31506C
C
APPLICANT TO PILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BU"ING DIVISION APMC
BUILDING PROJECT IDENTIFICATION
NO.
31506
B[EDINO ADDR6S5:
SANITARY NO.APPLIGATTON
SOHMITTAL DAIS'
OWNERSNNAA� PHONE:
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CONTRACORB NAM& LIC NO:
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��CONTROOL9
LTB'fBLT/E4 LIC ND:
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CONTACT; PHONE,
BUILDING PLENTY WFO
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❑ Conettitmt I= PLdd by Applicant Rnitiai)
BLDG ELECTt� NMM
LICENSED CONTRACTORSDECLARATIONBLBLTRIC
timeby"Mme Lot l am Lammed under pmvW= ofChaptec 9(comermmios
QTY PERMrr FEE
JOB DESCRIPTION
withsecdoa TOW)01Dlvislon3oftbe BusimsaeedProfeuicm Code. amtmy Lova in
14LWtfoma sal
PERMIT ISSUANCB
❑SFD ❑MOfEN REMODEL
APPLIANCES RESIDENTIAL
Limine Cha Lic,0
❑ADDMON ❑PLUAMINGRE-PIPE
❑MUfdT-lIN1T ❑SIRUCI'URAL
MODIFICATION
INTERIOR ❑alumEY RRPARt
IMPROVEMENT
EIBATERBMODELAWAIRDEMOLITION
EJ �,
Dora Coanactot
ARCEITBCTS DECLARATION
l mderad smypba aitch be OW aspvbiic rzc ab
PANELS
UPTO 200AMPS
LkeosnlProfel
OWNS-BUBDERDECLARATION
I hereby eEm that I am exempt Rom We Contractors Lleenao Law fm the
following reseon.(SeWm 70313. Business ad Pmfeasicns Code: Any chy'm corny
which requires a permit to construct acv; improve. demelielt or kapok any, menthe
201-IOODAM IS
OVER 1000 AMPS
SIONS®.ECI'RiCAL
primes N beuanro, also requhesLee appiiceotfor such permit to me a sigad smmmont
SPECIALCIRCUIPARiC.
Lid 1.isBomaedpresutm me provbioaofdmCorneal Liane,I.(Chapter9
m
(� be is exeSection 7MD) of I)Msfra mpt ami ft bads im90m alleged m®pOoa Any violation of
TENNIP.M6f�t OR PgLEINST.
ONS. MON ❑DEMOLITION
Swdm7O313bymyappU=fmapardewbjmmtbeaWlka MacivBpondtyof
ret mese Lean eco hmdred doBere($MD).
❑ Laownm of the piopeny,orvty emplogeawkla wages as Lhek Bale amgwaeWon,
will dotltewah, andtlmekmlme is ort hall moHmedfew sale (SM 70% Business
POWE9DEVLCES
E]IgNANT ❑ FOOD SERVICE
BIPROVBENT
❑OTNSR
SWO04INGPOOLELECPRIC
and Protadava Code: The Connectors License Law dos rer, apply to se center of
TA A W M-. _ FD W RES
properly who burl-; or Imlrol the eo0. and who dom such work blmeBm-sough
bie own employers, Iwmded diet aoch im)mvemmm em not hdeoded m oHerW fm
ack, M huwarv,Webddingmimpovemont b sold wddim one goer ofcompldioo,tln
nwmx-buLLtlerwllieevethe bmtlen ofproWeg,haz dart- mtbm7dm�Twva fmpm.
SQ
9Q. Ff. AREA
p
4'e
SBQ. Pf.
/
Iso ed o Ian the
pose ofeela).
4aowmr of the property,emexolhdvelytmicwdmg aiW ]tamed mamaaem
o tractor an r Own
e�+fagg�a
cmatrel the project (Sm.7094, Became ad Profeadcm Cade) Tho Contractors U.
a Lflwdm=aWymmownmofpropvtywhoboOdsmimpuves Reel and
.he emanate, fineach prejecte wffi "commercial mm(s) Ikevmdpmeumt ro dee Corneotot'a
Q eTimearc�ae�mdet Scor ,B&PCfmdtsmmxm
�1
'404%c�N�
or Vu��
p� y
E0-PonsibNtf1S Q ring ad IIim,
renis son
e )
Dam
VA[AATfON
DECLARATION
CONnatty
Wm
oEY rjwy are
weder'p
1 hereby affirm order grmaeY oP perjury one oP me following dacimatlam:
Ihave®i will maemmaCertficmaafCorsmtbaof-muvafmWorka'e Compw•
DRAINS-Iq.00 OOF ARBA,COND.
