28421 TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY __
tlwbaLSb-elet.l ntLat. FERMI'I NO.
JPERTINO APPLICATION/PERMIT PLUMBINf-MECHANICAL, n Q /I n
DIVISION BUILDING PROJECT IDENTIFICATION : .° I G o 4 G
JREgS
SANITARY NO APPLICATION SUBMITTAL.DATI
I
Dr. UNIT# LOT# a'-';1
lA E' C! •C9fO�R'S NAME LIL C NO,q/GY r]
NIC CONTHOLp
' p 'SGnidn phU_- n. y
R R. EC/CNGINIER. LIC JO 9 �(Jb73
!. ��1 gNZL Ir El
CONTACT PHONE J r l.•a^I ,(J,vq ;:JI BUILDING PERMIT INFO '
QTY, ELECTRIC PERMIT FEE '
tl1.IN1 ELECT PLUMB MECH
e
PERMIT ISSUANCE ❑ [!X- ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
30H DESCRIPTION
OZ (hereby a-firmlhatlamlmenuJ underprovnmmmCTepmr9lcommentlngwnh ('�
s
t�CC Section70ghat Dtvnlno 30t the Buvoeaa,utd Freeumm Code,and my licenseum PANELS -
d.UU full forte and e(fem' UP TO 201)AMPS 11
IQ,ZUI License Class Lic.# t
y ay Date Contract, 201-Hall)AMPS
F.,CAZ_ ARCHITECTS DECLARATION OVER 11100 AMPS SQ FT.FLOOR ARIiA S(SQ.IT
�'C'^ I undenlanJ my plain shall h uasd.0 public recoNS.
OZ—O
CC SIGNS ELECTRICAL
2 LteenseJ Pmmsnohad
z OC6 OWNER-BUILDER DECLARATION SPECIAL CIRNR/MISC.
KOaU 1 hereby affirm that 1 am exs:mpt fmm die Connannrs license Law for the
wF�Cy following reawn (Section 70315.Business and Professions Cod,An,city--coumy T[.MP.METER OR POLE.INST.
which rcgmma a permti to consumer,alter,improve,demolish,or repmr any stmcarc
pdonn its iss once.also requires the applicant for such permit to file a signed thereon, I POWER DEVICES
=,<C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
9(commencing with Section 700(f)of Division J of the Business and Professions Code)
W^� or that he is exempt therefrom and the basis for Sent leged exemption,Any violation of OUTLETS-SWITCHES-FIXTURES L/#.�C�p 0G
Section 70315 by any apphcum s for a perm w1hectsle h upplmanno acivil penalty of VVV
C_� not more than live hundred dollars SSW) NEW RESIDENTIAL ELECTR _SQ FT.
❑ I,uownerof depmpM.ormyemployeeswMwegesmthcrsolecampensanon, 57ORIES TYPE CONSTRUCTION
y3L2 will do the work.and the structure is not intended moffercd f-rsalclSce.7B14,Business
and Professions Code:The Contracmrs License Law that not apply w an owner of
own property who buJJSOnmpmves therron.and wM1Odoes such work htmulfonhrough iris
employees,provided that improvements we net mtendedondfered---sole.IL OCC.GROUP RES.UNITS
however,the building or Improvement rs sold wahm one yew ofcomplaton.the owner-
budder .will have the burden of proving that he did net bold or improve for purpose of TOTAL.
sale I. I'"
❑ Las owncrofine n QTY. • . PL PERMIT r�� ;cj :vFEE:' �s' F10oU ZONti APN
pmpc ywncxclusrvelymmmcting wnhlicensedcommetorsm v. , 2!I
ansuuct the perfect(Sec.70t#.Business and Profesvome Code Tire Contractors
License Low does not apply to anownerofpro pony who maids Or Improves thereon,end PERMIT ISSUANCE
whocontrams forsuch pre ecs with aconvanortst licensed pursuenuo the Commerce s �.
