29600'. APPLICANTTO FILL IN INFORMATION WITHIN REDLINES -'USE BALL POINT PEN ONLY' - - - -a I '
CITY OE ULPEBTINO' Iw 11- " BUILDING - ELECTRICAL '.
BUILDING DIVISION _ I APPLICATION/PERMIT PL -
- BUILDING PROJECT IDENTIFICATION
PERMIT NO. /� (] 0 O
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BUIILLDINGADDREESSS
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SANITARY NO s'
APPLICATION SUBMITTAL DATE
OW NAME: ^ •. PHONE: CONTRACTOR'S NAME. LIC NO.
N/C
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ARC TECUENGINEER: 'LICNO: gDDRESS:
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CON^TA�CT. - PHONE -
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❑ -C6 ds-it ant Fees Paid by Applicant (Initial)-
BUILDING PERMIT INFO
BLDG ELECT r PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 herebyQTY. ELECTRIC PERMIT
affirt6 that I nm Iflhcse$nhder provisions ofsCOdO:9manufacturingmy ticeFE8
with section OtN)0)of0ivisin otter Business Chapter
and Professions Code; and my license is
_
m full force an PERMIT ISSUANCE .�
Licens CSS, # �� �'
D.m Comrauor APPLIANCES- RESIDENTIAL I
-
.JOB DESCRIPTION
p
, RESIDENTIAL �
- ❑ SFDW L ❑ KITCHEN REMODEL
(]ADDITION., ❑PLUMBING RE-PIPE-
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„ ARCHITECTS DECLARATION PANELS.
- 1 understand my plans shall be used as public recordsMODIFICATION
Ucen dProfes 1 UTTO 200 AMPS •
-
OWNER BUILDER DECLARATION 2(11 I000AMPS
'ElMULTI .[]STRUCTURAL,
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
aj
'Rj a F
Cme
mJ
p,
p0
e y
iiWWW%GG.n Wy
p.not
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]; thereby ffrm Ih t I am 'pt f m theContractors License Law far the OVER 1000 AMPS,
follo 8 a (S tl 7031 5 B a d Professions Cad Any city county SIGNS ELECTRICAL
which requires a permit to dround” atimprove,demolish, r P any structure -
prior to its issuance, also q theapplicantf hpermit [ FI a.'g'd statement SPECIAh CIRCUIT/MISC.
Thal h licensed p n as 'hep Ism-1 f IM1 Contractor's L Law (Chapter 9
(comm g ilh Sec,i n7W0) fDry n 3 fthe Businessand Professions Code)or TEMP, METER OR POLE Isi
that he is exempt therefrom it be basis for the alleged exemption, Any violation of
Section 7031 5 by y applicant for a Permit subjects the applicant a c 1 penalty of POWER DEVICES
more n fi e ndred dollars ($500) -
Ih me f Nh p Open
❑ L. y,., or my drad.yos with wages as Ifis le c pensm n 'SWIMMING POOL ELECTRIC
will f me k and the sr ctom is not intended ffered forsale(Se 7044, Basin,,,SER
end Pn f i n Code, The Cmurncmr s License a Law dues not apply to an owner of OUTLETS- SWITCHES - FIXTURES
Progeny who builds nr improves thereon, and who does such work himself or through'
his own employees, pro ded that such imp .... mind, are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale if, however, the build'% firpsomenter, is sold withmane y"" oumplelio¢the Y
owner budder will hove thebmdor of proving that he did not build nnmprove far Pur-
]les fth prop tty loslvelyconlmelmg with bcense❑... Indermad, - TOTAL:
remsuu 1 did pr 1 t (Sec 7044 Bu ire and Profesime, Code) The Contrecmr f.i-
cense Lawdce tapplyi an w ofpropenywhei builds or improves thereon and QTY, PLUMBING PERMIT FEE
who contracts for inch prmools with. contucur(a) licensed pursuant to the Contractor's /
License Law. / PERMIT ISSUANCE
❑ tom exempt undergo. ,B&PCfur this reason O
!❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
t,
NE /ADDITION ❑DEMOLITION
'TE✓✓✓NANT' - 0 FOOD SERVICE '
'Jk�PROVEMENT P. v
IX
SQ, �,[. FIsQO�ApEA
IIJJ
1996
(�%- u
OCT,
CITY OF,vUf thI Bil
/
$/SQ.FT.-
7,
'
-
,
"
•,
Owner - ALTER -DRAM & VENT- WATER (EA) .
Date
I•,
VALUATION
-'
4...
