S 0951 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION A PPLICATIONIPERD7 IT
LICNo
✓9
PERMI 1NO
S
NITARY NO. APPLICAHON SCENE FAL I:
//-ar-92
NIC CONTROL#
OFFICE
❑ Cansaltant Fees Paid by Applicant (Initial)
xIJIG ILtcr PLUMB MECH
OZZ
k Op
F -w_
lu�
Z
LICENSED CONTRAC ORS DECLARATION
I lrrtny worm tom 1 am Beeme,l ander Pn,vision, of Chynm 9 (mmrrcrcmg
wile swoon n##0nnlivialm3nnlr Rualrx.aW P<naxdl... Cate. anamyEN�INe i.
hBrRfurcc vd ?A `
l.iwrcc Cln: J ` Lk'M
Ihrc Con.
Qjy ELECTRIC PERM PP FEE
JOB DFSCRIPTION
RESIDENTIAL:
❑SIUK'1, El KITCHEN RIiMODIiI,
❑ADDITION ❑PLUMBING RL -PIPE
PERMrr ISSUANCE
APPLIANCES - RESIDENTIAL
FF W
to 61y❑MULTI-UNIT
f-17er 2
Z4 -
QFC
AYE
K K U
a U
13 a,
[I STRUCTURAL
BION
CHIMNEY
[I INTERIOR ❑SWIMMING PDOR
IVIPROVEMh:N'I' [D SWIMMING I'WIS
❑ BATH RFMODF,IAF,PAIR ❑DINOLITiON
[I OTHER
Jelin
AR ❑ECI'S DGCLARA'i ON
l urate u W my PLv.a .toll be usN vz IuMk rwlN+
UP 10 2
UP T0291AMI'.S
LieasN Pref Glmnl
OWNER-BUILDERe,se,DECIARATION
I M1tasc eRrm thet 1 um exemM fmm )hr Clnions, Co Licence law for the
f hieh ag ,ares , (S.it 1 ]0allo Bus'url. and t'mfeasioni Cole: Any city or cscnty
wnicn i. i a Parra m.Im,sthe mor, al fiernu dencranil Ir s si troy xtmcmrt
a uder,ed Paoti Jr Ikxntfor Con IIORkasi umcmat
prxr of rmFlira vpP Penni IPIN
Poor
mm he ie liccnscA Pursuant mlNC Pnrvixinne nfthu Clnr tiur'n Lkwclaw fCM1uf#crE
2tll-If#p AMPS
OVER IOf#)AMPS
SIGNS ELECTRICAL
SPECIAI. CIRNIT/h115C.
—R-�� -
'ICG�O
.deer
^H
' ��
a 3 e4
Fcornncrring with Satim]n00) of Division 3 M the Buxiam.0 and Piofe ion, Cark)or
Pan he is umnPl IMmtmm"the haws for N, alleged exemption. My vialolion of
See,icarW315 by my.,O.c.Fort Penniteabscls the ippli. to a civil Pcosh, of
net m.ve fban live huwLed&Ilan IS500).
El xe pyeny, nrmycmpinymwithwnga n[theirNneNmPCraalinn,
will Jolts wurk.vrld the uracturt u not untold] oroRcml for sale(Sec. 7(w. Buairesa
ore Profession, Clcc The Conlic loh Licunc law docs rat .,,Iy to an Invtrr of
who hada, ar impnvea instance. arc who Joen each work hora<If or thrwgn
n'.\n. Ml:-IF.R OR POLE WST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLrr10N
❑TUNA# ❑ FOOD SERVICE
IMPROVEMFINT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
SWIMMING
OUT_ 175- SWITCHES -FIX UHES
property
hie mwn mrployecs. ponidN that snob impmvcnums are n t arlsorN Ir olferal for
One. ,hassescr, Or WiWingurimryov<mrntix WJ winlin me yam UcmlPlnim.the
NEW RESIDEM'IAL Fl.ECIR SQ Fr.
SQ. IT. FLOOR AREA
5/SQ. ET
�rr-haildcr, will Lave the buNcn ,f Pnrvmg Pro be did. hui1J Or improve for Pra-
nf.ak.)
1, esIheaof IFCp
aamecia gwish I)The
PAID
AL:
onotea'Isi-
.70,, Btin,,sively
cor.vnrtthe neat (Sec.oda eof arc P,who,nrlxCrate:)TheConhereon.l.i-
mlawdoe_cmtyglYmmowneroflnorrny wnuhuil
QTy. PLUMBING PERMIT / FE.
O`
Peouratprovca Coaan.md
woonseU,for such pnrjccts worn vcuntmctmis)Iiwn cJ Punuenl torts Clmtrectl✓a
��y��,`�
Fla gp�ga'T�
PERMIT ISSUANCE me
License law.
