99110074APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERT'INO BUILDING -ELECTR
BUILDING DIVISION APPLICATIONXERMIT rLust B!NG- MECHA:
OFFICE
_. __._ 153 -6 9-36
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ADDRESS: ^yy
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CONTACT:`� PHO�NYEG �I r� qr�
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[DConsultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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hICI?N.til?Il CON 'IHACfUNS UhCLARA'1'ION
heresy affirm that 1 am licensed under provisions of chapter 9 (commencing
with Section?000) of Division 3 either Business and Professions Codcend my license is
in ran waCee and effect. _ a
4cense Class Lae.
Data- Condom FxSA
ARCHITECTS DECIARA'L'ION
I uodentand ry i lmxs shell he used a, ,ad he rwaNs
QTy ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SPUWL ❑KI'TCIIEN REMODEL
❑ADDITION [I PLUMBING RE -PIPIT
Oh1ULTI-UNIT ❑STRUCTURAL.
MODIFICATION
E3 INTERIOR FICHIIINEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
❑ HATH REh10D'�RIiPAIR ❑DIih1OLIT ON
El OTHER
PERMIT ISSUANCE:
APYLIANC�S-R IDENl'IAL.
PANELS
UPT0200AMY5
Licensed Professional
OWNER-BUILII[k UIiCLARAI'ION
I hereby anion that 1 am esempt from the Commuter'. License Law for the
following reason. (Section 7031.5, Btomds.. and Professions Gale: Any city or county
C"Cure, ' I ',t a I Ih. ' F til p any saucurC
primu, it,':. I y m ppkwa ma,fu1Eps ,an, file asi,ded,ndearson
that tic licensed ptt the provisions of the Cormi License Law (Chapter 9
hermoudc,gwth Section 7000, fb]amtnT fthe lm,i cs 11 f msCNc)'r
mat he is Csempl Ihwefmin, and Ise basis lir the alleged emmmien. Any vham of
Settien]I1l LS by any applicant forupermit objects the applicunnoacivil Femally of
not mon than rive hundred dollars(1500J.
I] Lo the%ornf the thepeny, re, is otintendes with wages maeir sole(Sec. comped......,
will do the work, and the strmure is not intended or offered ferrate (Sec.]OLt,Bminns
and Profession, G.le: The Contractors License Low does not apply man owner of
Property who build, or enprldes thereon, tool wha dna, such work dinsellc through,
his own employees, provided that such improvemen¢ am not intended or offered for
,ala. If, however.thebuilding erimpmseman issold within one yea of nnnpinion. the
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MIS
TT:MI'. METER OR .1; INS
COMMERCIAL:
❑ NEW BLDG/ADDI'rIONr 0 DEMOLITION
❑ PROV ❑FOODSERVICE
IMPROVEMENT
❑OTHER
POWER DEV ICFV.
SWIMMING IOL ELECTRIC
OUTLETS-SWITCHILS-FI01
NEW RESIDENTIAL. BLECTR
SQ. IT. FLOOR AREA
ASQ. Ff.
t hand nr intpefor per -
ownechuilder will have the burden of proving That be did norov
,,a o1'su1c.).
❑ L as awnef of the property, exclusively con cid nmtrcmrs
TOTAL:
riming :) Thei-
nstrn the pmjsat (Sm. ]UYi. I3us and loo@, ns CsxleJ TheCnmmcu,r,
. B
aLi-
r,
mown.and
sclnwdocsnrnch d
awn+nonateduny whesed
Q'TY. I'I,UMBING PERMIT FEE
-
parr,nnproves
who cemractsfor such projec¢wimmm�tractorts)IicenseA punuammlM1e Comracmr's
Projects
_
PERMIT ISSUANCE
License Law.
I mu osempt under Sac .B&PC lbr dins moon
OI
ALTER -DRAIN & VENT - WATER (EA)
d err Date
VALUATION
BACK I7LOW 1'R 1'HCT. DEVICE
#1
WORKER'S COMPENSAHON DGCLARA'I'ION
I hereby alifr, under penalty of Perjury one of the following declarations
iiUT(j c�
enoself-inure for Workers Comped-
have and win maintain a Certifcme of Comu
smmn, as Provided for by Swam 3710 of the LaMrr Core, for the pedbrnurcc of the
DRAINS -PLOD . ROOEAREA,CO'
SIORIES
TYI'Ii CONS 'I'RIIC2'ION
rk in which this peruit is issued.
FIXTURES - PER IRAP
1 have and w'BE maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code, for the pedommncc of the wed for which this Nnuit is issued
My Worker G�nn ,s nnlnwtanc Curtin and Policy neo o in
Cannery. r '7T-�1� Policy Na.: 0- Can
ly
cEKIEFRATF.OPpXEMPTION PROM WORKERS'
COMP17NSATION INSURANCE
OCC. GROUT'
AI'>
O
GAS -EA. SYSTEb I INC. )UTLIHS
GAS-EA.SYSTEM ) :RJIIiA)
GRIiASU1NDl1ST 'ASTB INTERCIiI'IT)R
BUILDING DIVISION FEES
(Missection neednmbeeompletediOM1e pe. fit, fnronenundeaddonars Bl(Xb
or less)
GREASETRA
PLANCI{ECK [:BE ,
I,mfyddasen duc,dommnwnflhework for which Bo,enrn is issued, l Mull
not employ any Person in any manner so m to become subject to the Waderi Compcn-
SEWER -' NI'TARY-S') IEA. 210 Fr.
ENERGY FETE
I WATER EATER WNEM1T/E1IiC 1Z
t DING FE,�\
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z O
=
C Q
5 z
U 0
CS. L-
WLender,
.�. Iail
U z
cation Laws of California. Date
AppliC:mt I
NOTICE 10 AMILICANI: If, after making oris Ccnificam of Exemption. you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this porn shall be deemed revoked
CONSTRUCTION L17NDING AGENCY
1 herebyallinn that hem i.sa rorwrnlon leraim,.gency for the pantformanttof
the work for which Thi, Fenn.. is issued (See 3097, Civ. C.)
I.Cnder's Name
WAI'I2R SYS 'TEMTIU ATING
I=
FEC
AT 11 t t
WATER SERVICE
NOV 15 1999
NEW RESIDENTIAL PI,SIB. SQ, 19''
Doc Rcaipt p
TOTAL'
-
TOTAL:
Address
II:UtN'RI'BB —
I certify that 1 have read this application and state that Oto above Informamm is
correct. I gal comply with all city and coumy ordinances imitate law, relining to
building construction. and hereby sunburns, representatives ofdas city to enter upon the
QTY, MECHANICAL PERMIT FEE
SEISMIC ItiE
PERMIT IS SUANCiE
ELECTRIC FEE
aMov-amrtimmd property fnr inxpectlon purposes.
(we) agree a, save, indemnify and keep Leander, the City of C,mr ina against
OR ADDMECH.
PLUMBING FEE.in
liabilitieajudgmens. costs and expenses which mayinany wayocem, againstsaid CaryALTER
asequence of the granting of this permit.
AIR HANDLING U 1'1'(TO 10.m)0 )
MECHANICALFEE
CANT UN UERS'I'A N DS AN II WILI, COMPLY WI'I II ALL NON -POINT
SOURCE REGULATIONS.
AIR IIANDhINGU IT(OVr 0,000 CPM)
CONS 'fRUCIION TAX
Signature of ApplicantlConrmcmr (late
HAZARDOUS MATERIALS DISCLOSURE
EX HRUST IIOOD( .LT7
HOUSING MITIGATION PEE
HEATING ONE '1'(T IN1.0g1 ❑'IU)
Wdinvtpplicam or future haddmguceepam sloe or handl, morolou,material
as defined by the Calderon Mnulc'Iphl Code. Chapter, 9.12, and the H.11h and Sutmy
Cafe. Section 25532hor
Yes PIN"
HEATING UNI OVE 100.000 BTU)
PAID hate Rec'qu' -
LATI PAN l51 OLE ItIiSIDI
BOILER -COMP (3HP OR 100.0X0 BTU)
Will the applicant at future building occupant use equipment or devices which
emit Immuch r, air cunmminanu as demand by the Bay Area Air Quality Management
10
BOILER - COMP (OVER 10(100) BTU)
Dxuict f
E3 Yes ]A No
AIR CONDITIONER
I have muslin, hrceanlnus material, rnp,irnncnlx under Ch::pur r.95 of ❑m C:Ji.
forma Heald, & Safe,, Cale. Sections 25505, 25533 and 25531. 1 understand Inas if he
ISSUANCE DATIi
41—
/
NEW RESIDENTIAL MECH. SQ. FT.
building docs not currently have a tenant, mat it is my msgmsibility m deify the recusant
,,I
of the nyniomwtsw nun Mtact Fri tri ora Claffcme'dO Cu�nuy�
5 � alt
TOTAL:
ISSU12D BY.
Owner ,, Timebarroadii' Date
OFFICE