' WORKER'S COMPENSATION DECLARATION 'BACK FLOW PROTECL DEVICE
1 hereby affirm under penalty of perjury one of the folio ing J 1 1
Q ihuveund will montaiu a Certfictm of Consenao self-Insumf W k •C,mpen- DRAINS- FLOOR, ROOF, AREA, COND
Galion as provided for by Section 37W of the Labor Came for the performance of the
weak ¢h this tisissred. -
Rrm' FLXTURES-PER TRAP _t
h ❑ ill intain Workers Compensation Insurance q d by Section
J]W of th IoM'Cade, far the perfdrmnnce of the work for whichth perm l's issued. GAS-EA. SYSTEM-1 INC.40UTLETS
MyW rker ompensr nlnso me carrier and Policy num
Kee
Carrier' Policy No OAS -EA. SYSTEM -OVER 4 (EA)
STORIES
I
'
PCC GROUP
.TYPE CONSTRUCTION
APN
RTIFICATE FROM WORKERS':
COMPENSATION INSURANCE GREASEHNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
.
_ ('Dili section mord not be completed if the permil is formic hundred dollars (S 100)
z
O
a [^
W Q
• z.',
fJ 0
w!�
or less] GREASE TRAP
'/ / erffy in.,m the pert rte fthe work forwhch lhisperml 'sued Ishan
not empty yperson m yea e.. sea becmmesu63ecvolheW kersC pen; SEWER-SANITARY-STORM EA. 200 FT.
cation L. f Califmmia Date s ;
'p1ANCHECK FEE
'
ENERGY FEE
-
1
WATER HEATER WNENT/ELECTR
NOTCm - -
GRADING PEE .
Exemption, you should WATER SYSTEMITREATING
NOTICE TO APPLICANT If,after inking n Certificate the
y the Wo k r Compensation this Posts." of the pled Code, you most
became subjectcomply
forthwith ply uh . h provisions or Ni pe rt shall be de mrd ked. b
II , ,: WATER SERVICE � / .
CONSTRUCTION LENDING AGENCY- NEW RESIDENTIALPLMB. •.�' 5 FT.
,.Ih by affrm shat there) 0conswcY lending agency for the performanceof Q
the work for which this parrot i.sued(Sec 3097, Civ. C.)+
SOILS FEE i �
-
PAID
k i '
Date Receipt#
_
Ue
�'y a
0
G�
LendtosN
TOTAL
BUILDING FEE
n
'
:,
Leader's Address
TOTAL: #
the above o s miction is --
L certify that l have h d nils application and sure ordinances QTY. MECHANICAL PERMIT FEE'
milling agreetoconiand with ad] city and 'repmyauffie,ces and sole la enter
buildingconswcliroert M1erebyaolhon purposes. ivesmfthis city to'anter upon the
Olson
above-mentioned progeny for inspection purposes. - '
PERMIT ISSUANCE
(We) agree to save, indemnify and keep harmless the City of rue agan, no against
liabilities, judgments, of i wincadd of this ermit. may many way accrue ngvnstsmd City ALTER OR ADD TO MECH.
in consequence of the %renting of this permit -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT PIR HANDLING UNIT (TO 10,000 CFM).
SOURCE REGULATIONS, 'MECHANICAL
SEISMIC FEE. '
-
ELECTRIC FEB
PLUMBING FEE ,
' D
FEE
"
AIR HANDLING UNIT(OVER 10," CFM)-
1
CONSTRUCTION TAX.,- s
Signalurc of Applummucommedur .' Dale -. EXHAUST HOOD (WB)UCT) 1.
HAZARDOUS MATERIALS DISCLOSURE '
HOUSING MITIGATION FEE
Will themidisma61 future bolding occupant tore orhandle hazardous material HEATING UNIT (TO 100,000 BTU)+
as defined by the Capers do Municipal Code Chapter 9.; 2, and the Health and Safety_ _
Code, Section 25532(1)? 1 - - HEATINGUNIT(OVeR 100,000BTU)
❑Y 1 t ❑N i .. .,, -v
I
i
VENTILATION FAN (SINGLE RESID)
PAID
•' Date Receipt#I
,Will the applicant re f t bis Idlng occupant use equipment in d ices which -
1
emit hatemlousair cartainuounts as defined by the Bay Arca Air Quality Management BOILER, COMP OHP OR 100,000 BTU)
District] ."
.,
❑Yes .O No •''t., ". BOILER- COMP (OVER 100,(100 BTU)
1
NOTAL:.
,
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^, 1 h.ve read Oe by ous materials requirements under Chapter 6.95 or the Cali-' AIR CONDITIONER
torrid Heald & Safety Cadd, Sections 25505.25533 aad 25534.1 understand that if the -
building does an,currently have a tenant, that it is es bili) ,mint thea ,NEW RESIDENTIAL MECH. SQ. FT.
Y pmsi Y Y Pam
of me uireme set h 1be met prior in ed of a Cdo, to
1
ISSUANCE DATE ,
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1.
ISSUED BY.
r at o ❑agent -f r(� to - TOTAL: - -
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OFFICE .,
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