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Home My WebLink About100 Casa Unit B Permit HistorySifi'tu[q,gplilpo BUILDING PERMIT Miscellaneous EPM-3549-2016 I ssuance D ate: 21 1 9 1201 6Building & Safety Division.919 Palm Street. San Luis Obispo, CA 93401-3218 ProjectAddress: 100 Casa Street 0 Unit or Suite(s): Project Description: Contractor Furtado & Sons Plumbing (Manually Verified): Business: (805) 543-7037 Owner: %EBV PARTNERSHIP Assessor's Parcel Number: 052-183-082 Legal Description Fire Sprinklers: Census: Occupancy: Stories 0.00 CodeYear: 2013 Dwelling Units:Motel Rooms: Construction Type: Dimensions Category: Valuation SQFT:Group Type sq. Ft Factor Valuation Fees Payments Receipt #Fee Name Fee Amount Date Amount Permit lssuance Gas System Repair/Replace/Extend $172.00 $52.00 2t19116 5,863-02-1 9-201 6 Total Paid $224.00ffi Total Fees $224.00 Plan Check Account Payment by Contact Gontact Name Account Name Status Total Gredits Total Debits Account Balance Total Account Balance Balance Due $0.00 Legal Declarations tr2 IDENTIFYWHO WILL PERFORM THE WORK 2a - CALIFORNIA LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license is in full force and effect. #3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in section 3706 of the labor code, interest, and aftorney's fees. 3a - WORKERS' COMPENSATION DECLARATION I hereby afiirm under penalty of perjury one of the following declarations: I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. #4 DECLARATION BY CONSTRUCTION PERMITAPPLICANT By my signature below, I certify each of the following: I am a CALicensed Contractor. F\,, {>-Februarv 19.2016 Signature of Contractor, Authorized Agent or Owner Date a Building Address IOO CASA R Project Description TENANT TMPROVEMENT - CENTRAL COAST OBSTETRICS & GYNECOLOGY Occupancy Group: -P Occupant Load:Permit Number: 28414 Fire Sprinklers Provided No Building Owner:T TCKNtrSS DANINY T, TRF tr,TAT, Owner's Address:1OO CASA ST #ts SLO CA. 93401- Date 2nU20rs Citl of San Luis Obispo This certificate is issued pursuant to Section I 10, Appendix Chapter 1 of the 20i0 California Building Code and attests that at the time of issuance, this structure or portion thereof was inspected for compliance with the requirements of this code for the occupancy and division of occupancy and the use for which the proposed occupancy is classified, and determined to be in compliance with this code and the various ordinances of the City of San Luis Obispo regulating building construction or use. $ifi'Lut*,gpl$po BUILDING PERMIT Alarm FtRE-l078-2015 lssuance Date: 41 1312015Building & Safety Division . 919 Palm Street. San Luis Obispo, CA 93401-3218 ProjectAddress: 100 Casa Street. B Unit or Suite(s), B Project DescriPtion: FIRE ALARM Contractor: Smith's Alarms & Electronics Business: (805) 61 9451 0 Owner: LICKNESS DANNY L & SUSANNE E FAMILY TR Assessor's Parcel Number: 052-183-079 Legal Description: CY SLO PM 29145 UNIT B & PTN LT 1 Fire Sprinklers: Census: Occupancy: Stories 0.00 CodeYear: 2013 Dwelling Units Motel Rooms: Construction Type: Dimensions Category: Valuation SQFT:Group Tvpe Sq. Ft Factor Valuation Fees Payments Receipt #Fee Name Fee Amount Date Amount FireAlarm System $291.00 4t13t15 4113115 2,058-04-13-2015 2,059-04-13-2015 Total Paid: $210.00 $81.00Total Fees $291.00 $291.00 PIan Gheck Account Payment by Contact