S 2428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CPPY�P CUPRR•PINO If UILIIINf.�ELECJ'RI CAl� /J� 'ERMIT NO.
BUILDING DIVISION APPLICATIONWERMIT I'INCPRNG.NECIIANIC.U. re5 {//�_ (+ /I n O
❑IJILUING vHUJI!G'1'IDENTI FICA'rION O 4 G Q
_1,JILDING ADDRE i) A APPI.ICAl[ON SUBMITTALDATF.
/ Pee6 veli /cJ
OWNE'R'S NAME' PH�OcNE: - CONTRACTOR'S NAM'!: LIC NO:
z-55W NIC CONT'ItOhM
-AmokI 'lll'II' ENGINI'�R: LIC N(l: "h+` ADDRESS: ❑ '
J Y/�\ xriA7- I \
CON'I'ACIJGV10` 11 PHONE: BU ILDINGPERMITINFO
�IIQUPX 65L Z74 - 0( ❑ ConsultantFce.PaidbyApplicantTridial) BILLDDG/�ELECr PLUMB MECH
A lY .JZ LJc ❑. ❑ ❑
LICENSED COST RACTOWS DECLARATION QTY ELECTRIC PERMIT FCC.
1 nearby mBmh that I at liveried under pmai,ma,of ChE r aoumormg _ t - JOB DESCRIPTION
DMZ with Section'nXq)ofDivision 3of me uusine.x and Professions Code,and illy license ie RESIDENTIAL
.WOO PE.RMI I'ISSUANCE
F in full force and checo
sr W-' (� ❑ShDWh ❑KI'1'CIIIIN REMODEL
a_U I,iansc Class Nlu.ro APPLIANCES-RESIDENTIAL ❑ADUI'I'ION ❑PLUMBING RE-PIPE
ri7jW U Cunni"f'r
a,iGG ARCI I I'IITC'I"S DECLARATION ❑M(ld[-UNI''' ❑SI'RIIC'I'UI2N.
E,P m PANELS
ZO°'Z I understand my plans shall lee used as puhhe record, MODHHCAIION
OZ- UPI'0200AMPS ❑IN'I'IiI210R ❑CIIIMNI!Y REPAIR
FQ��W Lnemed Professional 201-I000AMI'S IMPROVEMENT SWIMMING POOLS
CY .4 OWNER.BUILDIiR DECLARATION OVER TXXIAMPS ❑PATH REMOIIEIIREPAIR ❑DEMOLI'I"ION
tY S'Q 1 ncecby affirm that 1 um exempt from the Contractor's I.i.m.I.aw fur the
X3 6 U fallowing reason.portion 1031.5.Business and Profession,Cade:Any city ur county SIGNS ITA:C'FRFCAL ❑OI'i TER
W a in which reyuim,a permit Io construct,nitnp inhprose.demolish,or repair any structure
C) prior to issuance,also acquires the applicant for such Permit to file a signed smmnmm SPECI AI.CIRCUIUMISC.
Eby that he is licensed pursuant to the provisions(if the Contractor's license Lrw(Chapmr9
1�¢O (commencingwun section]W(1l of ilivision3 nfthe Business and l'rnfcxninn.v Cndcphr TEME ME'IIiR(ll<IKl1.P.INS COMMERCIAL:
6Mo e' Thin he is evetnpt therefnmt and me basis ror ate allcgul enemptlon.Any violation ul' ❑NEW BLDG/ADDITION ❑DFMOLI'I'ION
iC t+. Sactien 1(131.5 by any applicant fm n pennil subduct,the nppliumt u:a civil penult,of POWER DEVICES
- ❑'fl!NAN'I ❑FOOD SERVICE
^'Z
I'll,more Than live hundred dollars(5500).Y IMI'ROVEh 171,11
xes 'i I•asowner arthe prosumc mm rou wages .aleSale cnmp.....ins, S\VIMMINO I'(IOLI!LELTRIC
F- will Jolhewon,andthasomreurn,',I.itsmorav,doesor,,,.,,I, it.11 I,.c,o. ❑OTI{lilt
m tmA I'rufcssiom Cale:The Cmnmcuhr's license law tices nm appy'nh un owner of OU'I Lli'I S-SWI'I CITES-FIXTURES
property who brilds or improves thereon,and who does such wad himself or through
his awn employees,provided shat such impnasmems am not intended or offered for NEW RESIDENTIAL ELECTR SG
sale.If.however,the building or improvement issold withinone year ofcompletion,the SQ.Fr.FLOOR AREA SISQ.PT.
owmar-buildhara have the harden of proving that he did not build or improve for pur-
Tsec oLsnle.). �/
I]1,as owner of the property um exclusively contracting wbh Beta sed contmmors to TOTAL: /1
,vamuruct he P mer,(S 7044 If 111 fiewinic,C.d.)I he C ' I :L- t•
wh1 d . I lidyt tProperty 'n h 'll: 1 :n d QTY. PLUMPING PERMIT FEE,
n0 ux f:-wclp hjemx w)I i.. t lon,)IecuMp r...........te l deli, I _
Idcen.e law. PERMIT'ISSUANCE
Into exempt under Sea B&1'C for this Trains
Owner Dale ALTFit-DEALS&VENT-WATER(EA) VALUATION
WORKER'S CIIMPENSA'1'ION DECLARATION BACK ITLOW pROrECr.DEVICEx[/y l
I hereby affirm under Penalty of pe jury one of the 10110w of tleriamillia : J 00/ "_
Ihave andwill maintain a Certificate ofConsenuo self-insure for Workcre ComPen- DRAINS-FLUOR,ROGEAREA,GOND. STORIES TYPE CONSTRUCTION
.;tion,as provided for by Station 321X1 of the Labor Code,for the performunce of the
work lin which this permit i,1....J. FI STORES-PER TRAP
❑ I have and will maintain Worker's Compensation borriv re,in natured by Section
17k0ofde,Labor Cade,for the Nem..tnunceef'he work fur which Oil.prunil is issued. GAS-17A.SYS'I'HM-1 INC.40IJTI.EIB OCC GROUP AITN
My Worker.Contpensdien Insmancu cal ocr mhd Pulley mimher aro: -
Carrier Policy No: GAS-CA.SYS'I'IIM-(OVER 4(EA) ��j'I
CERTIFICAIE OF EXEMPHON FROM WORKERS' VV
COMPENSATION INSURANCE GI EAS131IND(IS'IRI.WASTE INTERCEPTOR
BUILDING DIVISION PI!IIS
(ihis.eninn Decd nm b.:cotnplcicJ if Ihcpenni'is for one LunJreJ Julian(51(X))
nr ars') GItIiASIi'i'RAP 1'LANCIIISCK FT:C
Iced{fythal in lhcperfnrmanendtnc work fim,hichbispemtil is i...rL Lshill SEWER-SANITARY-STORM EA.200 IM
not employ any person in any manner m ms to O
become subj; o the Workers'Cuntpen- C:NI3NGY ItiE
Z satins Laws of Culiforce,hale WATER1{I!ATI!R W/VF.NT/F.LECTR
2 Applicant GRADING FEL
h NOT CIE TO APPLICANT.If,uBurmnking tIu%Certificate of Exemption,you should WATER SYS'I'EMET HEATING
f•+ become sub at ro the Worker's Cont easation f the Lubar Cndc,you mixt SOILS FTU
i r proni.bhmn
PJ I'cnhwiih comply with such luovmmns or this pttnnit shall be deemed revoked. WATER SERVICE
A
7z CONSTRUCTIONorro,aun, U?NDINGAGENCY NIIW ItESIDIiNTIAL PLM It. Sp,I'I', vAID _
C.J 0 Ihereby nf0muhauhere 1,nennswdirn lending agency fur the perfnnnance of al R;eipltl
the work for which this pemhit is issued(Sec 3091,Civ.C)
f"h Leader a Name 'r(GALE
V Lender's Address TO'T'AL:
F y 1 certify Ihm I have read this upphemin.end ,are Inas rhe abave infrmealion is - BUILDING d!Is. -� fJ
,00
zn rorarct.lagreemromply with all city:nW rnumy arJinances and stale law.reWtinx lu QTY MECHANICAL PERMIT FEE ..
U Z buildingcunswctienn and herehy:mthurizc repre.enwtives of this city nhmnr uqm the SEISMIC SEE
shove-meanound property far impaction purpsnes. PERMIT ISSUANCE
(We)agree m rove.Indmnnify urd keep fannies, be City of Cnpenino ngn.re, ELEC'[RIC P
Hubilitic.,juJgmems,cognundcnpcnscs which may in any way accrue again,'said City AIB'HR()It ADD 10 MI!CH.
in nn.cyumne of the granlingy4Y'a Ph:rnii1. PLUMBING PI!I?
NTLI ANT UNDERSEA )S A Il WILT.COMPLY WI'fll AEI.N(INPOI N'I' A1I211ANPLING I1NI'r(TO Ifl,lJdf)CPM)
5(IIJf ; I1 F, ATIONS. MECHANICAL Idil3
AIR HANDLING UNIT'(OVER 10.0X01 CI M)hi CONS'TRUCTI(IN TAX
FSignof �mr or Unc GXHAUS'1'lIOUD(W/WCq HODSING MI'1lGA'fl(IN HY.Iin LAI GUS MATERIAIS DISCLOSURE
mar more builJing'hccupam store or hendlc hanMous matctial 1 IEMINGUNII'(10100,00 BTU)Din Municipal Crhde.Chapter 9.12,and the Ilenhh vnd Safety
(e)'! HEATING ONI'I'(OVER 100.000 BI'IE-1 No PAID VEMI'lLA'I']ON VAN(SINGLE RESID) pule Re;ipiM
f Will the applivant or filum bulldii1g occnpanl use e9uipntemor dwias MIT ❑OILER-CUMI'(31IP OR If1l),fNX111'1'()
i'u hantNnux air amtaminunlx ax def Dad by the Bay Arm Air Qnnllly Mmmgemenl Tfl'1'nl
✓ sni I
❑YesNu BOILER-COMP(OVER 1001000B1U) ^
I have read theh bus materials myuirements under Chapter 6.45 of the Cad- AIR C'ONDI'TIONER ISSUANCE DA'I'13
famin Ilcahh&Safety Cale.S ,)5505,25513 and 255JJ.1 unJemaul that if the NkiN'RI?SIIIENI"L\L hJEGH. tip.IT. / _ (� _
he din Ices cunemlyhen n.thm it is ry responsibility tit notify the cec'mant l F
of:M is which mu. to issuance of a Certificate(if Occupancy.
Own nn ' a gem Dare TOTAL: ISSUED It Y:
OFFICE
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