S 1445 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPFRTINO BUILIIIN(:-ELEC'I'RACAL 111,1811'NO
CAL
BUILDING DIVISION APPWCATIOWPRRMI PING PRNG.SH:CHANIFIC \J 1445
RI111.IIINO IROJISCT II11SN'fIpICATION
fi LDINGAFFRESS: SANITARY NQ APPLICATION SUBMIT FFAQnAIII
(`� 1� a
� S NAME: I'IION C " ACI')I:S:S NAMh` LIC NIC
IROhK
•I iYl �S 5-�7 S Vh4 ��`c chS
ARCHIFECf/ENG. EER: LIC N(l: RESS: ❑
A14-
CONTACT: /� PHONE: BUILDING PERMIT INTO
W-2
///� ❑ Consultant Fees Paid by Applicant(Initial) BLDG LEC( PLUMB M[CII
LICENSED CONOTRACTOR'S DECLARn'I]ON QTY ELECTRIC PERMIT FEE
1 hereby nfrtnt that I ton licensed under pr.vi.i.ns nr Chapter mummenc;ng JOB DESCRIPTION
ZCZ with Section of Division 3 ufthe Business and l'massions Gmannd my Names is RESIDENTIAL:
4100 wt 111iRMIFISSUANCH
F kur in Nil force send t 3 �yN9i8 ❑SFDWI. O KITCHEN REMODEL
¢V O Licens C ss Lie# APPLIANCES-RE.SIDIiM1AL ❑ADDITION ❑PLUMBING RIi-1'IPE
FzW Data Contractor
on¢d •\HCH'ITCTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANEIS MODIFICATION
z o;!1�.�-/ r.mnd my pons I H he used as pnnHw records
Z�� A UP T021XIAM1'S ❑LITERIOR C3 CHIMNEY REPAIR
P,:4 t: 1 Licensedl 2UbIgX)AMIS ISIPROVEMENT E]SWIMMING I'OOIS
�¢Is,W / OWNER BUILDER DECLARATION OVER RXXIAMPS OBATHREM EPAIR ElDEMOLIT
C W¢ 1 hereby affirm that I am exempt from me Contractor's License Irw for the
3.La.F- following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS IJ.ECI'RICAL ❑OTHER
,� which requires a permit to construct.altar.improve demolish,or repair any structure:
F't="CI prionnim iu...ac.aku.,.am,meapphemat fnrokh permit In FiR.,i,mil vmemem SPECIN.CIRCUITIMISC.
that he is licensed pursuant o the provisions nflhe Commit License lrw(Chapter 9
z2�C�0 (commenting with Section71X01of Division 3 of the Buninns and Professions CIAO air 'DIME Ail OR POLE INST COMMERCIAL'
4
c.a e C that he is a.empt therefrom and the ba.Hs for the alleged exemption.Any violation of O NEW BLDGIADDITION O DEMOLITION
^h Section 7031.5 by any applicant for a permit subjects the applicant uracivil pcnahy of IN)M'LR DEVICES [I TENANT ❑FOOD SERVICE
not none than five hundred dollars($5001 IMPROVEMENT
550 L]Las owver ofthe property.or my employees with wages as their sole aompanaion, SWIMMING POOL ELECT RIC
F will do the umk,und thestrvcmm is nut immnd-mitrad Irritate,(See 7044.Businros DOTTER
a 3 ea and Professions Code:The Commam's License Irw Jens nut apply m an sm or,of OUTLET'S-SWITCHIS-FIXTURES
property who builds or improves therein,and who Jrns such work him e f or through
his own employees,provided that such improvements are not intended or offered for NEW Rf SI ENI'[Al.EIX R SQ FT.
sale.If.hossevcf.the building or improvement is sold within one year of completion.the SQ.FT FLOOR AREA 5/50.14.
