27045 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEPERMIT NO.
SIO NO APPLICATION/PERMIT PLUMBING-.MECHANICAL 2 7 0 4 5
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDI6ADIRFS$: \ SANITARY NO. APPIJCATIONSUBMD'I'ALDATE
SS[[YY//JJ//UU Lew) 'aVUNIT LOTH
OW NA i O P' 'nl'�/ CO NAM �L �1
NIC CONTROL♦
RCHITECOHNGINLIR LIC O: ADD ❑
Ct INT :f': - PHONE: QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
I BLDG ELECT PLUMB Cf
PERMITISSUANCE1:1 El
1 T NSED COMRACfOR'S DECLMR TION APPIJpNCPS.RESIDEMIAL 101 DESCRIPTION
OCZ Ir,7=.fO thu lamf,c Be.]eNapmviY rain Clugcr9(c re,fi t ,ion 1
W00 Section]Ig0)of gn,}PfJrt Burrrr end eui s dmylicrnuis in ppNEls
C full face eml of ,{/IN/) Up]p Zpp AMPS
FQF.VV W Lime CI Lie.N
to<N Uvlc Convenor 101-i"AMPS
T
ZOyG ARCHITECS DI: OVER 1000AMPS SQ.Ff.FLOOR AREA S/SQ.FT.
04
• I undenaod my loons shall M used n Public records
;o,F I�i SIGNS ELECTRICAL
Qy� LicrnaW ProfcwiaW
Ly
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/ABSC
x�d4 OyuI-. I hertby affirm Nal l.m exempt from Jnh L
e Comv. akaue L. fa w the
N:`i-ln felhwing rcaaon.ISe L(m]0315,Business rend Profnaiorca Code:Any city a rouvry TEMP,METER OR POLE INST.
E'�O which t an coravuc6 sher,1
,O� rtquirn•puna rnpva,dvoeret t,aea)v'vany Reueturt
N5 ce primtoils ivmmc.also mryira the epplicanlfasech pamitto file eeignW staaetwit Po55'F,R DEVICES
,c'<O dw he is licansed Iteration,to the prnriaiom of the Convxtala Lroace,E.w(Chgtta SWTABNBJG POOL ELECTRIC
d X.Fx 9(conmercing wlN Section](p0)of DTrieion 3 of the Buiircu.eri Pvfaiw Code) i VA UA ON
I,
_, or that It ie exempt Nmefmm and the huffs for U aidlegal exrnption.Any vloletim of
hZntim
_> S ]031.5by.,.,Ii.for.pmnit subJ.the.pplimntto a coed peWOUTLETS-SWITCHES-
ry of FIXTURES
O
< not morctMn w
BvcM1Jrd dollars($SW). NEWRETI
SIDENALELECIR _SQ.FT.
u�' ❑ I.nownaofthc pmlany.amyempbyeea with wagnu NeBade mnlpaaelim, STORIES TYPE CONSTRUCTION
a3� will An doe wed."theamlrlueC ileo intmdal aiffemd fmaale(See.](W4,1u.im.
and Pmfasicros CMe:Tie Conv.nor'a Lw don ro
Leese Isoapply to rn owner of
fact
PtaPertYwho buildermhtrymsc tltnnm..ed whodon..,.h wah MmsNfa achoer
empinyea.lanvitleJ ihsi such impmvrntrntaerc mtimrnded«affemlWe.Ir, GROUP RIS.UNITS
howcvcr,the builJinga vnpvvarcnt is and within one refe mplacion,the.-
builda will have the buMen of pmvhig thu M did mot build ry
or imove for Pugnr<of TOTAL
ante).
