25562 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
11 ILII ,-EL1,,C'rRIC L NRMI'I'NO.
IADDRr�S:
ERTINO P 25562
l$ION APPLICATION/PERMIT PI-UMBING-MECIIANICAI.
111111.UING PNOJEC'1'IBEN'I'n'ICA'I ION
BUILSANITARY NO. APPLICATION SUBMI 1-1AL DATIi
ITVN N LOT#
;AR7C1
ERS NAMPO " 1 J PIfONGE: pC t— CO RACTOR'S N E: l LIC NO: er�1l.
1 37/o N/C CONTROL#
ECT/EfNGINEER: IC NO: pD
�37/a 6� div TACTU PHONE:
''J pp[�—f QTY, ELECTRIC PERMIT :.FEE. BUILDING PERMIT INFO
37 lam /pJp.�, PERMIT ISSUANCE �� B}IyG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION If/T�7 �lrYTyll ❑
Z=z Ihcrebyaffirm that l an licensed under onsol'Cha ler 9(commencin APPLIANCES-RESIDENTIAL
provisi p eis in TOB DESCRIPTION
It10p Section V1k1 itefDivision3of the Business and Professions Code,and my license is in PANELS
tK W full force end effect.
tiQa Datense Cl s7s hie.# 637io `` UP TO AMPS y�` '` \/ fJ.l►CQ„�"CA �
=y �GOnwtlor or\ {Wf� 201-ItlIX1AMPS
ZO,i`oj� ARCHITECTS DECLARATION OVER 1LYIIlAMPg SQ.FT.FLOOR AREA �SISQ.FT.
0zFF—� I understand my plans shall lx used as pubinemurNs. ! 1^t
SIGNS ELECTRICAL Fa '1 ^ -, 1�=,•
fi�dd. .] Lmcnsed Ihofessumal t
y�'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. y—• �-
�aU I hereby affirm that L em exempt from the Contractor's License Law for the
co, (.(lowing mism".(Section 70315,Business sod Professions tide:Any cityor county TEMP.METER OR POLE INS1,
lin J which requires a permit to construct,alter,improve,demolish,or repair any stmemm
CW>� prior to its issuance,also rcyuimshe applicant far such permit m file.signed statement POWER DEVICES
,,4Kipm that he is licensed pursuant ve
o the provisions of the Contractors Limits,Law(Chapter
x�C ��
x.LL 9(commencing with Section 7000)of Division 3 claim Business and Professions Cade) SWIMMING POOL ELECTRIC
W_,,,, or that he is exempt therefom and the huxis for the alleged exemption.Any violation of VALUATION
FzQ Section 7031.5 by any applicant for a permit subjects the apPlicunt to a civil penalty of In LETS-SWITCHES-FIXTURES `
t tome then five hundred dollars($500).
o ❑ La nanterofdepmperty,ormyemployccswith wages as theirsolecom cnsation, NHWREMDENTASTORIESLELECfR _SQ.FT, TYPE CONSTRUCTION
Lo willdo Ne work,and the swno
cture isnot intended oroffead foriale(Sec.7044PBusiness
.nd Professions Code:The Convartnr's Lima'-Law does nm apply to an owns,,of
PmNdy whn builds or improves thereon,and who dues such work himself or through his
wn employees,pnwidW mat such impmvememaaa notimendedorofTared foraele.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year ofeadmicdnn,theowner-
builderwillhavetbeburdenof proving that he did not build or improve for purpose of 'A : �•
ale.).
❑ I.asownerofthepropeny.omexclusivOyconvaningwithlicensMeantncmrsm QTY. PLUMBING PERMIT •FIiE FLOOD ZONE APN
construct the project(Sec.7014,Business and Professions Cadc)The Coman.rs
License law does not apply no an owner of property who builds or improves thereon,andPERMIT ISSUANCE
w.,dam mets formch projects with a convenors)licensed pursuanrao the Contractor's
License Law. A ALTER-DRAIN&VENT-WATER(IIA) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this aaann BACK FLOW PROTECT.DEVICE7 I LFL
Owner Date SANITARY Y_ry
WORKMAN COMPENSATION DECLARATION DRAINS-MOOR,ROOP.AREA.CONI. RECEIPT#
❑ Thereby affirm that have acertificate of conxnuo xl6insurgmucenificateM SCHOOL7'AX Y__N
FIXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance.,a ccnified copy thromi Sec.3g1111,Lab C,)whiph PARK FEE YN
pavers all employee's under this permit.
Policy q GAS-EA.SYSTEM-1 INC.4 OUTLETS REClzjn#
Com BUILDING DIVISION PF'
yGAS-EA.SYSTBM-OVER 4 EA)
Certified copy is hereby famished. PLANCHECK FEE
Cenill,,l copy is fled with ter city inspection division. GREASEJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CFRTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
(This 110huUeednm be completed ifths,permit is for one hundred 1.11.(;100) SEWER-SANITARY-STORM EA.200PT.
ENERGY FEE
.,less.)
Icertify that in she performance ofthe work for which this permit is issued.I shall WATER HEATER W/VENTIELECR
not employ any person in any manner as as m become subject to the Workers' PAID
z ComPensution Luwsof Culifomio. Dote WATER SYSTWUREATING
Applicant Date Receipt#
NOT ICE TO APPLICANT:If,ufier making thin Certificate of lixemptinn,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
y NOT ICE T ecuome Worker's Cumpemin,his
Cell cam the Lebo,Cada ynumust
l-^ forthwith comply with such properm
visions or this it shall beeemed revoked.d
0.!
;> forthwith FEE
per,• Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
..- z I hereby affirm that there is n construction lending agency for the perfmmence of
U O Ne work for which this pemrit is issued(Sec.3097.Civ.C.) ELECTRIC FEE
Lenders Name
ULanders Address QTY. MECHANICAL PERMIT .. Flit: PLUMBING FEE
r w I renify mat I have read Nis application sad state Nat the above information is '
EA, incorrect I agree m comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
" V) building construction,and hereby authorize representatives ofthis city miater upon the
U Z above-mentioned propeny for inspection putpous. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree t.save,indemnify and keep door leas the City of C.Nninm against
liahilitiex,judgmcros,comand expanses wwhtmay in a m
qu eany way ace againstsaidCity AIR HANDLING UNIT(TO K."CFM)
in nphe Panting o`� %��'-s'�✓.� �// t
AIR HANDLING UNIT(OVER III,BIX)CEM)
ignatu plicantlCnmmnnr
Data EXHAUST HOOD(W/DUCf)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant orf rum building occupant store or handle hazardous material
as deGnrd by he Capstan.Municipal Cale,Chapter 9.12,and Ne Fleelm and Safety HEAPING UNIT(OVER 100,0110 BTU) TOTAL:
Code,Senior 25532(x)?
❑Yet ❑No VENTILATION FAN(SINGLE RESID)
Will iheappliccaorfuamh�ildingoccupantusee(iuipmentordeviecswhichemlt BOILER-COME QHP OR 100.000 BTU)� ISSUJkANCE DATE hazudous ser codurninants to defined by the Bay Area Air Quality Management P A I D
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes 1:1 No NEW RESIDENTIAL MECH.—SQ,ET. SEP 17
I have read the heaardous materials reyuirements under Chapter 6.95 of ins 1993
California Health&Safety Code,Sections 25505,25533 and 25534. 1 underhand that
ifthe building dues not currently have arenant.that it is my responsibility to notify the
occupant of me requirements which must be met prior to Issuance of a Certificate of
Occupancy.
Owner or padlocked agent Data
TOTAL: ISSUED BY:
OFFICE