S 1974APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I I 1'1' NO
CITY OF Cy;PLUMB-NG - MECHAItUILDINC - ELECTRNIC---. / c_7 1974
ISl1I1,DIN, 1) VISION VISION APPLICATION/PERMIT umu)mlfrnnnmt:'r IDHN'I'IRICATIO 1
Sgblt P62
LICENSED CONTRACTORS DECLARATION
1 hereby affirm mal I am
m ucend under pmvismnz of Chapter 9 (commencing
0
CZ witn Section7000)ofDivision 3orlhe Business unit Profession+ Cade. end my license i.+
° n r.11 force and effect.
zu�
QU License Class� Conor m T'SDE
ANCHITELTS DECLARATION
zOtnz I understand to, plins,hidl bit used., public rcennls
Oz`s
F'3 h M !Limned Professional
ON
❑ Consultant Fees Paid by Applicant (Initial)
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W° i-
F y
pp y;
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1 OWNER -BUILDER DECLARATION
1 hereby affirm mal 1 am exempt from the Conlmcmed I.i'vele Lew for the
follewing reason. (Section ]0315, Busincsa and Profession+Code: Any tiny or county
whirl. myui .. a ter it I cunntnl.1. alter, improve deumli'l, a c"r..l' any sw.trom
nail to file a 11'red emmnam
requites the visions .for Con pe g
pursuant mlhc ptuvisionsn the
that he incensed personal
that License Wo(Chaptercdvor
1111WL
D KITCHEN REMODEL
DADIIITION.
1900
d y m C
LLXl lye
Z QD
4 m
offCommcmr's
me ccenmd
(commencing with Section7000)no haivi, for oftheegedrsantl Pnr An, 64
teat he
IM1m rte is exempt Ihercfrom and the nasi+for the alleged exnnptiva Any violation of
Sa,enn 7031.5 by any applicant for a permit subjects the upplicont are civil penally at
not mere man Eve hundred dollars (8500.
1, as owner of the property, or my employees with wager as their sole compenvtion,
will do the work, and the �wcmm is not imended or named for sale (Sm.70TI. Business
and Professions Codd The Cu.itorelo', L,mnw Law docs nal apply m no owner of
DSTRUCI'URAL
MODIFICATION
DINfER10R
6
property who hui Ids or Improves !hereon, and who does such work hi ntcdf or through
his ,an employees provided mal such improvemems are nal intended or.neral for
silo IL howmnn the building or improvement is sold within one yem of completion, the
GSWIMMINGPOOIS
D BATH REMOUI:L REPAIR G DEMOLITION
D O'1'11HR
owner. builder will have the burden of proving that he did not bend or improve for par-
poseorsale).
Ej 1, as owner of the property, am exclusively connecting with I cemed contractors to
instruct the pmjecl (Sec. 7814, liminess and Professions Cale:) The Centimeter's 1.1.
ceruse Law does not apply to an owner of property who builds or improves thereon, and
QTY,
who contracts for such projects with a eoln melons) licensed purmam m she Contncmr's
s e Law.
l un. mento nota Sea , B & P C he this reran
net 0
WORKER'S COMPENSATION DECLARATION
I hereby.Ilio under penally of perjuryone of the lirllowing declandi
❑ I have and will maintain a Certificate of Comentto self-incure for Work Compcn-
xldioq as provided for by Section 37M mine Wbot Calc, for the pe ante of the
work for which this permit is issued.
D I huvc and will nminmin Worker, Cm fran,ulion Insnnlnm, cohered by fimninn
3]1X1 nI the Labor Cale, for the performance or the work for w this permit is issued.
!thy N'otke" Compenmlion Insumntt norm anJ Policy n ram.
Cartier: Policy No.:
CI: RTII I CAT] i OFE"''ONF WORKERS'
COM If EMIN --NCI;
(This srmidn need urn hecanplemd ifthc it is Bt ranehundrNdo1lms(S100)
or less.)
cemifythot in the performance oft vfk for wlhich this permit is issued,lsbull
Olz
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nm cnlploy any pcmnn in any manner so oho'mnerunjcellolheWnde,Contpcn-
+Minn laws mCnlifomia. Date
Applicant -
NOTICE 'M APPLICANT: If, aft making this Certifinm of Exemption. you should
become subject.) the Worker' a u penmlinn peovisiomot the Labor Cnde, yon lnmt
Gmhwilh comply with 'atop mor lFls pa'lnit ,boll be dmmhW ruvnked.
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0.
A
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CON RUCTIONNQ(�JJasWWUING AGENCY,
1hembyuflinnthm cc nacnmJGjFtibn leodihigagmmy fonhe pcRnrmantt of
the work for which it ilr is lssned(Sce. 3119], Crv. C.)
Led . Nam 1' "•
s
. C_
QTY
Lend . Add .ss 1" t
I c iffy than 1 ve mailohs appll/�nm andA:ue but the Myo,informationC
lanenlg the ply th 11 'flys ilge tY�rll. once lid tt'Pw: rel lobo
atIf rig construct h andibrebyandhon' �Ir_ t t axoflh IY1 c IcnP II
un i roperty f : pmbon ps'
(We) a c to save, indemnify an
liahilinics,jud enl,mv, and extemes
mscyuc enl the granting ul Ibis pct
APPLICA UNDERSTANDS AND
SOURCE EGULAI'IONS.
