B 0661APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY IUI-LDING- ELECT RICA], ,PI
,RMI 'I'NO.
CUPFRTIN
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL S99eI0
0
mullsomrPRnml^r men`IIPICAI ION I n n
_
.�;' TiLsoN
PHONE:
NAME:
❑ Consultant Fees Paid by Applicant (Ionone,
`j_lw:cl T�--$-V+-5 moi% 3896
I hereby 111, in Ina, I um license under,mvouom of Chapter 9 (cou naming v_
Oct�Z oinSectior,00)ofDivision 3oflhcBusinessand Pmfeaium Cale,undmy licuow is
E W. infullturce nndcRem.
�UU Liccnw Class Lic.p
H Q 1 U,ue e
Comcon
ARCH[ FECI\S DECLARATION
f'vZ Iundenwndmy,lon,hall bemedamblumcard,
OZ'O
F F W Licensed Pralesousal
Q�.j�;
OWNER -BUILDER DECLARATION
1) C Q 1 heachy affirm that 1 an exempt from the Commnor's Liens Law for the
XO a U following vxom (Section 7031.5. Business and ProRssims Code: Any city or county
413 4 i- which requires a permit to roaaum, alley, improve, demolish, or repair any stmemrt
OQ prior m its i»uuncc.olsn requires the applicant for such permit to file a signedsmremenl
Vitt
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section ANNA of Division 3 of the Business and Professions Code) or
Is. a C ,hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
R.
Seetion 7011.5 by any applicant for a permit subjects the applicant vac a civil Penalty of
nut more than five hundred dollar 1$51107.
❑ Las mvner of,h.property, or my employees with wages as their wale cnmpensmion,
p. willdothe work.andthe samclure is not intendedoroRered fn,ole(Sec.J144, Business
3 m and Professions Coda The Commeam" License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered war
sale If, however, the building or improvement k said wultio one year of amtple,am, the
owner -builder will have the burden of proving that he did not build or improve far mr-
pu c..t'sale.).
Qsl, ns owner, of Lhapngn+ty. um exclusively cont meeng wllh lieensed cmnmetms nr C
nsnucl da Pray.. (Scc 7144, Bush ass and Pmfrown, Code) Tim Cnninml..r'e Li�
sc Low does nor apply,.. tot owner of pmpeny who builds or intpmvm @creno, and ury
who contests far such projeo with o eonraanr(s) licensed punaant to me Coamemr'.
U'rosc Law.
0 I am excmp, miler Sec. . H & P C into this rcawan
ELECTRIC PERMIT
PERMIT' ISSUANCE
APPLIANCES -RESIDEN'1'I AL
PANELS
61151
GO rLErS- SWITCHES -FIXTURES
NEW RLS I DENIAL FLEC'FR SV IE
L17 = 3ss
PLUMBING PERMIT
PERMIT ISSUANCE
_ ALIHR- DRAIN&VE- ER(HA)
tuner Dam
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTE EVICE
1 hereby affirm under Penally of perjury one of the following decorations:
Q lhave and will maimuineCenificamof Conum to selLinsurt for Workers Compen- DRAINS-FLOOR.R RAR. OND
scion, a provided far by Section 1701 of the Lahr, Cee, for the pe formas of the
work for which this permit is issued. FIXTURES - PER TRAP
❑ 1 base and will maintain Worker's Compensation Insurance, as required by Section CAS -EA. SYSTEM -1 INC. J OUTL S
3]00 of the "Far Code for the pedre ornanof the wok Lor which this permit is issued.
Myw laces Comycaation Insurance earner and Policy number aa: GAS - IIA. SYSTEMOVER4(EA)
Carver. Policy No.:
C12RTIFICA'I'ri OF EXEMPTION FROM WORKERSGRF.ASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
This xalirnnnetl nolMcomplered ifthe permit is for one hundred dollars 1$ 101) GREASETRAP
or less.)
lay that the mynaeor,a , sh,bhe rkfmobjrh,hio permit isirs Coisha11 SEWIiR- SANITARY - STORM P.A. 200 P1',
nw cntpiny any pulsus In any manner nn ns m become subjcn In the Workers' Cninlan-
Zi suntan Laws of Cali hania. Dotc WAIT ER I IHATLR WIVENI IELEC'OR
zQ Applicunl I
.No NUI ICE 10 APPUCAN'1': ILL after inuking,his Cam,,are of Excau,n on should WAI'lzk SYS' I'EM?REATING
a ,
he,., ne ubJcel I, Ne Wokar'a Ct....pcosaninn pmvisinm' u I the Labor Ce, you inunt
ti lmhwill, comply with such provisa.m or this ,cam, vhell bed timed revoked WATER SERVICE
O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SV IT
U O I therebyfin
hy aIn thm there is a constmcllan lemi ng ageaoy for the 11f na ance of
CL (•-' the work for which this perant is issued(Se. 3197. Civ, C.)
O V Icndlrs Name
'r U Iwander's Address
Gr 1 certify that 1 have read this application and stare that be aMve information i..
F-' h c arca. l apace m comply with all city and coumy ondi... cev and state laws relating to QTY.
U z building construction. and hereby authorize representatives ofthis city to enter upon the
aMrvcrnrntia ted property for in.spection,uryoses.
1 W4 ogres to mve, indemnify amt keep handles, the City of Cu to
against
liobilitica.j )dgmems, costs and a ,,,dses which may in any wvy aceme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY wl'I'H ALL NON -1'0101'
SOURCE REGULADONS.
S lgn:nurc of ApplicapdCuntr:aaar —1-
IIA9ARUOIIS MA'ng,,c. 5 mSC1ASUHli
Will the npCuwa ur lumm bn t Co xcupom snore ar hundlc Heurdom ll Saial,lul
as Acfnral by the C,grenino Municlpul Cndc, Chnpmr 9.12, and the licalth and Sul'cry
Code Section 25532(x)?
El Yes E] No
Will the applicant or future building occupant use equipment or devices which
emit hvurdouv air contuminanls as dchned by the Bay Arca Air Quality Management
Lillie'!
E3 YO, ❑No
I have text the Incautious nmtermis ba,memeno under Chapmr 6.95 of the Coli
forms health & Sulcty Cede. Seisms 25505. 25533 and 25534. 1 undentaml that if the
building does an currently have a tenant. mar it is my responsibility to notify the occupant
of the ha unaments which mel be met Oar to issuance of a Cerlfcam of Ofcapnncy.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IOAq) CI'M)
AIR HANDLING UNIT (OVER 10.(0X) CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT ('r0 11)0,000 II'IIL
11CATING UNIT (OVER I(Nkd(p IFIL)
YEN'I UNI*UN FAN (SINGLE RESID)
IIOIL17R -COMP (3HP OR I011,(N 0 BTU)
BOILER - COMP (OVER III BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, 17,
OFFICE
TOTAL:
FEE
FEE.
6, 2—gy
yysi
BUILDING PERMIT INTO
BLDi ELECT 1'LUr 12 -
JOB DESCRIPTION
I,;
REE
WL
FDWI-
❑RUCHES REMODEL
ADDITION
[D PLUMBING ItISI'll'IS
❑MUCfI-UNIT
❑ STI RUC'I UIKAI,
MECHANICAL FEE 1
MODIFICATION
El INTERIOR
❑ CIIININ17Y REPAIR
IMPROVEMENT
❑SWIMMING PUOIti
❑ BATH REMODEUREPAIR
DEMOLITION
❑OTHER, q-
�/-EJLIiC
COMMFRCIAI
❑TENANT, I' i)SERVICE
IMMOVENIENT o �n
01 THER
FLOORAREA
6>a (ikx
199 rsTm
vn,.onurm o C�
00 o
REE
STORIES
TYPE CONS1'RUCr15
ELECTRIC FEE )
BUILDING DIVISION PEES
PLANCHFCK FEF. 76 r
ENERGY FEE Lir
GRADING ITE' /
SOILS I�TP��gf/[J-A✓—��(,/ s7
PAID YLYJ_ Rot' --
Date Receipt N
PAID
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DATE:
a
BUILDING FEE 1 '
REE
SEISMIC FEE z,
ELECTRIC FEE )
PLUMBING FEE s
MECHANICAL FEE 1
CONSTRUCTIONI'AX
HOUSING MITIGATION PER la�G
PAID
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DATE:
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