24901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO RUHDmc-ELHCrRICAI. PERMTI NO.
APPLICATION/PERMIT PLUMBING.-MEC•HANICAI, /� A (�O a�
BUILDING DIVISION BUILDING,PROJECT IDENTIFICATION 2 4 9 1
BULLU�IN,G rA�DIIkESS SANITARY NO. APPLICATION SUBMITTAL DATE
/008 UNIT# LOT IT ���
O?L*RS1.N1pMG: (� PHONE: CONTRA O ;S NAME: LIC NO:
`'0 ken c-� �• nL N/C CONTROL#
` ARCHITECT/ENGINEER: k L LIC NO: ADD kli55;1�2 J MOA
IO/I ` ❑
'ONTACT: PHONE: {/ r VA
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
8LDG ELECT PLUMB ECH
PERM11'ISSUANCF, to ELICT`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRI ON
Qd.Z I herehyeffinn that l am licensed underpru sof Chvper9(cn ing with
�00 Seetion]000)of Division 3 of the Business and Professions Gd duty license;,in PANELS
ca force andcBmt. T,,IAC o
=<up. License Clvss�I # f J�O I S- UPT02MAMPS ♦♦
co<a Date Contfamor 201-100XAMPS
Foil ARCHITECTS DECLARATIONSQ.FT.ILOOR AREA $/SQ.FT.
oCOO—
z—a I understand my plans shall be used as public records. OVER 10010 AMPS
SIGNS ELECTRICAL .
=X2, Licensed ltofeaional
XOa'< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
yU 1 hereby affirm that 1 stn exempt from the Con¢ennr's License Law for the
F4pvFi following reason,(Section 7031.5.Business and Professions Code:Any city orcounty TEMP.METER OR POLE INST.
Which rcqunes a permit to construct,alter,improve,demolish,or repair any structure
W m its isannec,alsom the licmd to .it Fileasi edstaemenT POWER DEVICES
prior quires pp perm; gn
w <C that he is licensed w pursuant m the provisions Of On Contractors License Law(shaper
a,M,S 9 That he is exempt t erefro and
Division Soflle Business and .Any viola Code) SWIMMING POOL ELECTRIC VALUATIO�/r
W Sectiohcisex b any applicant
ram and the permit cube tst alleged t An T f / (Y
W—w P ge pion. yvicaiono UTLEI:S-SWITCHFS�IRXTURF.S �O V
FZQ Section Ill. by anyapplicantfora permit subjects the applicant toacivil penalty of �O
WI: not mart Nanrofthehundred dollan(5500). NEWRISIDENTIALELEM SQ.FT. STORIES TYPE CONSTRUCTION
WI: ❑ Lhowncr ofdfle,ueny,Ormy emperidedwiNwead fwdr(Sole 0u ,Business
t1'Y— will do Newark,ande she Cmir.anoUm;cense Law
does
tilSec.I.So.wile,of
and Pm W1W ins Code:The CO thetas s License Law does not apply f an owner of
own,mTe y whees,ldsor intpmveu thereon,ver enoweranwhadou ch work oroffi fnnbrrmghhls
own employees provided Nat such improv<men¢aenmintended orof(cred forsale.If, OCC GROUT' RES.UNITS
however.The building or improvement is sold within one year ofcompletion,theowner-
builduwill have the bu Nen o[proving Ntn he did net hmid-improve lar purpose of
sale)' QTY. PLUMBING PERMIT FEF, FLOOD ZONE APN
❑ Las the project
(See ert44.Business
sivelycmntn Professions
Code)
Me ontenorsm
License
the projat(Seo to an
ow eroffa and ywhosdom CWeQ'1'he Cnrnmcmr's
Lice nae Law dfor such
apply manowncrofpropcny whosed pursuant
Orimpnwee thenen.and YERMI'I'ISSUANCE
who rat¢formch projens with acontraaor(s7licertsM pursumumhc Comecmis ALTER-DRAIN&VENT-
wAT[R(EA) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. .&P C for Nis reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data RECEIPT a
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN CUMPEcate ofIONDECLARATION SCHOOLTAX Y N
❑ Ihereby a(Brmthmlhave
.an,.or i veme ndinthere thereof(Sec.