]lam cxcmPt arcrr see ,B&P C for this mvlu
-���ll {Yi
Owncr Dale
ALTER - DRAIN&VENT - WATER IFA)
VALUATION
.JI A;92
WORKERS COMPENSATION DECLARATION
I herthy affirm u Wes Penvlly of Perjury one of Inc folMwing Ikclva(irmx
BACK FLOW PRODICr. DEVICE
C3 I hestandwill malotain.Ccnifeamuf Con. 1. of -inion, furwmkcrY. Comlrh
es Provided l r by Section 3](M of tHc IaMr bate, frc do Irrnmwnac of �
Kwt L for which Of, Fremont is i.w.
erd
I Save aW will ouanwin Worker'. Cumpcwtiln houranw, u required by ScOl n
) M the L,br Code, frc time perfom eof the wok for which this Pmi is isaucd.
cM
DRAINS-FLOOR.ROOF.ARRA, FIND
STORIES 'ryPI; CON'STNUCI'ION
-
FIXTURES - MR TRAP
GAS - FA. SYSTEM -I INC. i OUO.M_
(ICC. GROUP
APN'
My Wurkrrr Co K Winn arnl PoGry nu}�r cr
Canter: �Q���G— Policy Nn. ,a; � a
GAS - G.tiYSIIJN OVER 4(L1)
GREASFIINDUSTRL WASTE INTERCEPTOR
M W01.____g
CLRTIFl C EXPFIONI NFROMW00.KL'R
COMPP,NSAI)ON INSURANCE
BUILDING DI VISIUN PEES
(TTlisseetionnmlyd bcasnlgaNi[the permit ix fmmehuWaU JNIma($Ifq)
or eece.)
GREASETRAP '
PI.ANCHECK 113E
Iceisifydut in thePMmmana of the wort: forwhichthisprmdt is ism.vl, I shelf
not employ any pemso in any Ilcnnerw as to necmrweuhjat w tae Workers Coda da-
SEWER - SANITARY - STORM EA. 39)17
ENERGY FEE ,
WATER HEATER WNENT/E1.13 R
GRADING FEE
0Z
Z Q
p ;
Wforo
1
V O
t•+
Fh
L) z
nation Law. Of Califoraw. Date
A,hcant
NOTICE TO APPI.ICANT: If, after making this Cerif etc of ExcmMion, you Jaunt
becrnr ser", to the Words- s Cunyrrwtim Provisiem of tK Labor Code. You rout
lhc.,I, with such Prosiaiorvam this Pcornit shall be dame) revoked.
CONSTRUCTION LENDING AGENCY
I hereby afflnrbaot here is. con irm kerding.gere, for Perto a.f
,he work fur which this Penaa Is issued (Sec. 3197, Civ. C.)
IrMer's Name -
WATER SYSTEMNRFA'IING
WATER SERVICE
SOILS !L:
PAID RcdPt
NEW RISIDWI'I Al, I'LMx. SO. IT
TOTALF-'
- TUI'AL:
],We, AMness
is
HUILDIM
trod state al tieave .linfoamtion
"atiun n
I rectify tlw I have iced Nu Iic
.rxrtct.I ogrre murmPly win, entity ardeounry lxJEurca uW watt law. nladngm
MJIJing cnnstanion. anJ hertby eutnorire rtPrncnlativcs of this citymalcr ulmlthe
QTY. MECHANICAL PERMIT FEE
SEISMICFEE
PPRMITISSUANCE
BLECMIC FEE
"
above-nrntimed Pmpcny fa in.lectim PuTr�*.
(We) agree to ave, imkmnify mW keep lurnskv the City of Cupcnino agninu
PLUMBING Fl31
IieNlilie.judgmenu. coast and exlrenci which may in my stay accrue aguinu acid City'
cnuyuctre of the granting of this Permit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT FIR) 10,000CFM)
MECHANICAL LE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGUL\TTONS.
AIR HANDLING UNIT (OVER IB,f#10 CFM)
CONS 'IRUCTIO'TAX
Signvlae of AMbeav/Cmlrector Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUC)
HOUSING MITI TION FEE
IIEMING UNIT (TO 100,000 BTU)
WTII nr,,Aicmn or fmmc he ilding occnlmnt stort or hmcic llaavdous mateial
as delict by the Culenirm Munie Pat Crate. Chanter 9.12, and tae Hewn vol Safety
Code, Swoon 25532(r)]
HFATING UNIT (OVER 100,000 BTC)
VENDLATION FAN( SINGLE RE9D)
L3 Yes, I ❑Nn
PAID
Dan ReCelptl
BOILIiR-cGi.IP (3HP OR 91,()If111TU)
W d the air ricant ln fumrt himbathing Mche tiny A m Airrrnt rr JMana wM1kn
trail narmdNe air uinmmiwnle en Jcfrrd by the Ovy Area Air Quality Mamgenrm
TOTAL
ROILER-COMP(OVER 10C.9p BTU)
D l
El Yes C1 No
AIR CONDITIONER
I one obvurduu, ertals a mccr Clugaef b95 Of in, CWT-
nod llr mmmryin
ISSUANCE DATE,
NEW RESIDENTIAL MF.CII. SQ. I'f.
foram Health & Safmy Cute, Sen'uns 25.VD, 25533 trod 253if.1 mdnstaW than if be
Fainting Ino. rxx Nrrendy have a r11:NI.Ihat It I. my ttaPinathillty to notify tK wayum
n must he et prto mrccof a Cenifcured kculwr.y
of the mryiremau whkmier isw
A , �:M. ,7
'fOTA L:
ISSUED BY:
I?vrmrm vat, zed gentnn. Date
OFFICE