S 2302APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ld1TUV UUI'VK I n TWX PLUMBING -MECHANICAL.
BUILDING DIVISION APPLICATIOWPERMLP 111111 In Nn PRnIpCT I nFIN'I TFICAITON V C ^/ L 3 O ^/ L
❑ Censellanl Fees Paid by Applicant (Initial)
I-ICIiNS13D CONTRACIORIS OECLARAI'ION QTY
I hereby effimn that 1 um licensed trader pmviwom of Chapter 9 (coura ening
ce Zp suint Seaian](XXII of Division 3nfthe lsusinosand l4afessions Cailotodn+ylicenuis
W F- in full famc anJ caber
U U Liccnu Clxss Lic, p
Z Dale COnlfaClar�
1
ARCIII'I'IiCTS DECLARATION
tiZ 1 understand my plan..hall he, used as public records
E" LL Licensed Professional
E� OWNIiR-BUILDHR DECLARATION
Q 1 hereby affinn that 1 am exempt from the Cnmmalor's License Law for the
a U following action. (Seaton 7831.5. Im,irw s and Pro&sdons Code: Any city or county
O h which requires a Permit u)con.amet, alter, improve, demolish. ur repair any structure
Lear no its issuance, also requires the applicant tor such varrou to file a signed statement
} that he is licensed pursuant a the provisions of the Contractor's License, law(Chapter 9
(commencing with Section 7000)ofDivinion 3nf the Radius, and Processions Co or
oC that he i, exempt therefrom and the basin for the alleged exemption. Any violation of
t Section )831.5 by any applicant for a permit subjects the applicant h+a civil Penalty of
m a"' not more than five hundred Jul Mrs (55118).
❑ Lm owner oflhe pi or my emph,yees with wages as their solcenngsnrarnn,
ywill do the wark,and the structure is not intended or for vale (Sec. Boons'.
�
3.. and Proes ons Guic: The Contractor's License l,aw Ams not apply P, an owner of
pmpcny who mild. m innpn+vs thereon, and who cities such work himself or through
his mployces, provided that such hola, crit. !are nor intended or alfemd Iia
sale. If, however, he hudi ing or Improven ccal is suId wabi n one year of completion, the
owncobuilder will have the houlrn of proing Ilan he did nor build or mproa lin pct
Pre. of ane.).
❑ I, a, owner of the Pro,ny. non IT vuly cnntmcti its with licensed I Ilmnors to
unsaact the mojeO (Sec. 7(W4, Business and Prufcssions Codkip) the Cbhiracou, Li
-
whacLawd+o tar apply To of Pnpmty who hnildx or lmpn,vcsahcrmm.and Q1 Y,
o contracts farsuch I jeer with vl aahtmcaogsl licensed puoamnl it, (lie Conwam's
Liarr,c Law.
I non ercmp...oder See ,B& 1' C far this nwann
Owner Sue
WOR K 1: IES COM PINS A IION DI iCI.ARAI'I ON
I hereby at ii ander Penalty ul Jaen toy oou al Ih. holowing deelm'ati ,rw
Ca and willmlmtdo It Ceatificacoi Coos.it, tos.11:innnrcfor W..ki,Can+Pvn-
pmvuled far by Seems, 37W O he Lamm (:,,do,loathe I11i'lnnnnee of the
work fm or Which this pemdl is issued.
I have and will maintain Worker's Comp.nsmi( In,mmu,r, ria ,mcd by Scctinn
37( of the Lubar Cede, lin the pirmarmaaccotme work lar which Ibis ponait is insocd,
My Worker" Cnmp�etj^-wi Iy�' o rand ["they numr ora:
Carrier: �+-f �= Pol icy Na.: / a
CI:RTIFICA'l l! Ola EXIMPTON FROM WORKERS' 1 EYEf /.
COME, SAIYON INSURANCE!
flhisnecd..n aced nm Macompinul it me permit is Ina ane handiest dollar, (51(X))
or Icoo.)
1 emit} that in the it.atrace nt the work Iia which his permit is i .... do l shall
nal employ any person in any manner so as to became .subject m IM Workers' Campem
Z setion laws of California. Date
ZQ Applicant
NOTICE TO APPLICANT. If, aller making this Cenilieme al Exemption, ysm should
F "N" bceomc subject... the Waded Compensation provisions of the hMn Ctxle, You meal
foul,, an comply with such PmordI m, nnhis Per ni,sh ill he deemed revoked.
o.
CONS '1811C1"[ON LENDING AGENCY
UQ (hereby atfinn than there is a construction lending agency for the Pc,firm mnco, of
D., the work for which this Permit is issued (Sec. 3147. Cit, C.)
O U Ecnde,s Name
,r U lenders Addi
6. I cenify that 1 have read this application and state that the above infomuuon is
rorrect. I agree m comply with all city and county ordinances and state law, relating to
U Z building conswctions and hereby autbuaiec repreamt nvcs of this city to enter upon the
above mentioned pruNny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cu Sir in r against
Ilabi lines, judgments. costs and expenses which may in any way aacme against said City
in nsc4ucnce of the grunting of this permit.
APPLICANT ON OERS"IA NDS AND WII.E. COMPLY WE fit ALL NON -POINT
SOURCER+GUL IONS.
�J 6
'a -4 6A, an Cantor >am
1 \%ARDOUS MAA IIRIALS DISCLOSURE
Willthcap Land
or future building occupant store (or handle hovolous mutcrial
as defined by the Cupenimo Municipal Gde. Chapter 0,12, and the Health and Safety
Code, Section 23532(0)!
❑Yes
WIII 0vs applicant or future building necnpanl use equlphmnl or devices which
tit hwanlhus air cuir,or nantf as ddined by the Bay Arco Air Quedo, Managnncut
wo
Yes
I have lad the hneartlour nmmriuln rcgnirenteots wader Chapter 695 of rbc Cali.
fhmla Heal& k Sufcty Cod, Secsimrs 25511.5, 255331 1 ^-5534.1 undcnla ul That I the
building does nut carnally have aI,,I than it Lsmy." ,lwihility lonadythe occupant
.,nn..,..mm,a.Jr sohi �a he mot a or m lasaan.0 0 a Cen'llaln A Occtmahcv.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RISI DENTIAL
PANEIS
UP TO 208 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICISS
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -13X'rURES
NI?W RESIDENTIAL ELECIR
PLUMBING PERMIT
PERMIT ISSUANCE
ACI PH - DRAIN & V ENT- WATIIR CA)
BACK ILLOW PROI'EC'I'. DEVICE
DRAINS -FLUOR, ROOKAREA, CONE.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS -PA.S ER4,(F.Ty
SQ FL
SEWER -SANT RSRY-STURM EA: tW I -I
WATER HEATS tW/VENT?:LIiCTR
WNLR SYSTEI TING
W'ArER SERVIC
NEW RF_SIDENTIAL MMB. SQ. IT
TOTAL
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
AI TF.R OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER W." CFM)
EXHAUST IIOOD(W/Ducr)
HEATING UNIT (TO 100,000 BTU)
I est-ING ONI'i' (OVER 100,000 BTU)
VENTILATION FAN (SINGLE REID)
BOILER -COMP (3HP OR I W.000 BTU)
MOILER -COMP (OVER 1001000 O U)
AIR CONDITIONER
NIIW REMDEN'r1AL MITCH, SQ. IT.
o- 7 -9Y
0
FEE
VA LIIAI'ION
STORMS
OCC,GROUP
BUILDING UIVISIUN IIi1:S
PLANCHECK 1:14H
ENERGY 11:17
GRADE
SOILS FEE
PAID !i
TOTAL:
BUILDING EEE
FEE SEISMIC FIz,
ELECTRIC ItiL
PLUMBING FEE
MECHANICAL Fii
CONSTRUCTION TAX
HOUSING Nit rIGN ION Bili
PAID
Dale RcccLET, N
TISSUED BY:
OFFICE
ISSUANCE INVI'I,
❑ M, ❑ ❑
FEE
J013 DFSCRIPTION
RESIDENTIAL:
❑SFDWL ❑ Kll'CI IILN REMODEL
❑ADDITION ❑ PLUMBING RIiPIPE
[:1 NJ ULTI-UNIT []STRUCTURAL
MODIFICATION
[J INTERIOR ❑CHIMN17Y REPAIR
IMPROVEMENT ❑SWIMMING TOOLS
❑BATH REMODEL/REPAIR ❑BENICIA'1'[ON
DMHER
,ZO
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVFMI?NT
❑ OTHER
FEE
VA LIIAI'ION
STORMS
OCC,GROUP
BUILDING UIVISIUN IIi1:S
PLANCHECK 1:14H
ENERGY 11:17
GRADE
SOILS FEE
PAID !i
TOTAL:
BUILDING EEE
FEE SEISMIC FIz,
ELECTRIC ItiL
PLUMBING FEE
MECHANICAL Fii
CONSTRUCTION TAX
HOUSING Nit rIGN ION Bili
PAID
Dale RcccLET, N
TISSUED BY:
OFFICE
ISSUANCE INVI'I,