Contact Name Sr,thb Al"rms & Ele"tt""i"- Account Name Status Total Gredits Total Debits Account Balance FrRE-1 078-201 5 tn use $210.00 $210.00 $0.00 Total Account Balance $210.00 $210.00 $0.00 Balance Due $0.00 Legal Declarations #2 IDENTIFY WHO WILL PERFORM THE WORK 2a - CALIFORNIA LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license is in full force and effect. #3 IDENTIFY WORKERS' COMPENSTATION COVERAGE AND LENDING AGENCY WARNING: Failuretosecureworkers'compensationcoverageisunlawfuland shal lsutiectan eploye tocri niral gal tiesardci vil fi16upto $'100,000, in addition to the cost of compensation, damages as provided for in section 3706 of the labor code, interest, and attorney's fees. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. #4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT By my signature below, I certifu each of the following: I am a CA Licensed Contraclor. April 13,2015 Datenature of Contractor, Authorized Agent or Owner 'ruro ctuy o; san luls oBtsJo diorir -Q21Q o 1aa a1 onBuilding & Safety Division . 91 Project Address 100 CASA B Legal DescriPtion CY SLO PM29I45 UNIT B &PTNLTl Assessot's Parcel Number ICS & GYNECOLOGY Project DescriPtion Permit Type Property Owner Mailing Address City/State/ZiP Contractor Mailing Address City/StateZiP Project Manager Lender Name C.B.C. GrouP Census 437 TENANT x Building X Mechanical X Electrical X Plumbing LICKNESS DANNY L TRE ETAL OccupanVBusiness Name CENTRAL Sign -Demolition -Grading COAST OB/GYN 1OO CASA ST #B ArchitecUEngineer License #sLo cA,93401- Contractois Phone No. 925-8779ALAN ROINESTAD CO Contractofs State Lic. N o. 721912646 INDUSTRIAL PAR]<WAY,1OO SANTA MARIA CA 93455 Project Manage/s Phone No. Lender Address 541-3848BRIAN STARR B - Commercial C.B.C. TYPe V-B Stories 0 Codes: CBC'13 cEc 13 Alteration or Addition Dwelling Uiii-s 0 Motel Rooms 0 Valuation Non-Residential Alteration Fees Building Permit Plumbing+Electrical+Mechanical Permit Grading Permit s.M.l.P. Green Building Fee Demolition Permit Sign Permit Misc charge/credit 265'00Administrative Permit Archival Fee subtotal 1'988'88 lnvestigation Fees Building Plan Review Fee Fire Safety Plan Review Plan Review Subtotal 2'069'15 Development Review Fee Fire SafetY Surcharge Fire Systems Fire Sur/SYs Subtotal 0'00 Construction Unit Tax Water lmPact 0.00 Area - Water Meter lnstallation Wastewater lmPact 0.00 Area - Traffic lmpact 0.00 Area - Affordable Housing Public Art Code Enforcement Park lmprovement Area - Engineering Development Review Fee Open Space ln-lieu Fee Total Fees Balance Due 122,700 2,713 Sq Ft @ Total Building Value $122,700.00 $122,700.00 1,693.11 0.00 0.00 25.77 5.00 0.00 0.00 0.00 0.00 -Legal Declarations 2a - CALIFoRNIA LICENSED CONTRACTOR'S DECLARATION I hereby afflrm under penalty of perjury that I am licensed under provisions of chapter 9 commencing with Section TOOO of biuj"ion 3 of the Business and Professions Code, and my license is in full force and effect Contractor: ALAN ROINESTAD Class: B License#: 72'1917 3a(2)-WORKERS'coMPENsATloNDEGLARATIoN.lhaveandwiIlmaintain workers' comPensation insurance Fee Exemptions: Comments: stormwater fee 0.00 2,069.15 0.00 1,655.39 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 '113.50 0.00 0.00 0.00 0.00 as required by section 3700 of the Labor code, for the performance of the work for which this permii is issuid. My workers' compensation insurance carrier and policy number are: Carrier: Policy #: 7600000986412 Expires L0/0'11!5 5,826.92 0.00 Payme Amount nts Payment #1 Payment #2 2,069.'15 3,757.77 5,826.92 Date 05130114 10to6114 Receiot 65454 67304 Total Paid Application Number 1 40434 Application Date 05/30/14 Permit Number 28414 lssuance aatelf;iiFffTT- Address File or Date ,ru ctuy o(-san luls oBtE)o Buildinq &Division . 