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CITY OF CUPF.RTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENT'IF'ICATIDN
PEI`v fl`NO. 1648
BUILDING ADDRESS:
I0W7S CLL'bhayse LLA.",
SANITARY NO.
APPLICATION SUBMITTAL DATE
6`12
OWNER'S NA PHONE:
eD JO -7-15— oboy
CONTRACTOR'S NAME' LIC NO:
-%Okv11$ P�VW16/ u r^yp r
NIC
❑
CONTROL#
ARCHITIiCTIENGINL'ER: LIC NO:
DRESS:
V94136z Afi A 9507r
CONTACT: PHONE:
BUILDING PERMIT INFO
LEC9E39IR MECH
❑ Consultant Fees Paid by Applicant (Initial)VEIIWERIOR
❑❑
LICENSED CONTRACTOR'S DECLARA9'ION
I hereby a1Brm that 1 am licensed under provision. of Chapter 9 (commencing
with Sectio 70D0).f Division Sof the Brmaratsand Pradvoimm Coole,undmy license i.
in full force and effect �(plI le r
I License Cl...G' 36 Lb. # �=
Dam S canmaemt
QTY. ELECTRIC PERMIT
B D
:
N REMODEL
RE -PIPE
URAL
CATION
Y REPAIR
IMPROVEMENT EjSWIMMING POOLS
PERMIT ISSUANCE
APPLIANCES - RIiSIDI:NTIALING
R
i ARCHITECT'S Dx pebli TION
I Iundemand my plans shall be used as public rtcoMs
PANELS
UP TO 200 AMPS
1 Licensed Professional
2111-1000AMPS
1 OWNER -BUILDER DECLARNHON
1 hereby ofWn Thal 1 am exempt Interim Commences License Law far the
1 following reaam. IScedon ]031.5. Rosiness anti Prmfesaiaa, Code: Any city or coumy
W requires a permit to conduct. alter, improve, demolish, or repair any smamure
Cl BATH REMQDEIgJFR,1AIR ODEMIOLITION
MOTHER 1 nSh� 1, 4S /IAS
L -
•fit -An U 0 k 4.eD
OVER 10)(1 AMPS
SIGNS ELECTRICAL
SPECI AL CI RCUIT/MISC
61
F +yam0 ARD
prior to its issuance, also frquires the applicant far such permit to file a signed stmereem
that he is licensed pmsuam to the perso mos of the Commodes License Law (Chapter 9
COMMERCIAL:
(commencing with Section 7000) of Division 3 of the Business and Prohssions Code) oar
that he is exempt therefrom and the basis for me alleged exemption. Any vidider Of
TEMP. ME'IGR OR POLE INST.
[I NEW BLDGIADDITION El DEMOLITION
• Sectian]0315 by anyapplieant fora permit mud's the.faliemuo a civil penally of
POWI7R DEVICES
[]TENANT❑FOOD SERVICE
not mom than Eve hundred dollars ($500).
�[:1 I,axowner ofthcpopeny, or my cntployew with wages, lad, d, nmpenwo n,
rill do the work, end the s0ucwm is nal intended m offemd Brute (Scc. 7044, Business
and Nord cions Code: The Contmamrs License Law en,s not apply m na .am, of
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ IT.
property, who build, or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended