2618APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
If I.DIM.- .0 ICAL
CITY OF CIIP DIVISION
PLUMBING -MECHANICAL PER''lIrTo-
BUILDING
°'
BuanlNr, DIVISIONIslory APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION 2618
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BQAD C421WFEeSDO E1252 -nloJ
LICENSED CONTRACTOR'S DECLARATION
CKZ Ihereby affirm that l am licensed under provisions ofCTapmr 9(commencing with
FOO Section 9000) of Division 3 of the Business and Professions Cal, and my license is in
KUI- full force and effect.
<Z License Class Lic.4
ot <a. Date Cummanr
F -,z ARCHITECTS DECLARATION
OZyc I understand my plans shall he used as public records.
F�2F--�
L7, Licensed Pmlces mim
E:04 OWNER-BUILDERDECLARATION
KOWF 1 hereby affirm that I sen eacmpt from the Courtrai License Law for the
J3n-m following reason Section 9031.5, nosiness and professions Code: Any city orcounty
which requires a permit to convect, alter. improve, demolish, or mPaif any swmure
1 W } 7 I novo llx issuance. vlsa regolms the applicant for tech pe.iuo file a signed sm¢mem
that he is licensed Pon. , no Jct provisions of the Camrsmr's License Law (Chapter
aXo�, 9('maromcing with Section7w).fDivision 3 of the Business and Profusions CMO
L_m or that he is exempuMrefind and the basis for the alleged exemption. Any violation of
FZQ Section 7031.5 by any applicant for a permit ubjects the applicant do a civil Penalty of
than fare hunof ddnllan 155W).
z"o 's erofthepropcny.ormy emplovm with wages in their sale compensation,
y3q willdotba nrk, and the sducmreisnot imendeJomffcredfor sale(SecJ04J, Business
and Pmfessions Cale: The Conductors License law does oat apply to an owner of
pmplany who buildsorimproves thro om and whodoes such work himselfor through his
cmployees.provided thauuch improvememsarena imendedmoffendforsale. If,
however. the have
the
order of pmcm is sold within one year of improve for @e owner-
bde.). will have the burden of graving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the progeny, am excl mively contracting with licensed conhactom me
c rdswm the project (Sec. 9DA, Business and Professiam CMe:) The Cantmemer
License lavedas not apply to an ownerof progeny who builds or improves themon, and
whocomucts for such projects with aconvsmr(s) licensed parmanuo the Contractors
License Law.
E)1 am exempt under Site , B & P C for this mason
Owner Date
WORKMAN COMPENSATION DECLARATION
I orkers'Cam firmthat I Insurance or aanifed pent thereoffSea 31100. LibC)which
geyeeru copy
rs all employee's under permit.
Policy N
Company
❑ Certified copy is hereby famished.
❑ Cenifed copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
❑Tin section need not be completed if the permit is Parent, hundred dollars (SIM)
or Ices.)
1 ccnify uhat in the performance of the work for which this psoman is issued, [,hall
nm employ any person In any manner so as to become subject to the Workers
z Compensation Lawsef California. Date
O Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
F.N. bechwithc comply
Ne WorkersCompewtiis Permit shall deemed
yoked. mus
forthwith cnmplY with such provisions or Permit be deemed revoked.
y (� CONSTRUCTION LENDING AGENCY
Z) z I hereby al Cru that hen is a xmnswaion lending agency for due performance of
U O the work for which this gmmit is issued (Sex. 3099, Ci, C.)
Lender's Name
C) U Lender's Address .
I clarify hot 1 have read his application and sum that the above information is
correct. I agree to comply with all city and county onirsommi and some laws relating to
f-- LG building mnovunion. and hereby amhon z, representatives of th is citym enter upondic
U z abovumemioncJ pmpeny for inspection purposes.
(We) agree to save, indemnify and keep ha leas the City of Cupeninu against
Nabi lilies. judgments, costs and expewtlich y in any way aecme against said City
in t,,nemcncx of the enaRk¢ t ma
RA'LARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sure or handle hazardous material
as JefneJ by the Cogcnioo Municipal Code, Chapter 9.12, and the Health and Safety
Coda Section 25532(a)R
❑ Yes Cl No
Will the applicant or future building occupant use equipment or devices which emit
`w oolins air smeary trams as JefneJ by the Bay Arca Air Quality Management
ismia?
❑ Yea ❑ NO
I have mad the helorbardous materials requirements ander Chapter 6.95 of the
Cdi16mia (Health & Safety CM, S¢limot 25505, 25533 add 25534. 1 trnJersmn i that
if the building does oat currently have a tenant, than it is my respandlohly to notify the
cupum of the regniremmints which mud be met prior to issuance of a Cenilicam of
Owner or adhorued agent Date
LOT
.: ..`ELECTRIC klklklrr`", ;i.S BUILD]
r �.
BLDG ESk
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL IOB
PANELS
UP TO 200 AMPS of
SIGNS ELECTRICAL
SANf1ARY Y
RI
SCHOOLTAX Y
RI
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VA
0
cmRtFc
UTLEfS- SWITCHES - MIXTURES
NEW RESIDENTIAL ELEC R _SQ. FT.
ALTER -
DRAINS.FLOORROOF.A ,CON
SANf1ARY Y
RI
SCHOOLTAX Y
RI
FIXTURES - PER TRAP
PARK FEE Y
rl ME
, I
PLANCHET
GAS - EA. SYSTEM -1 INC. J OUTLETS
GAS - EA. SYSTEM-OVER4(EA)
GREASE'INDUSTRL WASTE INTERCEPTOR
GRADD4FF .
SEWER- SANITA"TbR�tEA. SOOFf:1 I'.: i; )
I
WRGY IEE
91
WATER HEATER I ELECIIt i'I 1 • ^
WATER SYSTEM/f TING"
NEW RESIDENTIAL PLSQ.
.
P
Due
I c
TOTAI
-
BUILDING FEE
0270
SEISMIC FEE
ELECTRIC FEE
Z
TOTAL:
.r'>•sY, �>T��yy.r•,
,F# M AJiMECHANICAL PERMIT;'.
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECIL
CONSTRUCTION LAX
AIR HANDLING UNIT (TO I0,IXt0 CFM(
AIR HANDLING UNIT (OVER 10.00) CFMI
EXHAUST I IOOD (W/DUCI)
PAID
HEATINGUNIT(TO IOII."EITU)
Date
Receipts
((EATING UNIT (OVER 100.000 BTU)
TO
VENTILATION FAN (SINGLE RESID)
BOILER- COMP OHP OR 100.000 BTU)
ISSUANCE
!
DATE
}AA
5 1�'
BOILER - COMP (OVER 100.IXp BTU)
NEW RESIDENTIAL MCCIL SQ. FT.
INFO
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