STORMS
TYPECONUMUCTION
ami®, m psovidrd Arby Settlor 3700 of me tabor Cod0. fm tbo deerfore of me
wok[mwhichoris pemitlaoad.
lvr Imm,llhiiper by SeWm
El haw ad w0dmdv Worker'sCompemmma
nofOmsamirfm which Leiepermitlsbwed
370DofteelabmCede,fmtbepafaamaa
-
- YSTHtd•I .4 OUTLETS
OL'C.CROUP
APN
My Waal Coupon®B® momma carrier ad Policy number em
Carrier Policy No.:
GAS S
CERTIP/CATE OPEXEMPTIONPROM WORKER5
COMPE4SAIfOND9SURANCE
USTar. WASTE R4TBRC�'IOR
--
BUILDING DIVISION FEES
(Ibbamdon WWretbewmplUWBdzlm*isfw=bmnddollm($100)
m qua,)
GREASETRAP
PLANCFIBCRFEM
SEWER - SANITARY -STORM EA. 200 FI:
ENE2GYPEE
lordly the in tlmperfammm oflhawe* fmwhkhihle permit taIssued, l SW
rmmgduyanypenmimmy—mambememwbjmwdw Waken'Comp®-.
WATERHBATER WN@ IMILI C1'H
P88
adon LawaofCelikerda. Dam
AppltantGRADING
NOTICE TO APPLICANIl U. of making Oda CmtlHam of Humpnon, yon show—
>
subject m Om woeal Compmation providom of Oto Labor Cada. yon�
WATE&SYSTEbUFRBAENO
SOILS FM
forthwith amply with such provisions or this permit Shill be reamed ral
WATER SERVICE
CONMUCTIONLBNDINO AGENCY
Ihereby al&mtba flmeis a ambaWmlwding agency for the pedmal of
NEW RESIDENTIAL PLM. SQ. Fr.. -
PAID
DmB p
Lee work forwhich tMa permit I. IaoW (See 3097.Cia G)
,�,�:
Tarlo Name
TOTA^
ledm'sMidass
B(N.DINO LT9 r
IatOfy thalhave mW OdeappBatlmadm thapmaboveint'mmedw he
real Iatiaa tocomply with all city redmmty mBmmsad mar lam millbdnsto
battling commutator, and hereby gra mme representatives of this dry to creatupondm
QTY. MECHANICAL PERMIT PEE
SHISMICFEE /•
PERbfr ISSUANCE
IO.ECI'RIC FBe
abo—mandonW ProPectY fmtapeWon purpose%
(We) ogres m cove. IadomnifY and kap hnrmins Ya [Sly of Cupatim agdmt
PLUMBING FEE
➢at0Rla,jaagrnwm,ecmtred expense, which may in any waymmmagaivaadd City
In mtmryonaofrim sm ing oftbis permit.
ALDIRORADDTONffiCH.
AHL HANDLING UNITUO 104M CFM)
NMCRANICALM
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Alit BANDLB4OUNIT(OVEt10,000CPM)
CON MUCRON TAX
IDOIAUSf HOOD(wB)UCn
HOUSING MITIGATION PEE
SigmmLaofApp Dam
HAZARDOl]S DYSCIDB
H73ATQQ0 UNIT CTO ]W.00DSRB
RSlthe appllcmtmfL[me gacmTtontamemhec0e hazadom melmld
ale0mdthe uo M Coda Chaptm 9.12, mrd the Radlh and Satay
Cate, Section 25532(c)?
HEATING UNIT (GVHR 100,000 BTO) '
ElYee QNo
VENTILATION PAN(SWILE RRSID)
PAID
Data Receipt
Will aro Will a forme bmMiag compact are ximpmnt or devices Whkb
' h.d. or as defh d by the Bay Ara Air Quality M®gammt
8011M- COWL" OR 100,000 BTU)
BOILER -COW (OVER IO%0D0 13M
Infdm7
❑Ya ❑No
AIR CONDITIONER
I have red the heardoa maerla(e requirements order Chapre' 695 of the Codi-
ISSUANCE DATE
NEW RESIDENTIALMECii SQ. Fr..
far&Hel& Safety Cada Seakrs 27903.25533 and 25534.1 ttdereod Lha if the
buWlivgdoaretemremlYhawa NaA myreaponerVilymmtilydnmvimm
Of ivies ofa CeniOam
Owoorm
TOTAL
ISSUED BY: W —
OFFICE