CEM) /J
SOURCE REGUTAI'IONS, MECHANICAL FEE
T
AIR HANDLING UNIT(OVER I0.00CFM) CONSTRUCT ION TAX
SNamurc of Ap,dica oComoctnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MA'1'ERIAIS DISCLOSURE
Will the applicant or future building occupant store or handle ha,mdous material HEATING UNIT TO 101,001 BTU)
as definM by the Cii,oinn Municipal Code,Ch.,,,,9.12,and the Health and Safety
Com.Sectio 2553200': 1 HEATING UNIT(OVER 100,000 BTU)
E]Yes FIN. VEiY]HAI']ON PAN(SI NGLE RESID) PAID
Date Receipt p
Will the applicant m tutee building then use equipment or devices whish
mnmonhv,nNmi
uus sir conmnvnby the as AeOncJ by Ray Area Air Quality Munug,ment BOILER—COMP f.3HP OR I00,000 OT1B O'1'AL
Dlmrin't
Ya ❑No BOILER—C(IMP(OVER IN)J W B J)
❑
I Laic n adlhe humnto-ntmcrial,re vmndcr Chnmrf,95 ofthe Coh. AIR CONDITIONER s, ,IISSUA-/�1N :DATE
yuiremm� P 4Y`
fbI'nin Ilcullh&Suli;ty Csslu,Su'tium 2.550.5,2.553?and 25514.1 undesumd Ihnl if the NEW RESIDEN'I'I Al.MECH, SQ.Irl
building docs nal enrrcolly an's o c man,that it is my resgonslbuity to notify the oecupnm
of the re,niremmus which nnal he met prior so issuance or Canilirnm o l Occupwey. 3
Owneror authnri'ecd ng,m Data Is 6 O ISSUEDBY:
OFFICE