❑ I.uowtertsfthcpWmY,am caclusivNymnrnctin/with licaaed conmaonto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onetrtsn the project(See.7014.9mireve rend Prnfeoime Code)The Convacw/s PERMIT ISSUANCE
IJccrue Lew don not mptY a rot mw ter of 1+apenY who bu i Wer a vn poen tMrem,ere W
whoccent fer such pmjure with a cmtrrsant
acta(a)Iicroweal puuto the Conlnmor's
Lia c law. ALTER-DRAIN&VFM-WATER(EA) FEE SUMMARY
❑nl un hemp uMa Sec. ,B&P C fa Chia roan BACK FLOW PItOTECf.DEVICE
SANITARY Y N
Ow«e Dose DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ibertby elTtrm Nal Mveacmtilaa of caumtto self-ionone,«a mtifRve of RFCTBPI'#
wn,ia C ti 1 ¢ iBMc nmf(Sa.3g00,1«b Cd which Fl%TURIS-PER TRAP PARK FEE Y N
ars ell em P, t t®3O raGAS.FA,SYSTEM-]INC. O RECEIPT N
Policy♦ 111/// EM- 9' ILDI GDIVISION IT",
❑
1y GAS-EA.SYSTE -0VER 4 HM NCH F
GaJBM copy u M
❑ Certified copy,u filMwiNthe riryi ium. GREASFJINDUSIRL WASTER uBPTOR
CERTIFICATE OF FXFLHPDON MOM WORKERS' GRFASETRAP SOILS
COMPENSATION INSURANCE
Glda aecuoo rteedto be campkted ifda pamites f«me huMeeddoWn(SIW) SEWER-SANITARY-Sf MEA. E =111
m iced
I play that inhere in omurcc ofd w,.for which this Permit n the W Iitimill,.' WATER HIiSTPt WNtNf/ELF.CTR —�
Co cmplati.ny waif in arty D er a u to bccmte svbjea to the Woken' PAID
Cmyeevalim l�wa of Celifomie. Date WATER SYSTFM/IREATING Due ReaiptN
A,katav
C NOTICE.TO APPLICANT:If,afar making this C,,mE.,of Exemption,you nhnuld NEW RESIDENTIAL FILM B. SQ,FT. TOTAL:
(- benmse subjectto theaW«kda Cempecesu Modilmss of Ne Libar Cade.you rota
C4 > forthwith comply with such prowlaitau or Nu pemdl.hall Podecmeel reacted. BUILDING FEE
y CONSTRUCTION LENDING AGENCY SEISMIC FTE
1 herchy.ilirm that IhCR is•ram unction Imdlng.gaey for the perfortranea of
U O the,the,wok for which Itis permit I.Icacd(Sec.309],C.,C) TOTAL ELECTRIC FTE
Irndn'e N.O _E— lindrev
lcr'a Ad . QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify"Jart T have retl this"Basion and.lea Jut Ne.bove infmrtution is
mtren. le toe m ywiN ell r�ry vd county oNitwweml state lawn rt[.inga PERMIT ISSUANCE: MECHANICAL FTE
C) .bcw'-g sac httebyaathaixertpracatadrn of Nie city amts upon the CONSI'RUCItON TAX
acne-rrc tior��ai f«imparim putpoc_s. ALTER OR ADD TO MLCU.
(W agrcF t 'w itdctmify ami kap hermku the Cititq ag.irm
lieblliti ,j nWex w 'ch may inany yo' mid Ciry AIR HANDLING UNIT TO 10,000 CFM)
he I' g
ABt HANDLING UNR(OVpt 10,000 CFM)
Signers of 1' omrictor IUaa EXHAUST HOOD(W/DUC)
PAID
IIA%Afe W US MATI➢t1AIS DISCLOSURE
HEATING UNIT(TO IW,000 BTU) Doa Rccdpt0
Will the the Crx inn feature building Ia,Chatstort«and le 1,e II Ithand seen# 11 EATING UNIT(OVER I W,M)BTU) TOTAL:
m def Sed by the 32(.)?nu Municipal Ci 4,Chapter 9.Q,and dte Ileehh end Solery
Cada.Smim year e)? VELTLAITON PAN(SINGLE RESID)
❑Ya ❑No
(THP OR I .,.ISS�1gjJr6DA7
Will the, MP 100,001I,flTU) YY �A 11
epplwmit mfuluebuilding«cupmt gptao-COM1
use equipment«Jeviaa whi<haoit
bv,ir a air remtaminanu u&Emd by the,Bey Area Air Qraoity Management BOILER-CONIP(OVER 100.000 BTU)
District?
ID (k�
yea, ❑Nn NEW RESIDENTIAL MECII. SQ.IT. NOV 10 19
1 have ecad the hard loos materials ecquiat nor under Chnpta 6.93 of IM1e
Cliromia llcWN&Safety Coda.Sctioru 25S(P,25533 and 25534. 1urdvstatd Ow CITY Uh l#UYt !
if the Wilding den not cman0y heu
Ma a Ia m.Nat it is my te>p«.aibility to notify Ilia H I IN
«cupont of the"aimrent,which moat be ma pro«a�.auenr of a Cenieratr of � ✓
oeapancy.
Owrcr«eulh«Ilnl agent Dae TOTAL SSl1ED BY: