22241 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building en Pro emlf"tion PERMIT NO.
BuBding��,: 6rapnej 22241
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rC atnaon'.1eJarre: N¢ APPLICATION / PERMIT
yp. iki"t) t,. U BUILDINGELECTR1CA1,11LUMBINGME FANICAI, CATEGORY CONTROL If
Archil /Engtrcer. LIc.N¢ .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PER1,9TISUANCII - ❑ ❑ �- ❑
LICENSED CONTRACTOR'S DEM RATION
I hereby a(fremthat l am Is sed under provisions of Chapter 9(mmmen APPLIANCBSRESIDENTAL J DF9CRBRION
Ing with Section 70(0)of Dlvlaton3 ofthe Bednassand ProfessionsCode,and
♦items U in full fora and effect. PANELS 1L -
LlaseClara Lb.s -P/ b
UP TO 2DD AWIS
Ode Cls,9 r
ARCHITECTS DECLARATION 701-000
atzCO I understand my plana shill be used as public remNa OVER 1000 AMPS `•Q.FT.FLOD AREA 5/ .FT.
O
M0 u Llaaad Profewbnal SIGNS ELECTRICAL
61�, OWNER-BUILDER DECLARATION g+[zIAL CIRCUIT/MLSC
71.., a I hereby affirm that l am exempt frmnthe Contndori License law for the
d ..� following reason.(Seclon 7MI5,Boain.and Professions Code:Any city or p. AOR POLE INST.
Fm wuntywhkhrequ4 ap� Wmv Malter,lmpm demolbh,orrepair
anys MmpM tolbbe con aWnqu4 theoppho tfmwchpem to O POWER DEVICES file•signed statement that he b limnabn
ed pursuant to the pnevbof the
Contrecior'n LXese Law(Chapter 9(commencing with Section 7D0D)of DM-
non Sof the Bu ahem and Professions Cade)or that he b eampt therefromand SWTIAMNG PCOI,ELECTRIC VALUATION
a y.' the bsx for the alleged exemptim. Any violation of Satbn 70715 by any OUTLETSSWI'ICHESFLYTURFS - 1
appnontforapemdtstnb).c theapplkanttoac ipe kydnm=m Hun
G. 7 Bbundrad MM.dollars M.
u I,as owner of theproperty, 'NEW RESIDFNIIAI.ELFLTR PT.I \•� r. ... SID PS CONSIRUCDON
orhe employes wenwages r thereink _
C <
.—k
psat0Klast,wllldotbe workssslons odurcbrct Wended oronse,Law �l , � � 1�
p dale(Sec appy to an owner
ProfObs Code:TheCilds or improve.hemar,Lw II
does.d apply roan owner d propertyis..who erplymprodeathereon,sol / UNITS
who d comma sueh are nal msen ed or
Naowne.If,ho wprothe b that suds
improvements arewtithindM oroofocerffered maak.If,hwver-buBe building or - TOTAD TE
Improvement bald whhlnorcynrdcompletbM the ramer-bullderwill have - -
tl1j�rdenofpmNngthxhedld notbuildorlmpmvefmpurparoraak.). QTY. PLUMBING PERM FEE pLOOD ZONE APN
U 4 as owner of the property,an,evcbslwly cadracting with Ikxnsed
contractors to instruct the projed(See 70K Bushes and Profession.Code: PERMIT ISSUANCE �nD
The Contndots Lw"..Law dm not apply w s owner d property who ALTER-DRAIN&VENT WATER(FA)
bulls or Imwu i
prthn,and who contracts for such p5apets with a FEE SUMMARY
offmda(d her-read Pursuant to the Contradm's Llwase law. BACK FLOW FRDTTZ7.DEVICE
LJ t aexenipt under Sec B&P C for thio reason
O.vn<r Date' DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT 4
❑I hereby affirm that I haw a anl0cate of ea nsent to selFbuure,or a I PER TRAP O SCHOOL TAX Y N
artlflate d Workeri CornpvsaHon Imunna a•artnied mpythereof rases. RECFIPI's
3K0,IZbC.) GAS EA.SYSTEM-1 INC-4 OUTLETS PARK FEE Y N_
Palley
^Y CAS EA.SYSIT.I/-0VER4(EA) BUILDING DI VISION FEES
IT
copy x herefil with theed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK IT
CeutWed copy b need with the dry IspeGbn dlddorr.
