27895ILICANT TO FILL IN INFORMATION WITHIN RED LR
BUOF CUPENO APPLICATION/PERMIT
BUILDING DIVISION
LICENSED CONT'RACTOR'S DECLARATION
I herehyaffirm that Tum I irursed under pma idon, of Chapter 9(wmmencing with
Sciatica Was)) of Division 3 of the Business and Pmmisions Code, said my license is in
full force and effect.
License Class Lln#
Dem Contact
ARCHITECTS DECLARATION
_bandersmnd my plans shall be used m public records.
='-¢ OWNER -BUILDER DECLARATION
.,W, 1 hereby affirm that I am exempt from the Contactors License Law for the
413 {Ly fullnwi ng re"on. (Section 003L5, Busiqns code: Any city or county
which requires n .it 10 construct, almve, emolish, mrepair any stmetute
' pdnrloi sea ce,.lso quires PPrsuc oEieeaig ednemm t<pthat he is licensed pursuam eprovisthe Co tactors License Law(Chapter
a'Q9(cormarming with on]000)ofDofthe usinessandProfessionsCode)or that he isex therefromandthebhealle d exemption. Any violation of
Seutiun0 hynnyappllcum for. pehjatslh applicunt m a civil penalty of
re hea five hundred dollars (550m I, asowneroflhepropeny,ormyemswith wa a nslheirsolecompensation,
will ochework,orifiWp��'.caciraran
nroffcree o eele(Saa.9094,0usinws
and fessions Code Lewd not apply to an owner of
pro tty whohewhohhhimselforthmugh his
own mpinye provemcnmuren nenduloroffcredTarsale.ILhow sertheb Idiold withi rte yearofcomplefin,the ownerbuild twill t at he t build or improve for purpose of
❑ aso pmpmy,amexclu' clyconwainga,iNlicmn dcontrecto 0
rnnm cl IM1c pro) ct Sec. ]014, Bui ass and Professions Code:)'IM Com rs
LiceI Lawdoes I M)ylonnow rofproperly who builds orimproves Cher n, and
wane stanch."no pmjam w' econtrnaorts)lmensed pursuanuothe nwmors
Liccns Law.
❑ 1 t xempt under Se- , B C for this reason
Owner Date
W KMAN COMP ENSATION DECLARATION
❑ There off that l have. cert man, m ememm to self -insure, ora ceirfczmof
Workers'Cn sestina lnsumnw or ocnth copy thereof(Se 3800, Lab CJ which
coven all cmployae's undenhis pea it.
Policy #
Company
❑ Cenifiedropyisherebyfumis ed.
❑ Cenifiedcopyisfilulwithth cityin}mcti n Ion.
flTia nertion need not neeeelea Ease fl,tids flares ann.r: (Slop)
or less.)
I certify that in the perform oftbe work for whit perm it is issued, Ishall
not employ any person in y neer so is m be bject to Ore Worker,'
Ap"p ... w.w�P.Ni
Applicant
NOI'ICE'fO APPLICing sCenifica¢of Exemption, you should
become subjcm to rhe. npmvisinnsof the Labor Code, you muss
;forthwith comply witThis Permit shall be deemed revoked.
w (] CONSTRUCTION LENDING AGENCY
5 z 1 hereby affirm that there is a construction lending agency for the performance of
U O�-t the work for which this Permit is issued (Ser. 3097, Civ. C.)
Lk. F' Loodcrx Name
O U Lender's Address
1 certify hat 1 have read this application and stem Nat be above infotmmion is
carred. I agree to comply with all city and county mmucances and slate laws relining,
building construction, and hereby esthotire represeadi ives of this city to enter upon the
U z above-mentiondlp mot, far inspection purposes.
(We) agree In save, indemnify send kap harmless the City f Cinn against
iniamsequirpre fthecostsend expenses may in tiny wlyylsrue eaifg"ld City
inamseyuenceords. granting of expenses whipermit. my
m /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harammus material
little food by the Cmvrti nn Municipal Cole, Chapter, 9.12, and the I Icolm and Safety
Code, Section 25532(a)?
Cl Yes ❑ No
Will the applicant or future building moment use equipment or devices which emit
hazmdoos air contaminants as defined by the Bay Area Air Quality Management
'Diemirta
❑ Yes ❑ No
1 have rend the harardous materials requirememe under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand Nat
Ifthe building does not currently have a mount, that it is my reeponsihility in notify the
rccupam of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or omhorized agent Date
IDPIIIEI
PLUMBING
. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2M AMPS
OVER RNID AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTAL ELECIR _SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN& VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
FIXTURES - I'ER TRAP
9AS - EA. SYSTEM -1 INC.4 OUTLETS
GAS
EA. SYS 'TEST OVER 4(EA)
GREASETNDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 20017.
WATER HEATER W/VENT/ELECTR
WATER SYSTF.M/IRPTING
NEW RESIDENTIAL ELME, SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE,
ALTAR OR ADD TO MECH.
AIR HANDLING UNI(TO 111,000 CPM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST ITOOD (W/DUC )
HEALING UNIT (10 100,0011 BTU)
HEATING UNIT (OVER 10(1,000 B'T'U)
VENTILATION FAN (SINGLE RISID) e+'
BOILER - COMP CUP OR Paid," R?U)
BOILER -COMP (OVER 100,000 /I U)
NEW RESIDENTIAL. MECII, --
� PW\•
SQ. FI'. FLOOR RG
_. 27895
.11 ORAS
SANITARY
NO.
APPLICAI[TON SUBMITTAL DAIII
Lt'lII-qq
3T!
J
N/C
❑
RIES. UNITS
CON I ROLN
FEE
BUILDING PERMIT ]NPO
ItF.E
BLDG
ELECT PLUMB MFC.H
� PW\•
SQ. FI'. FLOOR RG
1N�D`p A3 D
08
.11 ORAS
TYPECONSTRUCI
OCC. GROUP
RIES. UNITS
FLOOD LONE
APN
ItF.E
FEE SUMMARY
UT. DE �I:I.S
SANITARY
YN
RECEIPT#
SCHOOLTAX
YN
BE .ITT#
PARKFEE
Y N
RF EIPI'#
BU INC OVISION FEES
PLANCHECK FE
O
GRADIN lir
�1—
SOILS
4
FINEAW
PAID
=,aReceipt#
TOTAL:
BUILDING PER.
SEISMIC FEE
ELECTRIC ITE
hlil3
PLUMBING
MECHANWAL EF.
CONSTRUCT] NTAX
J
PAID
1N�D`p A3 D
08