28875APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
/PPP V nV /91UO1JTIN(\ BUILDING - ELELTR
BUILDING DIVISION - APPLICATIONIPRRMIT
' ^'II ISSUIiQ BY:
OFFICE
tp
J
OWN � � � � PHONE!:
C( fRACI' R'S NAMB�, LIC
G. ��N� aa�
N/C
I RUE.#
❑
`7 /1CON
/
IINFO
FRC ITE - GINEER: LIC NO:
gQrf N
35S
CONTACT, PHONE:
It ILDINGI/IPERMIT
❑ Consultant Fees Paid by Applicant (Initial)
BLDG PLUMB MUCH
/f_yV\ ❑ ❑
�alO—
X00
W I;,
�s,VyU
b6�
Fw
rn Z
LICUNSED CONTRACTOR'SundeDF.CLARATION
1 hereby arum that E an, licensed nodal prviaiann or chapmr v amnmense I
with SatinT000)ofDivision3nfNe Business and Pnfesninns Co a yhccnse is
. }Iy
I. all forte and t. �k T
Licen I LieM O�
Dal ARCHITECT'S DECLARATION
I understand my plans shall be used m public ruoNs
QTY. ELECTRIC PERMIT FEE
B DESCRIPTION
RESIDENTIAL,
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDITION - t ❑PL)U)MBING RE -PIPIT
❑MULTI -UNIT ` ❑S'rRUC'I'URAL
MODIFICATION
PERM IT ISSUANCE
APPLIANCES -RESIDENTIAL.
PANELS
OO
OZ—p
UPT0200AMPS
❑IMfERIOR 'CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL REPAIR ❑ DEMOLITION
❑ OTHER
P,� .W4
su e' y, b.
Y
Qi
Licensed Pmfessioml -
OWNER -BUILDER IIECLARATION
I hereby uflino that 1 on exempt from the Connamhrx Licence Law fnr the
following reason. (Section 7031.5. Business and Professions Code: Any city is, rummy
which requires a permit to consmact, doer. impress, demnlish, or repair any suuctue,
prion. its isxu;mm,.Im requires thedpplimut forsuch perminn filort,tisdstatement
that he is licensed pnrammt to the provisions (it lire Contractor's Limnse Law Chapter!)
(commmncing with Section 7000) of Division 3 ofthe Business and Professions Care) (it
201-INMAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMESC.
TEMP. MILE ER OR POLL INST.
COMMERCIAL:
,E62
that he is exempt therefrom and the basis Emilie alleged exemption. Any vit lmion of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
N
ffFIF.....
q 6
$
Section 703 L5 by any applicant for a Permit subjects the applicant m a civil penalty of
not more than five hundred dollars ($5W).
�I, as owner n{'Ihe pntpeny, or my employees with wages as their sole cmtpanvation,
will do los work, and the structure is nmintendedor offered for sale (See, 7(44, Business
and Professions Carle: The a mnracmrs License Low does nm apply m do owner of
POWER DEVICES
:NANT ❑ FOOD SERVICE
PROVBMENT
OTHER
SWIMMING POOL ELECTRIC
UTLETS-SWI'ICHIiS-FIXTURES
G
propeny who builds or improves Nere.n, and won does such work himself nr through
his own employees, provided that such improvements arc not intended or offered for
NEW RESIDENTIAL CLEC It SQ FT.
sulc.If, however, the huildingnrho,orement is sold'wiNin nnc yuncifclor,ictlon, the
- -
`• SQ. Fr. FLOOR dA
$/SQ. Fr
owoma-buildcr will have the burden of proving that he did not build or impress I'.r par-
poo of sola).
L as owner of the property, ant exclusively enntmeunwith licensed ntnr oarsto
TOTAL:
commit, the project (Sec. 7044, Business and Professions Code:) The Contractor's
omntcdrts Li-
cemeLuwdnesnm.pply to anowncr fp pay who builds in improves thcram,and
Q'ry. PLUM BING PERM IT FEE
who counters for such pooiece with a conunclarts) licensed pursuant to the Contractor's
PERMIT ISSUANCE
License L'aw'
I am exempt under Sec. ,B&PCfonhis reason
ALTER -DRAIN&VENT-WATER EA)
Owner' Date
VALUATION
Lot I�/�/�
WORKER'S COMPENSATION DECLARATION
BACK FLOW PRO'I'17CE DEVICE
A I hereby Ilton under porady of perjury one of the following declarations:
l f�4/
DRAINS - FLUOR. ROOF, AR G, COND.