mer-builder will have the human of proving that he did not build or improve for par
rocot sole.). TOTAL: P '` � D
❑1.as owner of the pmpeny,am eeclusively contracting with licensed contractors m
onsouct the project(Sea.7014,Ihv,im%s and Professions Calc:)The Comrectur's I.,. p�q
t1 (NS
Asa Ww does not apply to on owner of progeny who builds or improves metoon,and QTY PLU GPiRMIT FEE nJN� Ol p#ra#rD
who contracts fur such projects with a contract. ❑ u
.. licensed pursuant the Contractor.,
License Law. 1112RMIT ISSUANCE
❑1 um exempt under Sec. .It&P C for this reason
ALFCR-DRAIN V '1' 'ATI iA) II I HV\CIAATION
Owner [)ate
•
WORKERS COMPENSATION DIiCLARAIION HACK FLOW PR0d'LCD IC
1 hereby a0inn made(punnity of perjury one of the t'ollnwing dcclamttons:
(] I hmamdwill maintain.Ceniticmo of Consent o self-insure for Worker's Fontlxam DRAINS-FLOOR.ROORAH A. D STORIES TYPE CONSTRUCTION
scion,as provided for by Section 3900 of the Lather Gxic,for the sarfmntance of the
work for which this permit is.,sued. Iq%'FURLS-PER'I'RAI'
❑ 1 have and will muimain W..ker'v Compcnswion h=smrence.us required by Section
3710 at the Labm Gate,limhe parhsrmeac eflhc work for which losperatit is issued. OAS-I(A.SYSTIIM-H HNC.40(P'LE9'S OCC.GROUP APN
My Wnrk"x Cnm '"O=f'rricrand l•oHlryt GAS-PA.SYS'fl!M-OVIiR4(BIG
/ Carrier'0 lIONy No.: L8
CI!RTIFIC OM'VE SAI 11INSUR 1 WORKERS' GRIinSIsJINOUSfRI.WAS'T'E INfIIRCl31TUR
COMI9?NSn'1'IUN INSURANCI3 BUILDING DIVISION WILS
CI'bissccti.nIasi not hecnntplvaYt it the permit is fornne hnnJreddnllms(SEMI] GREASE'DN' — —
I'LANCHCCKPEE
,it less)
I certify that inlhep.rErnnmcenftbn work lir w hill,thio larnit'u lssned,l shall SEWER-SANITARY-SFORM ITA.20114.
nnanploy any persr many ..n.. tarsons to hmnre-subject l,,PC WnrkeM m ComMENERGY roe
ita
Z odor Lws.f Caotoroia.Fate WAFFIt HEADER W/VHN'I71FLECTR
Applicant
NOTICE
GRADING17]
ti NOTICEIOAPPLICAN'I!II,.1lernlakirg dr,celtilicnle ill lhcmpnnn,you should WA'1'lilt SYSfIiM/fNIiA'fING
SOILS FEE
been c'object ,,the Worker's Cnnrprelation p.rvisi.na of the Lubar Cita,You must
Wforthwith comply with-wet.prusivionsr,this)mail shall had am.it rcvu r, WNI Fit SERVICE
Z CON$'1'RUCI'[ON LENDING AGENCY NEW RIiSIDRN"fIAI.PLMH, SQ.Ef. PAID
IImoNyaffumthmdmmisumnsuncd..asadingagencytor meped.rmaneo of Oao Raalptp
W. the work[.(which this)cunt.is Issued(See 3097,Civ.C.) 'IO'rAL
O Isodur's Nome 'PII'fAL:
r W Lender's Address _ BUILDING FEE
y 1 ccnify that I nave read this applicmiov and sone nett the above infornmtuin ie
Hp) cone,I.,me n,=imply wim:dH city and coramordrance,.,d mare laws mlming m QTY, MECHANICAL PERMIT FF,E sulsMle FEE
U buddingamtmrnlon,and hereby aehuriac rep'ecmutives of this city(center upon the
.txwc-mentioned property Iia inspection purJros. PERM❑ISSUANCE ELECTRIC PER
(Wel agree m save,indemnify and keep hon law d.City o1'Col man again.
Hintalities,jtdgrani crisis and.spc'nses which may in any way.ecme against said City ACI'ER OR ADD TO MICA. PLUMBING FEE
in tucq.ence of me smming of mil Permit.
APPLICANT UNDERSTANDS AND Wild.COMPLY WI'I'�._NON-I• AIR HANDLING UNIT TO HIJXXI CFM) MECHANICAL FEE
SOIIRCP .Ill. TI(1NS. n L
AIR HANDLING UNI'1'(OVIiR IILIXXI CIM CONSTRUCTION TAX
Signal fAPPlicu lmoaaor Data 17XHAUST HOOD(WIDUCq HOUSING MITIGATION FEL
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or future building occupant sons,or handle hurmduus"'turned IWINE'INC,Ull0100.000 B'ED)
as dcfinal by me Calcium,Municipal Care,Cha ra,9.12,and the Broth and Safety
Code,Section 255321x)7 BRANC UNIT(OVER 100.001)HE
p Ye, E]No PAN
VI3NIILAf10N FAN(SINGLE BESIDE Date RecciPtp
• e Will the applicant nr future building occupan tau aquipmem or Jevicas which BOILER-COMP(311POR 100,(X0 BTU)
mit harardoas air conmminams as defined by the Hay Area Air Quality M...gmnera TOTAL:
Dison❑^. BOILER-COME,(OVER 101.000(ITU)
Oyes Fl No
I have marine loo dous momriaLsnniuirermm.s malar Ch.pmr 6.95 of the Cali- AIR CONDITIIHER ISSUANCE DATE
fomia Fieahh&Safay Cala Sections 25505.25533 ata{25534.1 understand that if Be NEW RESIUCN'I[Al-MSCI I. SQ.FT
building docs not currently have a tenant,that it is my tesptmsibikly ht notify the eccuryat
of the requirements which must Be tut prior to isnmwc of a Ceniticce of Oeeulaney.
Owneforamhmird agent Data TOTAL ISSUED BY:
OFFICE