91 s GoBGfo ugti o,n &errmits4o 1 -321 B . (805) 781 -71 80 Project Address 100 CASA B Assessor's Parcel Number 052-1 Legal Description CY SLO PM29145 B&PTNLTl Project Description ANTENNA MAST ON ROOF Permit Type X Buitding Mechanical I Electrical Plumbing Sign -Demolition Property Owner LTCKNESS DANNY L TRE ETAL OccupanUBusiness Name CENTRAL COAST OB/GYN Mailing Address 100 CASA ST #B ArchitecVEngineer License # Contractor's Phone No. City/State/Zip SLO CA, 93401- _Grading Contractor Mailing Address City/State/Zip OWNER Contractor's State Lic. No (JWNEI( Project Man ager ROBERT Lender Name C.B.C. Group Census 437 Lender Address -B C.B.C. TypeV-B Commercial Alteration or Addition Valuation Non-Residential Alteration 1,000 Fees Total Building Value $1,000.00 $1,000.00t--Legal Declarations 2b(1) - OWNER-BUILDER'S DECLARATION - l, as owner of the property, or my employees with wages as their sole compensation, will do all of the work and the structure is not intended or offered for sale. (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. lf, however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it was not built or improved for the purpose of sale) By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. 3a NOT SPECIFIED Fee Exemptions: Project Manager's Phone No. ag+-ZS2S Stories 0 Dwelling U-nits 0 Codes: CBC07 CEC07 Motel Rooms 0 Building Permit Plumbing+Electrical+Mechanical Permit Grading Permit s.M.t.P. Green Building Fee Energy Surcharge Accessibility Surcharge Demolition Permit Sign Permit MiscCharge/Credit 0.00AdministrativePermit Archival Fee Subtotal 168'50 lnvestigation Fees Building Plan Review Fee Fire Safety Plan Review Plan Review Subtotal 131 .27 Development Review Fee Fire Safety Surcharge Construction Unit Tax Water lmpact 0.00 Area - Water Meter lnstallation Wastewater lmpact 0.00 Area - Traffic lmpact 0.00 Area - Affordable Housing Public Art Code Enforcement Park lmprovement Area - WateMay Management Fee Open Space ln-lieu Fee Engineering Development Review Fee Total Fees Balance Due 49.49 98.00 0.00 0.50 't.00 0.00 0.00 0.00 0.00 19.51 0.00 0.00 131.27 0.00 122.65 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 422.42 0.00Payme Amount nts Payment #1 422.42 Date 04t15110 Receiot 46598 Total Paid 422.42 Application Numberl00294 Permit Numbet 24575 ApplicationDate o4l15l'lo ) Address File lssuance Date 04/15/10 Comments: or 1 roH|$ clty o[.qan luls oBls'l ffiBuilding&SafetyDivision.990Palmil6.ffr[tfi3.fi"fl.Tffii.i.9.