❑ lhav and will maimaina Cehin t of Cormenllaelf-insurefor Workers Compen-
µthan s provided.for by Seniors 3]W of the Luhor Code, fnr the performantt of Ne,
STORIES TYPE CONS'fRUCf10N
o
or which this Permit is'nsucd.
FIXTURFS-PERTRAP
1 hove and will nmintain Workers Compensation fir,mince, us required by Section
3]011 of the bar CoJe,fonhe Ppeerformance of Ne work for which Nispennilisiss
My War k ore enmi BI asLmnce car ic, tir Polis t 02!e.
Comer: Policy No
GAS -EA. SYSTEM.) INC.4 OUTLETS.
OCC, GROUP APN
GAS - EA. SYSTEM -OVER 4 (EA)
'uTIFICATE OP RXEMPIION FROM WORKERS
E'
COMPBNSATIONINSURANCEGREASWINDUSTRI.
fThis section need not hccompleted ifthe permit is tomos hurt d$I
didwI t30)
or laud.
WASTE INTEItCHMIR
Hllll. 'G ION ti
PLANCHECK
-
GREASCTRAP
SEWER - SANITA BY -STORM EA. 200 FT.
Z
i
I certify that in the performance of the work for which l' omit is issucd.Ishall
not employ myper,on in anymmoner en lsm bottomren the Workers' Cnngwn-
sall.. Laws of California. Date
Applicant
ENERGY
WATrR HEATLR WNENT/ELECfR
-
GRADING
NOTICE TO APPLICANT. If, oiler :his Cenificam of Exemption, ! shad
bscume Fybject mthe Woders Con ensation previsions of rhe Ln rC ,yt ust.
fonhwoM1 c.ngity'wlmh such provisiam onhis pcnnit shell he c d.
CONSTRUCTS NLENIIING E
Himebydf r mom them is d co vuoinnl din mheperfnnnance
Ne work I'or which Nis permit is ixsncd ea 31X)],
IIJer's Numc
ATER SYSTEM/rREATING
ul
f'+[
Wiry
O
UO
F
Q
50.5
WATIiN SERVICE
PAI
D e Receipt
NEW RPSIUENTIAI. PLMB. SQ. PI.
Lender's Address
} U�
y
mF.t rA
U
TOTAL:
BUILDIN FEE
I certify that I have mad this upplic tion and smte at m -Peel in4 .tion is
conte,. I agree to comply with all city and only ordins= and smm la mlaE in
building construction, and hereby authorize rcxentatives of duscity to mm upon the
QTY. MECHANICAL PERMIT FEE
SEISM: HE
hmewhemioned propenpe
y for insctlon FEEyes.
(We) agme to save, indemnify and ko Zi.
the Cityo u rich against
PERMIT ISSUANCE
ELECTRIC
- ALTER OR AUD'I'O hIECH,
s'-"
PLUMBING FE
lubilideNjudgnore, casts and expenses whic yin any w.yac sag' xt mid Ctr
in consequence of the granting of this pemut.
AIR HANDLING UNIT(TO I0,W0CFM)
MP.ti'
APPLICANT UNDERSTANDS AND WILT. 'OMPLY W H -POI. r
SOURCE REGULATIONS. /
AIR HANDLING UNIT (OVER 10,000 CFM) r
sf�NSTRUCTi N ' '7
Signature of Applicanl/Conlmemr \ are
I{AZARDOUSMATERIAI.S SC E l
EXHAUST' HOOD(W/DUCO v
HOUS s IGATI NF EV
-
HEATING UNITO'O 100.000 BTU)
occnpnntsmrzm
Will the applicant orfuture btildo" reor o elnanlounmerlel
as defined by the Cupenin. Muni al Cade, Chapter 9,12, on a HeaIN and Safety
YV
Code. Section 25532007
HEATING UNIT (OVER 100,(X10 BTU)
C3 yea
Will the applicant nr future h (ding occupant use cyuipntam or devices which
emit hdvardoas air contaminants a alined by the Buy Arca Air Quality Management
District?
[I yes VNo
PAID
Dale' ceipm4
VENTILATION FAN (SINGLE RES ID)
BOILER -COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER - COMP (OVER 100,0100 HTU)
AIR CONDITIONER
Rise the buwdn le' r w
is undepter 6.95 o1' the Cali-
ISS NC' A
NEW RESIDENTIAL MF.CH. SQ. FT.
f fie Health. it 25 25533 and 27,3Y understand that if the
' ^'II ISSUIiQ BY:
OFFICE