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CITY OF COS7a nnESA CONSTRUCTION PERMIT
ProjectAddress ��a- W • �� ��� � �
Applicant's Mailing Address
Owner's Name �� K� � �-�Phone
Address '
Arch/Eng. License No.
Atltlress ��,, � ��
Contractor'sName�/�-���Jy��LGS/—�.�usv—�i�� ��K-.vhonef'�'`�`i`�y
Addreu (mailing) �83 � `^'.�� N/c�. fi��• Z'�'�"� '
Ciry License No. 3��%�
LICENSED CONTAACiOR OECLAFATION
I hlrCby a(firm that I am lic¢ns¢tl untler proviSiOns of Charter 9(Commencing
with Sec[ion 7000) of Divi5lon ; of the Busine55 antl Protes5ion5 Cotle, dntl
my license is in full foice antl etfect. � .
�icanse c�ass ' c' 3� enso q. .�
Date � '37 --A 7. 5ignature '�
wORKERS' COMPENSATION qE RATION
, .¢Dy affirm that 1 hav¢ a Cerp(� a o( tonsent to 581f-Inwre or a cerUqcat¢
NOrkers' Compensa[bn InSUrance, or a certltletl Copy thereOf (SeCtion
� ,,..JO, l.ab. G.) �.�.�.'•
PoIICY No.�� $7 I y��'�ComPanY ���V'"" � ^w��
� �rtifietl copy is hereby fumished. . �
� er�ifi��py is 'lea with the city Builtling DI��i lon.
Oate __� APPqaant
EXEMPTION FROM WORKERS' CO P NSATION DECL ATION
(This sec[ion neetl not be tomplatetl' e permit is for on undretl (5100) or
less).
/ certify tnat in the pertormance of the work for which this perm�t is Bsuetl, I
shall not employ any pe�sOn I� any manne� so a5 to become subject to the
WO/ke�s' ComOensation Laws of Califomia. ,
Date � Si9na�ure
rvOTICE: H, aiter making Ihis tleclaration, you zhoultl become subject to the--
Workers' Compensation provl5ibn5 Of [he Labor Cotle, you must forthwi[h
cOmply with such p�ovlsion5 or lnis pe�mit Shall be tleem¢tl revOkeO.
CONSTHUCTION LENDING 4GENCV '
I hereby affirm tha[ there is a<onstruction lentling agency tor the pertormance
oi th¢ work fOr whith this p¢rmit is issuetl (Se<Ilon 3097 Civ. 0.)
Lantler's Nama
Lentler's�Atltlre55 -
OWNER BUILDEN bECLARAYION -
I herebv aftirm that I am exerrlDt from ihe Contrdcto�'s License'Law fOr the
county which reqwres a oermn to consvucc, aite
any snucture, prlor to i(5 issuance, alm require5
to tile a signeU Statem¢nt t�al h¢/She I5 Iicen5e0
the.Contractor'S Li<ense law (ChaD�er 9 (comma
;from antl tne basis tor the allegeC exemption. Any violatlon ot Section
1.5 by any applicant fo� d Oe�mit Subject5 Ihe applicant [o a Civil
�e0dlty,oi not mor¢ [nan flve bUntlreO tlollars (§500).
I, a5 owner of the P/oper�y or my employ¢as with wages as th¢ir sole
compensation, will tlo the work, antl tM1e sVuc[ure Is not intentletl or offeretl
ror sale (Section 7044', Business antl Professional Cotle: The ContraC[Or'S
Li<ense law tloes not apply [o an owner of a proparty who builtls or Improves
the�eon, antl who tloes such wo�k himself/her581f o� through his o� her own
em0loyees, provitletl Ihat Such imprOvements a�e not Intentletl or ofter¢tl to�
Shc2. It, howev¢r, lne builCin9 br Improvement IS soltl wlthin one yea� of com-
pletlon, the owner will nave the burtlen ot proving he/she tlitl not builtl or im-
p�Ova fo�the purpose of sale).