CERTIFICATE OF O(F.MPILON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA Date . Reed t#
(This dedlon need not he completed n the pemdt x for one hundred dollar
(S1 WImIrea.) WATER I-ff ALFR w/vkxT/ELrt.-IR ENERGYFEE Y N
I certify that N the pedorrnance of the work forwhlch this pemJt is issued,
1 shall not employ any perawu N any manner n as to become subject to the r
WATER SYSTEM/TREATING
Worken'Compesatbnlawsof Ulifomx. Date PAID
-
z O Z npp0ont NEVRE lDE LPLM3. SQ.FT. Date Recei t#
O NO77CE TO APPLICANT:n,after making tux Certl(Inted Eeemplbn,you
should become nub}at to the Workari Compensation provbbru of the Labor TOTAL
cc N Code,you must forthwith�nply with such provialos or this permit dull be BUILDING W > deemed revoked.
CONSTRUCTION nkNDING AGENCY SEISMIC FEE
CL Inereb .ffiron that w.rkfrwhketh aper rWd kndinga97, tv. tic pednrm A ELECTRIC FEE
Z anceafthe work brwhkhthb permitx xvM 6ec.3097,Civ.G) TOTAL: �`r d
U O Landers N. PLUMBING FEE 10700
LLI- Iander.Acid. QTY I MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify that l haw read this appBcatbnand statethat theabove information _
xcorrect. builds g complywRh alld hereby
auhorkee mpa nadstsdws ofthus PERMIT ISSUANCE FEES I
>. (L
city togtobupon t msDw-ron,sndherebyrtyodu rtnpurpmalthb -Z ..-Cf3 '
F Z city .9 upon caw,he inve-nnify a ed keep
for Inspection hCitpurposes. ALTER OR ADD TO MTQ-I.
(We)a b mw,lode Date Revel [#
gree mnify an d keep Iaroues the coy of cu trio SUBTOTAL: U C
V agaWtllabWtb,ja gmrnts,a.ts pews welch .y In any wayacvue AIR HANDLING UNIT 10,000 CFM)
against Ity cwseque f ggg In this pemdt
Lir. MR HANDLING ulvlr(OVER 10,000 CFM) CONSTRUCTION TAX
Bt mtured Appucant/ traria VY J Date EXHAUSTFIOOD(W/DUCT♦ CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WBltheappllont orfurusebundtng.P.Atetoneorhandk hatarderus HEATING UNIT CIO Ia%0D0IT"
ms Date Revel t#
aterial denrud by the Eupedlro Muddpal Code,Chapter 9.17,and the TOTAL: l O7
Ekahh.ndSafe75171
ty Code Section x)7 HEATING UNIT(OVER t00,IXp BTU)
Yes No
Will the applicant or tore building o¢upant use equipment or d evlcn VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
which rout haeare ous ab antambunts as dellned by the Bay Area Air
. Quality nagement District? BOILER-COMP OIL'OR 1000(10 BTU) - e ^
Yes ❑No V
haw read the ha dans nurterlab requirements under Chaper6.95 of BOILER-COMP(OVFFt 100,00D BTU)
the California Health&Safety Code,Scabs 75505,B533 and 75534. I '
understand that ifthebundlngdoes norarrentlynave.tenantttit it xmy NEWRE51DE.rTIALMECH. SQ.F
resDEC 291993
pus3nity to notify the ocadpant the requirements whreh rait mut be t -
prior to Lauaruc ofa Ccrtiflcate of Occupancy.
CaIIY 4 - vurchI11W
Owner or authorlad agent Date a I\1
' TOTAL: (SUED BY: �hl�\n1-'�'1`IL UC1
I
% OFFICE COPY
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