(805)781.718o Project Address 100 CASA B Assessor'sParcelNumber 052-183-079 Legal Description CY SLO PM29I45 UNIT B & PTN LT 1 Project Description 1 NON-ILLUMINATED WALL SIGN Permit Type Building Mechanical Property Owner LICKNESS DANNY L TRE ETAL Mailing Address 100 CASA ST #B City/StateZip Contractor Mailing Address City/StateZip Project Manager Lender Name SAN LUIS OBISPO CA,93401- U.B.C. Group B U.B.C. Type V-N Census number Electrical Plumbing X Sign -Demolition Occupant/Business Name MISSION MEDICALASSOCIATES ArchitecVEngineer License # Contractor's Phone No. 000-0000 Contractor's State Lic" No.o00000000 Grading NOT REOUIRED cA 00000 BRUCE ROGERS Project Manager's Phone No. Lender Address 466-51 57 Dwelling Units 0 Stories 1 Codes: UBC 94 NEC93 Motel Rooms 0 Valuation Fees Value ons 1. OWNER BUILDING I am exempt from the Law for the following reason: [ /, as owner of the propefty, or my employees with wages as their sole compensation will do the work and the structure is not intended or offered for sale. n 1 as owner of the property, am exclusively contracting with licensed c-ontractors to construct the project. I Not applicable. 2. WORKER'S COMPENSATION DECLARATION: I hereby affirm that I have a ceftifrcate of consent to self-insure, or a 'certificate of Workers' Compensation insurance, or a certified copy hereof V ceftified copy is hereby furnished- I C",tifi"a "opy is fited with the City. L) Not appticabte 3, CERTIFICATE OF EXEMPTION FROM WORKERS COMP.INSURANCE I I ceftify that in the performance of the work forwhich this permit is issued, I shall not employ any person in any manner so as to become subiect to the Workels Compensation Laws of California I Not applicable NOTICE TO APPLICANT: If, after making any of the foregoing declarations, you become subiect to any Labor Code or License Law provision, you must comply with such provisions or this permit shall be deemed revoked. I certify that I have read this application and state that the above information is coirect, I agree to compty with all city ordinances and sfafe /aws retating to building construction, and hereby authoize representatives of this city to enter upon the above-mentioned propefty for inspection purposes. Unless noted under "special Conditions", this permit becomes null and void if work or construction authoized is not started within 180 days, or if construction or work is suspended or abandoned for a peiod of 1 80 days any time after work is commenced. Special Conditions: Total Building I Declarati $0.00 Building Permit Plumbing Permit Mechanical Permit Electrical Permit Grading Permit s.M.t.P. Energy Surcharge Accessibility Surcharge Demolition Permit Sign Permit Administrative Permit Miscellaneous Charge/Credit lnvestigation Fees Microfilm Subtotal Building Plan Review Fee Fire Safety Plan Review Plan Review Subtotal Fire Safety Surcharge Construction Unit Tax Water lmpact Water Meter lnstallation Wastewater lmpact Traffic lmpact Total Fees Balance Due 58.30 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 58.30 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 58.30 000 Payments Payment #'l Amount 58.30 Date 06/30/98 Receipt 2450 Total Paid 58.30 Application Number 80565 Permit Number {2636 Application Date 06/30/98 lssuance Date 06/30/98 Address File Comments: , Authorized Agent or Owner 7/ee/77 ff RRM DESIGN GROUP "l r r iiiir'r lrirr'' iri:riririii.,.' i rr1:;ir r'i i;r,..' ii;ir'ril,rs August 4, 1987 City of Building POBox San Luis Dr. 100 Attention: Building Inspector San Luis Obispo Department 81 00Obispo, CA 93403-8100 Lickness Remodel Casa Street, Suite D' rc) ^haW Re Dear Sir: As project architect of the above listed project, I have determined that the Certificate of Construction Compliance, signed by the General Contractor (as listed on the