❑ 1, as owner oi the property, am ezclusively contractin9 with Ilcensetl con-
t�att0/s t0 cons[rUct the projecl (Sectlon 7044, Buslne55 antl Prote551on5 COtle:
The Contractor's License Law tloes mt apply to an owner of property who
builtlz or improves thereon, antl who conlracts Por such projectz with a con-
tractor(s1 i�cense pursuant to th¢ Contractor's �icense Law). I am aware that
prOof of tneir Worker's Compensatlon insurance shoultl-be provitle0 to me.
❑ I am exempt untler $ection- B. & P. C. for this reason .
Date Own¢�
I hereby certity 'tnat I have reatl this application antl state that Ihe.above
Intorma[ion is mrrect. I agree to comply with all clty antl coun[y ortlinances
antl state laws relating to builUing construction, antl hereby authorize r¢pre-
Sentatives of lhis city to ent�5 upon th¢ abOve-mentionetl p�operty Ofor
InSPection py�poses / !/� O�f� Daia ���%'O g
519natul� -)"'✓Ii !f ,/
TVPE OF CONSTRUCTION LJ rvEt
,0 CONVERSION ❑ DEMOLISH
DESCRIPT�ON OF WORK/USSpF B
heavy bortler
ADD�
an0 slgn all a0D/oDriate Caciarations.
�� UNIT NO.,
ALTERATION LJ REPAIR
TYPE OF PERINIT LJ GRADING LJ fOUNDATIOW LJ STRIKTU
❑ TENAIVT ❑ ELECTRICAL �aLUMBING ❑ MECHANICAL
❑ OTHER
PROJECT DESCRIPTION Sa. FT. � ' OCCUPANC�
CONSTRVCTIONTVP�� VALUATION$__
20NE GRADING CV. VDS. ACRES-
Remarks:
Bar Sink
Bacliflow Preventer � �
Backflow�lrrigation '
Bathtubs
Clarifiers •
Drinking Fountains
Floor Drains
Floor Sinks
Gas Service � 4 Outlets
Interceptors
Kitchen Sink •
Lavatories
P-Trap
Roof Drains
Reinspection Fee �� $15
Boiler
Duct - Under Ground
Duct -Strucmrel
Duct - Ventilating
Exhaust System ❑ Multiple ❑
Firepl/PacL BIL ICBO #
Heating System & Ducting
❑0-100,000 BTU 0100,OOOBTi
Reinspection Fea
Drivers' Idc se or 55 � �- - � �
CMF 0865�46, rev. ]0/B4 White • gulltling; Canary - Applicant; Pink - Actountinq; Goltlenrotl - Aszessor
$15
Showers •
Service Sink
Sewer Cap
Sewer Connection
Solar Collectors
�Solar Pipin9 . �
Solar Tank
�Swimming Pool w/Spe
Urinal
Water Closet
Water Heater �
Water Service �
Auto�Waih
Laundry Treys
laue Fae
Hoad or Typel ❑
Canopy Type II ❑
Refrigeration System
❑aioo,000eTu ❑�oo,000
System Repair/Alteration
Fire Dampers
�Registers _.
laue Fee
A.P. #
S Main Buildi
E
T Front
B Rear
A
C Ri9ht
c Left
Ping. Ref. #
Planning Notes:
, �.5.�-.._ .�..� ��.
2one
� r �
.... � • _ ; •.7 : : - -
Automatic Washer
Construction PoleSub. .
Cooking Unit '
Dishwasher .
Dryers ❑Gas ❑Elecvic
Fan
F.A.U. � •
Fixtures
Device Boxes -
Outlets
SWitCh¢5
Garba9e Disposyl
Generator �0.5�KW C
Parking Req./Provided
ELECTRICAL�
Transformer ❑ 75-50KW
❑ 50+KW
Me[er ❑up to 100amps '
' Meter ❑over100amps
Sub Panel
Motors �0.1 HP �1:5 - 8
Inc. Solar 09-15 HP �76-75+
Microwave �
Pole Light �
Range �
� Standing Sections
5-15 KW Trash Compactor
$ 3 I
�- Reinspectian Fee $15 Issue Fee
FEES
- DEVELOPMENTSERVICESREQUIREMENTS:
Zoning ApProved By
� Building Approved By �t�[.,(�p/
Appli�ation Issued Bv �--�--�`h � ' A-
$ 3
SUMMARY OF I
BUILDING PERMIT $
PLAN CHECK S �
P�UMBING $
PLAN CHECK 25% $
EIECTRICAL � $ �
PLAN CHECK 50% $
MECHANICAL S
PLAN CHECK 25% $
C
FEES
$
Z
O
N
I
N
G
R
E
Q
M
T
S
SMIP $
PERMIT �
ISSUANCE� $ ' �
ENERGV P.C. 5 �
GRADING $ - _
MICROFILM $ �
TOTAL FEE $ � QD
CONSTRUCTIONAND.PLANNING � POOL&SPA � -.
�APPROVALS Permit # Date � Inspector qppROVALS Permit # Date Inspector
1. Temporary Electrical�Service or Pole 52. Pool & Equipment Location
2. Soil Pipe-Undrgrnd.,' � 53. Steel Reinfarcement
3. Electrical Conduit Utility-Undrgrnd. 54. Forms -� i
4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding
5. Steel Reinforcement" 56. Rough Plumbing & Pressure•Test
6. Electrical UFER Grnd. -' 57. APPROVAL TO COVER-GUNITE
7. Footings . � � 58. Electrical Conduit-Undrgrnd.
8. Foundation , � 59. Gas Pipe, � Undrgrnd., Test �
9. Water Pipe-Undrgrnd�. � . , 60. Backwash Lines, P-Trap, � Undrgrnd. .
10. Structural Floor System � 61. APPROVAL TO DECK
11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final
12. Sewer Cap � 63. Heater & Vent-Final �
7 3. Roof Drains � 64. Plumbing System - Final
14. Rough Plumbing 65. Electrical-Final
15. Rough Electrical-Conduit 66. Solar System-Final '
16. Rough Electric Wiring � - 67. Fencing & Access Approval
17. Rough Wiring Sign , 68. APPROVED FOR PLASTERING '
�
18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL •
19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT � ,
20. Rough Factory Fireplace � . APPROVALS Permit# _ "w
21. Ducts, in Structure 70. Underground Hydro � '
22. Ducts, Ventilating 77. Product Piping O Gas ❑ Oil '
23. Gas Pipe-Rough & Test 72. Underground Flush . .,
24. Roof Framing 73. Undergrnd.StorageTank OGas ❑Oil r-'�-
25. Roof Sheathing 74. Overhead Hydro
26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical� ,
27. Frame and Flashing ' 76. Dry Standpipe ' � .
�
28. Lathing & Siding 77. FIXED SYSTEM FINAL � •
29. Insulation 78. FIRE PREV. FINAL '•
30. Drywall Nailing ' � HEALTH DEPT. REQUIREMENT
31. Plaster Brown Coat '. 79. FINAL INSPECTION .
32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED . •�
33. Final Electric ' Notes: . �
34. Final Heating & Air Conditioning • �•
35. Final Gas Pipe-Test �.(�-$'� (� . ' �'
36. Hood or Canopy
37. Final Factory Fireplace _. '.
38. Final Plumbing �((�� L(rp ,
39. Water Service-Final '. '
40. Gas Service-Final � � - �
41. Solar pomesticFinal ' - � -
42. Backflow Preventer � � �
43. Backflow Irrigation � �
44. Landscape Irrigation System �
• 45. Sound Attenuation • ,
46. Handicap Regulations � .:
47. FINALSTRUCTURE&BUILDING ' � �',t ,
4S. �Special Requirements Completed 'y� � �
49. Electric Release to Edison � --
� 50. Gas Release to Southern California Gas Co � '
51. CERTIFICATE OF OCCUPANCY
No. Date
•� . �