Lab C.)ate ofWhich FIXTURES-PER TRAP RECEIPfp
/WOrkers'Compensatinn lnsurancc oracenified copy thereof(Sec.3SW,Lab C.7 which � PARK FEE Y N
coverstill employee's under this Ecmtil, GAS-EA,SYS]EM-1 INC.A OUTLETS ❑cr
Polal as
icy N I BUT N DI ISIOIII I -
Company GAS-P.A.SYSTEM OVER 4(EA) LA H r i J
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with Ne city inspation division. GREASIIDNDUSTRL WASTE INTERCEPTOR A I 1 T i
CERTIFICATE OF EXEMPTION FROM WORKERS' OR EAST TRAP I SFEE
COMPENSATION INSURANCE
(Osis nation need not be completed ifthe permit is foronc hundred dollars SUIT) SEWER-SANITARY-STORM B.2001T. EVER
less,)
I cenifYThm in the pcRormance of Ne rk fnrwhiM Nis permit is issued,Ishall WATER BEATER W/VENT/ELRCfR
not employ any person in any roamer s to bec subject to the Workers PAID
Compensation laws nl'C:Jifomia, Dat WATER SYSTIvVTREATING Date Reccip#
Q z Applicant
Z NOTICETO APPLICANT:If,after making nificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.IT. OTAL:
^ beconm subject to the Worker's COmpmvaion r isions of the Labor Cade,you must
forthwith comply with such provisions or this pe 1i .Jslhe deemed revoked. BUILDING FIiE
W (.� CONSTRUCT ION LENDING AGENCY SEISMIC FEY.
OIherebyaf.rtnthauhere i.vac...Iuctien cndingagency for Neperrorman-of TO Al �r ELECTRIC FliC
the work for which Nis permii k issued(Sec.309].Civ.C.)
Lender's Name
u" F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING �.
L.1 I certify that 1 have read Nis application and see the The.hive irdo..it n is
>t correct. l agree TO Comply with all city and county ordinances and state laws relating to PHRMIT'IS
MF.CIIANI F.
F' haddingeonnrucerni,and herebyamhoriecrepmsene0vesoflhis ca,m merwpan the CONS 9 C' >N TAX
V Z above-mcmioned progeny for inspection purposes. ALTER OR ADD 10 MECH.
(We)agree ro sone,indemnify and kap h.lc,x The City of Coleman aga ma
halho ans,ju s,snand ex,cre.,whichmayinany way a ccrucagainst,lid City AIR HANDLING UNIT(10 10.000 CFM)
in conseel x f he granting Of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signalsim,6TA UComranor Date EXHAUST HODD(W/DUCT) PAID
AZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO IW.000 BTU) Date Rmeipt#
Will thea Tic at or future building occupant sere or handle Stuart material TOT.A .
as defined by he TOO Municipal Code.Chapter 9.12,and Ne Health and Safely HEATING UNIT(OVER 100.000 BTU)
Code,Satinn 25532: 1 VENTILATION PAN(SINGLE,RP.SID)
11 Yes ❑No
ISSUANC•DATE
Will the applicant Or future building Occupant useequipmenmrdevices which emit BOILER-COMP(3HPOR 100.000 BTU)
t humorous air contaminants as defined by the Bay Area Air Quality Management
BOILER-COMP(OVER 100,000 BTU)
Distinct? P A
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FI'.
I have read the haurdous materials requirements under Chapter 6.95 of The NAR California Health&Safety Code.Sections 25505,25533 and 25534. 1 understand The NAR 6
if the building des nut currently have a enanl Nat u is my responsibility to notify the
Occupant of the rcquireeents which must he met prim to issuance of a Certificate of Cil h 1 tr r
Occupancy. I
/fY
Owner or aothodeed agent Date TOTAL: ISSUED BY:
OFFICE J