22754 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building project Identification PERMIT NO.
B"iin ,"dd,a"� 7'Jlo( - ''II 0---. r'
Y
APPLICATION SUBMITTAL DATE
Q 22754
NO�Mknl CT�I�a �1c18 CITY OF
cmtr.e«'aN.m,< • ���� LU
Lk N. APPLICATION / PERMIT
t} hti'E �AcK LC fu nT• BRD NGELF�RCAP MBWGMECHAMCAL CATEGORY ONTROL.
Arthliect/Engineer: Lis N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PFRMITISSUANCE 1 ❑ 1:1 El
CONTRACTOR'S DECLARATION Lp
Ikrebyaf/IrmthatlamliceveduMerpe Wmso/chapter9(mmmm APPLIA CESRESIDEMTAL pB DESCRIPTION
ingwlth SrsMcm7000)o1 Dhddm3 ofthe Businessayid PmfeuimaCocie,and ory
license Is In fe fa effc2 �./ Z Z PANELS
Llcense Cbs Llca C/
Dat.�/�+ ��y'—Cmura¢or
I 1 ARCHITE S OECLARATMN )_01-1
K z I understand my pbro shag bo used a pub0e rends OVER IODO AMPS SQ.FT.FLOOR AREA f/SQ.Fr.
od EM
[d¢nsed Prfeslo OWNER-BUILDER DECLARATION SIGNS ELECTRICAL EiNAIJ- D ' N
!! 7��a IherebyafBrmthat I am exempt from the Contractor's License Law fee the SPECIAL CIRC UIT/MISL01 T
following reason.LSe+ims 70315,Business ant Professions Code My tlty or
!. jR
O I1TIP.METFRORI'OLE INST. a��
F5 entu, which reqs eetion rmB to Business a set Profpmv4 Code: ycity or L
anys Mmprl«toitsWamc alsurequimtheappb¢ntfaceudpe to T
POWER DEVICES DATE
[e O Ne a signed s atement that he b licensed pursuant to the provisions o/ the EG
3" Contract.el Lkerse Lw(Chapter9(mmmencingwbhSectin7000)ofDivi-
SWQAMING POOL ELECTRIC
t, 0 tl n3afthe Budne dPtalembm Code)orthdhebe rrTtthercfromand VALUAIJON.
6 the basis for the alleged exemption, Any violation of SeGlon 7m15 by any OUILETSSWITC33ESFDOlR(FS 12. K„
appBant for a permit sub a is the applicant to a dvil penalty of not more than ``
a- M ndrtd ddbn(5500). NEW RESIDENTIAL ELECTR
7 6 an owner of the property,or my employonswith wages a their sok SQ17' STORIES TYPE CONSTRUCTION
compensation,will Bothe w«kand the etreaurc b rat Irderded or offered for
O sok V.7IM B..trasa ant I4desloro Code:The Contractors LI.law
E3 does not apply to an owner of property who builds or improves lhereoRad OCC.GROUIa RES.UNITS
E whodoessuchwoh himself w lhrvugh hlaownemplgces,provided that such
Improvement.arenosintended caro/feredforsale.If,however,the Wile « TOTAL:
bnpmwe mbsulciwhMnoreyearofcompletlon,theownerWWerw lileve
tfpL*rdenofpmvinglhat he did not Wlldorimprovef«punpeseofsale.). QTY. PLUMBING PERMIT FEE
u 1 a owner of the property,am eacWsively Brimmidng with flemsed FLOOD ZDNE APN
contractors to BrslBG the project(Sm 7011,Business eand Professions Codr. PERMIT ISSUANCE.
The Condnctori Litmus,law don not apply to.n owner of properly who ALTER-DRAIN k VENTWATER MA)Wild. or Improve thereon,and who contracts f«such pngeets witha
ryW(+ctorfs)B¢nsed purww to the emtnaan's Lbmse law. FEE SUMMARY
LJ 1 am eaempl under Sec B 4 P C for thb reawn BACK FLOW PROTECT,DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
..sem WORKMAN COMPENSATION DECLARATION RETE T I
FIX'NRF_S PER.TRAP SCHOOLTAX Y_ N_
L}P eertby affirm that have a¢rtl0ote of consent 10 self-Inert,«a RF1:mrT
camilate of WorbenJ Cwnpewtbn Insurance or a¢rtRled copy thereof f$ec. GAS EA.SYSTEM-1 P/C10UH.ETS PARK FFP Y N
3800,lab CJ IZZI7 SL� ICI RDCEPra
1 GAS EA.SYSTEM-OVER 4(PA)
! Co rev )a�/h BUILDING DIVISION FTE5
Ten ed copybhercby mishea-' eREASE/Eulxmxl wASIE INTneeEPTOR PLANCHECK FEE
02LertRbd copy b filed with the dty bsprelon divbim.
CERTIFICATE OF IXEMPf]ON FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEIVFR-SANITARY-SNRM EA XIO,.r. Date Rccel t#
Ghlssetlbn need not be completed tithe permit b f«om hundred down
X001 ar 1tf1) WATER HEATER w/VExr/ELrr.rn ENERGY FEE Y N
I certify that in the performance o/the w¢4 for which Ws permit is based,
1 shall not employ any person in any runner n as to become subject to the WA.I.FRSYSIEM/TREATING
W«kms'Comperuatlon laws of CaWomY. Date PAID
O Z Applicant NEW RESIDENTIAL rMe. sQF. Date Recd t#
Z 2NOTICE TO APPLICANT.If,after makingthls Certfla
oteo/Exmptbn,you
should beBme orbita to the WurEen'Compenaatwn provisions of the Labor TOTAL
~ N Cuda you must forthwith Bmplywith such previsions orthb permit shall be
W ] dermed revolsed. BUILDING ITIE
CL c CONSTRUCTION LFNDWC AGENCY SE15MIC FEE
Iherebyaffirm thatth mbamrmtmdimlendingagencyfortheperform ELECTRIC FEE
M = an¢o/IheworRforwhkhthbpermitbbsued(5ee3097,CW.CJ TOTAL:
00 Lendee.Na re PLUMBING FEE
U_ Lendenindd. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Imrtlfythatl have read this application and Matethalthe above information,
S Iemrmot.Iagrcc to comply with all city and county ordinances an gat.laws PERMIT ISSUANCE FEES PAID,.
} rtlatmg to building construction,and hereby.uth.mu,representatives of thio
F CI dty to enter upon the above.mentbndi property for lopenbn purposes. ALTERORADDTOMF H.
? Me).grer to save,Indemrdfy an d keep h.rmden the City of Cuportmo Date Recd t#
V agalvt BabWlles,Iadgmenb,BatI.M expense which may inanywnyamue AIR HANDLING UNIT(TO I0A)0 CFM) SUBTOTAL:
gat la city in/mn.eg�aer�¢art thio p,�R� �IA�uNG UNIT(OVER lo,MCIWF ) CONSTRUCTION TAX
� `�p CONSTRUCTION TAX PAID:
Sigvtureof App HAZARDOUS
Date IXHAUSC HOOD(W/DUCT)
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or future WOding occupant Mort or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recd t#
materbl a defined by the Cupcni.M.Mdpal Cad,Chaplcr 9.17,and the
Hon❑ak,cad Safety Codee SS«tlom25533W7 HEATING UNIT(OVER 100,000 BM TOTAL:
WY.ill the appll¢marfuturt WBdingoavpanluse equipment«devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cMt hazardous air conlamW nb a deflned by the Bay Area Ah
Quality Management Distrust? BORER-NMP(3HPOR 10,000 BIM
RYe ❑No
havc sad the hon dws mate ah equU m nb under Chap er 695 of BO LII CV NP OVER 100,000 BTU)
the CaWomia Health 6 Safety Code,Sections 25505,7SM3 and 75531.1 I.. $�
understand that uthebuildingdoes maou rtIyhavvalen.rLthal It bmy NEW RL9OENl1AL MECdi. SQ.FT C P 1.
._ resporom04yto n¢Ifythe oaaparx of themquiremenbwhieh at be met �1
P to � aC<rtiBpateof parry. G� �I[`�'ry,1 Ea/ys.�{
ho�.Iell YJ ,
Owner«.uthorleed agent Date ISSUED BY:
rornL
OFFICE COPY