License Law. I ALTER-DRAIN'&VENT-WATER EA) 'Ir,., ^,. .4-;'FEE SUMMARY
❑ 1 em exempt under See. B&P C for This reason FLOW PROTECT.DEVICE OUTSIDF FFES
I SANITARY Y N
•Own- WORKMAN COMPENSATION DECLARATION DRAT FLOOR,ROOF,AREA,COND ISCHOOLTAX YECEIPI'# N
❑ Ihertby affvm tirmlhave ecevficatp of conummulf-insure,macmda5W& �Q FlXTUR -PER TRAP �� t RFCF rvra
Wn area Compensation interpose or a certified copylhercof(See Jg00.Lah 5;dwhich .^J (PARK FEE Y N
covers all employee'\under permit. / GAS- SY STEM-I INC.a OUTLETS RECEIPT#
Policy BUILDING DIVISION FEES
Court. GAS. SYSTEM OVER Y(EA) PLANCHECK FEE
❑ Centfied copy H hercby(urmshed
❑ Cmdi<d copy rs fled wish on division. GREASE NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFl COMP EXEMPTION MOM EORKERS' I GREASgTRAP SOILS FEE
IThts section need not be co plcted JNe petmnu`r one drcd dollwa lSlBB) SEWER I SANITARY-STORM EA "NATT ENERGY ME
I cipuythatira me, nrma ce of the work for s ern inslssued,I WATERIHEATER W/VENTIELECTR
na employ any person m any tie std m a to the W PAID
Compensation Lowsof Caliform ate T i 1` r ..L WATERISYSTEMTREATING Date Rca"
0 Z Applicator � _ /V t-
Z 0 NOTICE TO APPLICANT:If,. er entities ficat �ExWuon,you should/ NEW RESIDENTIAL PLMIL SQ.IT. TOTAL
r 110 become sublet m the Workers m aton profs (the Labor Cade,youryvsl
ronhwnh comply wish such pro sioro this ate rat,irailbedeemedocrom,iddd��� BUILDING FEE
0. Q CONS CIION LENDING AGENCY/ SEISMIC FEE
I hereby efftim that there a conswcuonlendinge <for the performance of
V Z TOTAL (� ELECTRIC FF.0
O the work for whmh Thu pe.air Issued(Sec.3097 .C.) I T
Lender's Near- •, V -rnsnx•;:..r:^,ay•..r:r..::.,,.+ygr;;., .t4vl-
U' F Lender.nedrr- / QTY. µ!;I;MECHANICAL PERMITb',_;;_, PLUMBING FEE
V I ccm(y that 1 M1ale real the application and vote that the abnvc mfomiaeon n - -
�"'
correct Ia rut maim IM1 011 cis Ja-um Jmances and Vain laws rdaun m PERMIT ISSUANCE MECHANICAL FEE
g �ywi Yon y-r g .
budding construction. d hereby uuthonu repmunmuses of Wes city mercer upon the I CONSTRUCTION TAX
U 2 Above Mentioned proper,lot nspenton purpous. ALTER OR ADD TO MECH.
(We)agree to save,indemnity and keep harmless the City of Cupenmo against
Imirdmes,ludgmen........ Jess.s which mayor any woywcmeagmnst.,J City AIR HANDLING UNIT(DO 14W0 CPM)
In consequence of the granting of this peat.
Al ft HANDLING UNIT(OVER 10,000 GITdI
Signature Of AppllcenUCommemr pate EXHAUST HOOD(WMUCO I PAID��s,`�'�. '4� #-
Will HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 11#,0x0 BTU) Date �e`'m"#e
Will lire applicant or future building nxcupant stoe or handle hazardous material HEATING UNITIOVTal IW.fNIII BTU) TOfAL'�O�_(,a�
as defined by the Cupemno Municipal Cale.Chapter 9.12.and the Heahh and Safety
Cale.Semmes 255321m^
El yet C3 No VENTILATION PAN(SINGLE RE SID) P ;
OOILER-COMP(SHP OR 101"BTU)
ISSUANCE DATE
Will the upplte untnr tuwre buildmgacupamuse egmpmenrnrdev¢eswft¢hcmu
hazardous Or comaminams in defined by the Bay Area An Quality Management BOILER-COMP(OVER 100.000 BTU) I )":I✓I�I .4'.,/ I�Wj
Dko
❑Ycs ❑No I NEW RESIDENTIAL MECH.—SQ.IT. ±,
1 have read the haaallom maenah rcqutrtmems under Chapter fi 95 Of the
Celdnmo I leuhh&Sulety Gdc.Sacnonr:3503.25533 anA 25533. I undemminA Ilia l!1:
occupier of n the requirements which must he met prior to s1panrce Of a Cemficw.e
of
D,.eupaancy I
Ownerramonal agent Date TOTAL (ISSUED 135'�+�' r '• r�-v"�
- - - - - OFFICE - -