Title Sheet, Item C of the General Notes) is not required by the architect for this project. If you have any questions in regard to this matter, please feel free to contact me. Sincerely, RRM DESIGN GROUP Chris Ford for Robert Kitamura Senior Vice PresidentArchitecture Division cF/RK/pb cc: J. Gann Enterprises lo:6 South lligirera Strte t, Sirn Luis OL.isPt,, (.rliiornja .r:+,rr Eo;i 5-lj- r /94 ..i r rlri,rrLa ( {'rf,'rlJ.rl 1 ctty oF san Luls oBtspo Certificqte of Occupqncy THIS lS TO CERTIFY thot the building described below wos constructed under Building Permit No. Dr. Dan Lickness 3364 , This structure, owned by ond locoted ot 1.OO CASA STREET, SUITE B, SAN LUIS OBISPO' CA meets oll the requirements of the Uniform Building Code for Group --- -!-:?-------occ u po ncy, Th i s certif i coti o n o p p I i es to INTERIOR REUODEL of this building ond remoins in effect until such occuponcy chonges. August 7 n i987 By Chief Building r MlcRoF;Llb{FA SAVE onreiirti; ctf,yco - r''of U san Luls oBtSpeL NSTRUCTION PERMIT A 3rs6 Department of Community Development,990 Palm Street/Post Off ice Luis Obispo, TYPE OF PERMIT ! Combination !! Retaining Wall !n Remodel tr Electrical Lot tr Demolition ! Moving 0ther ! Plu n Building mbing !Mechanical nSolar nGradlng Parking Project Address 100 Casa, Suite :1 Use Zone o Lot Number I Block '?\r, 29-45 T 'aat Calif orni a ?;ark Assessor's Number f/-t2i.!+/L; Beach CA Day Phone Jt^-.t /44,1/+a > -{]'l l-r - Phone E,J..& Architect or Designer i.ichmond Rossi i'loutgomery Address /+16 liiquera St. . SLO. C4hone 543-1794 Lic. No. OCCUPANCY & GROUP TYPE OF CONSTRUCTION V-rai FOUNDATI0N: D Wood EConcrete ! Stan ! Piers/Caissons FRAME: ftWood Stud E wtetal ! Timber n Masonry Tenani- Add Day Phone- PROJECT IN RMATION Type ol Project: Proposed Use: Tnterior demol-ition Setbacks: Front- Sides- Rear- 710o, Ns2 264J Garage- Barn- Carport- Covered Porch Storage- No. Bedrooms- No. Bathrooms- No. stories- Building Height RetainingWall ln{ormation: Length- Material Mobile/ Modular Home I nlormation: Year- Serial No.- D.o.H. No.- State- No. Bedrooms- I ocrtion EXTERI0R WAIL: n Wood Siding p Stucco n Masonry Veneer E Masonry E grict< ! Concrete Block E Metal D.M.V. Lic. No. STATE REQUIREMENTS: E tnergy ! Sound n Handicapped Moving Building lnlormalion: Present ROOF F!Built-up E Metat n Composition Shingle n tite Wood Shingle/Shake HEATING: n Electric Q Gas Furnace n Gas Wall E Solar LEGAL DECLARATIONS LICENSED CONTRACTORS DECLARATION: I am licensed under the provisions 0l Chapter I (commencing with Section 7000) of Division 3 of the Business and Prolessions Code, and my license is in lull force and etfect. License class B* 1 License Number 4,s3L7 A contractor J. Ganrr Enterprises Darc 2-5-\7 OWNER BUILDER DECLARATION: I am exempl lrom lhe contractor's License Law l0r the lollowing reason: E l, as owner of the property, or my employees with wages as their sole compensation will do the work and the structure is not intended 0r ottered lor sale. Sl, as owner ol the property, am exclusively contracting with licensed confraclors to construct the /pftiiect. ! I am exempt under Sec.8. & P.C. for this reason Localiry- Presenl Proposed Use-Tot. Lin. Ft. ol Fdtn.