/ HAZ RDOUS MAT41rr4,y}TISCL(SLR 'a •tet/ —
illtneapplicunlnrfunurehuildingoteat ,tons, handle maroons In .1
JefrAl by the Curveted. Municipal Code. Chalief 912, and tthe�i4al rely.
bile, Section 25.532(a)?�n .a C
❑Yes [:1 No Signature
Will thespplicanlor furore buildin�hr��cypaniYse cyulp ur Jdvices whuir
emit h:verdous sir cdnlaminant+a.a define f[JJp
DinrimP
❑Yes E] No
1 have mad the hayed.., materials Inluiremems under Chapmr 6.95 of the Cali
fomin I realm & Seely
ry Code, Seclinm 255!15, 2553. W. I undenamd that if the
building Jac nothuvcnlen.nt,ohm it i,ury slily Mdttenpmrt'
of oM rcyuiremenn whim muu he met prion. issuance of n Ccetiricam of (kcupanry.
Owner nr outhndeid agent Dote
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDEN'I'I AL
PANELS
UPTO2W AMPS
SIGNS ELECT RICA].
SPECIAL CIRCUITIM ISC.
TEMP. METI R OR POLE INS!'.
FEE
PERMfr ISSUANCE
ETTFli-11RAIN & VENT- WATER EA)
BACK FLOW 1'ItOTEC'K DEVICE
DRAINS - FLUOR, ROOK AREA, CONI).
FIXTURES -PIN I'RAP
GAS - F.A. SYS TEM- I INC. 4 OUTLEI S
GAS -P.A. SYS TEM-OVIN4(EA)
GREASHANI ltl SrrRL WAS'I'1i 1NTF,RCEPI OR
GREASE: TRAP
SEWER -SANITARY- S'I'OEM HA. 200 IT.
WATER THEATER WNENT/ELECTR
WA'IHR SYSTEMiTREATIN ,
WAI'Up SERVICE
NIiW RFSIDEMI'IAL PLMB. SQ. 14.
PERMIT �, FEE
PERMIT ISSUANCE; '•'')
ALTER OR ADOTO MECIL! r y
fFNNDLING%qj ]T CIO 10±0 CPM)
' .
AIR I IANULING UNIT (OVER IO,q)tl CEM)
IiIb1TING UgUJ IT'D Ig1,1NN1 BTU)
!!BATING UNIT j.
E ton000 BTI])
VENTILATION CAN (SINGLE RESID)
ypl4)IFllN1,000 BTU)
I I AIR CONDITIONER I I
CE
SQ. FL
to q
L
JOB DESCRIPTION
J NT
1111WL
D KITCHEN REMODEL
DADIIITION.
❑PLUMBING RE-PIPH
D MULTI -UNIT
DSTRUCI'URAL
MODIFICATION
DINfER10R
GCHIMNIiY REPAIR
IMPROVEMENT
GSWIMMINGPOOIS
D BATH REMOUI:L REPAIR G DEMOLITION
D O'1'11HR
COMMERCIAL:
El NEW BLDG/ADDITION 0DEMOLI'ITON
0 T17NANT [I FOOD SERVICE
IMPROV", ENT
00'1'14ER
FT.
VAI
SI ORIES
OCC. GROUT'
0
Hl
PLANCHECK Ir'E
ENERGY F -E
GRAIN
SOILS FE'
PAID
Dale Receipt p
TOTAL:
BUILD! FEEortj
(J
SEISMIC FE .
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING A1ITIGA'ION FEE
Did, Receipt#
ISSUANCE DATE
F—( 0-q y
•• Inspection Query 04fic Permit J 2/2*0
PERMIT#i_.
SITUS ST
r- '.tNSUESCRIP - In'sT p
_ITUS$TREET Lot# R:
ATEDESIRE
—
i f6Oo7i inspecfo Units Pass/Fail OPOe7-
S1974
20400
ISTEVENS CR
FRAME
8/11/98
8/11/98 DS
41P
S1974
20400
ISTEVENS CR
PLBG-R
8/12/98
8/12/98 DS
1 F
S1974
20400
ISTEVENS CR
DRYWALL SCREW
8/13/98
8/13/98 DS
3 P
S1974
20400
ISTEVENS CR
PLBG-R
8/13/98
8/13/98 DS
1 P
S1974
20400
STEVENS CR
CEILING
8/26/98
DS
1 F
S1974
20400
STEVENS CR
MECH
8/26/98
DS
1 F
S1974
20400
STEVENS CR
PLBG
8/26/98
DS
1 F
51974
20400
STEVENS CR
T -BAR
8/26/98
DS
1 F
S1974
20400
STEVENS CR
ABOVE CEILING
8/31/98
8/31/98 AD
3 F
51974
20400
STEVENS CR
T -BAR
8/31/98
8/31/98AD
3 F
S1974
20400
STEVENS CR
R MECH
8/31/98
8/31/98 AD
3 P
S1974
20400
STEVENS CR
R PBLG
8/31/98
8/31/98 AD
3 P
Page 1