- Grading lntormation: Tot. Tot. Fill-Cu. Yds.; Area ol Cu. Yds.; TOTALVALUATION...... Plan Check No. Gombination Permit Building Permit Electrical Permit Plumbing Permit Mechanical Permit Othgf: .llprrnl i tinn $ ?rl -,',i^, Other: n Construction Unit Tax TOTAL FEES TOTAL PERMIT FEES $." Date X WOBKERS COM PENSATION DECLARATION I hereby aflirm that I have a certificate ot consent to self-insure, 0r 'a certilicate of Workers' Compensation lnsurance, 0r a certilied copy hereof (Sec. 3800, Lab. C). ! Certilied copy is hereby lurnished. n Certilied copy is filed with the county Depa4morlL- REQUIREMENTSI water Fees to be paid I Fire Hydrants for Const. E Sewer Fees to be Paid E City Business License fl C/G/S Permit Reg'd. Dl State Contractor's Lic. ! Encroachment Permit El otner /to"' Date- CERTIFICATE OF EXEMPTION FROM WORKERS COMP. INSURANCE I certily that in the perlormance ol the work l0r which this permit ii issued, I shall not employ any person in any manner s0 as to bec0me subject t0 the Worker's Compensation Laws 0l California. SPECIAL CONDITIONS i\.-r=t, ,..', tza-t\ cl i-\c. ! .';)-1 Q---,--' '\' |\- t t'' q^ io \- E,,Z: t- ir r d -"r,1, r l\41 '" i' 5 r,l,r-r .1-1,-y. ;,ri t \1rr t- t li:$- i:i-t I I ,'-C.,i r./,--l i !3 i-lr..;,,-r- F '..,1',' .; .:,-r,:.'1,:, 'i .i '-'i 'i..,\\(J NOTICE OF APPLICANT: lf, after making this Certilicate 0f Exemption, you should become subiect to the l brker's Compensation provisions of the Labor Code, you must comply with such provisions 0r this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby atlirm that there is a conslruclion lending agency lor the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Address I certify that I have read this application and state that the above inlormation is correct. I agree t0 comply with all county ordinances and state laws relating to building conslruction, and hereby authorize representatives 0l this counly lo enler upon the above-menlioned property lor inspection purposes. NOTICE " this permit becomes null and void it work 0r construction authorized is not 0r il construction 0r work is suspended 0r abandoned l0r a Signature 0f owner (ll owner Builde4 YELLOW - File VALIDATION Iohn L. iteller:nan/;i,:t Lender's Name Unless noted under L-21-s7 Authorized Department Representative WHITE - Applicant PINK-Assessor GOLD - Couote/SEO DATE TOTAL AMOUNT Date I t, Cr ' "-,/-) ^t'4 j..,'- rLlAo'* " cq*t:l',*i; .-ttVtJ t $ oty of (- san LulsoBtspor-; CONSTRUCTION'PERMIT A 3?G{ TYPE ()F PERMIT E Combination! Retaining Wall ! Building tr Remodel tr Electrical tr Plumbing n Mechanical n Solar tr Grading n Parking Lot n Demolition ! Moving tr 0ther Project Address 100 Casa Street, Sui-te B Use Zone O Lof Number 79/Ptn" I ggs61 Cal Park tract 993 Assessor's Number 52-L?,2-7 g Dr. Dan Liclc.ness P.O. Box 29 Pismo Beac Day Phone 489-56100wner Contractor i rti , - ij-C "d.-!Phone0rAddress Architect or Designer Richnond F,ossi llont OCCUPANCY & GROUP EXTERI0R WALL: ! Wood Siding I Stucco E Masonry Veneer n Masonry n grict< n Concrete Block ! Metal R00F: n auin-up n uetat ! Composition Shingle n tite ! Wood Shingle/Shake HEATING: I Electric ! Gas Furnace E Gas Wall n Solar LEGAL DECLARATIONS LICENSED CONTRACTORS DECLARATION: I am licensed under the provisions of Chapter 9 (commencing with Sectlon 7000) of Divisi0n 3 ol the Business and Prolessions Code, and my license is in lull lorce and etfect. License Class r)- I License Number 483 170 Contractor Jdhfl)Gr6trdrtrlnmB3ng'nrtc 1+-8*87 " , ;.,.atl: i,::t+;--;1-r1.'s6", fl:C. OWNER BUILDER DECLARATION: I am exempt lrom the contractor's License Law lor the lollowing reason: n l, as owner 0l the property, or my employees with wages as their sole compensation will do the work and the structure is not intended or otlered tor sale. ! I, as owner ol the property, am exclusively contracting with licensed contractors to construct the proiect. ! I am exempt under Sec.B. & P.C. lor WORKERS COMPENSATION DECLARATION I hereby aflirm that I have a certificate of consenl to sell-insure, or 'a certilicate ol Workers Compensation lnsurance, or a certified.copy hereol (Sec. 3800, Lab. C). Certified copy is hereby furnished.,#Certified copy is tiled with lhe county Planning i'"'Date'---:Z tsi' il- Appticant Unless noted under.:'Special and void if work or construction authorized is ndt is suspended or abandoned lor a Address 416 lIiguera' SLo" CA pnone 543-179& Lic. trlo Day Phone- PROJECT INFORMATION TYPE OF CONSTRUCTION v-i{ FOUNDATI0N: lWood EConcrete I stan D Piers/Caissons Setbacks: Front- 277 0 FRAME: E wood Stud E tuetat ! Timber D Masonry Carport-_ covered Porch- Deck- TypeolProject: I]'ITERIOR RT"IODEL eropor.o urr, conmerrtial-/of f ice SidPq Rear Barn---_-r-- Material Mobile/M0dular Home lnformation: Manufacturer- No. Bedrooms- No. Bathrooms- No. Stories- Building Height Retaining Wall lnformation Year- Serial No. Locality- Present D.0.H. No STATE REOUIREMENTS: I Energy f] Sound I Handicapped Moving Building lnlormation: Present D. M.V. Lic. N0. - State- No. Bedrooms- I ocrlinn I lqe this reason Proposed Use-Tot. Lin. Ft. of Fdtn.- Grading lnformation: Tot. Cul Cu. Yds.; Tot. Fill-Cu. Yds.; Area ot Disturbance- TOTALVALUATION...... Plan Check No. Combination Permit s 200,00c. Building Permit Electrical Permit Plumbing Permit Mechanical Permit Other Other TOTAL PERMIT FEES n Construction Unit Tax TOTAL FEES $ s53.i)11 E63. D0 REQUIREMENTSI water Fees to be Paid n Fire Hydrants for Const. E Sewer Fees to be Paidl-J[[ City Business License tr C/G/S Permit Reg'd. E State Contractor's Lic. E Encroachment Permit ! finer t *..,-.-., Lender's Name Lender's Address SPECIAL CONDITIONScERTtFtCATE oF EXEMprtoN-Fnou woRreRS coMP. INSURANcE I certify that in the perlormance ol the work for which this permit is issued, I shall not employ any person in any manner so as t0 become subject to the Worker's Compensation Laws ol Calilornia. NOTICE OF APPLIGANT: lf, after making this CertiJicate of Exemption, you should become subject t0 the \rbrker's compensalion provisions ot lhe Labor code, you musl comply with such provisions 0r this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby atfirm that lhere is a c0nstlucti0n lending agency for the performance ol the work lor which this permit is issued (Sec. 3097, Civ. C.) I certity that I have read this application and state that the above information is correct. I agree t0 comply wilh all county ordinances and state laws relating to building construction, and hereby authorize representatives ol this county to enter upon the above-mentioned property for inspection purposes. NOTICE /-- "---'-VALIDATION "Iohn L. Kellerrnan/jkt 4-6"8"i Signalure ol ol owner (ll owner Builder) Authorized Department Representative WHITE - Applicant YELLOW - File PINK - Assessor GOLD - Counter SEQ DATE TOTAL AMOUNT Date r./tcrl0FtLMED $AVE ORIGI${AL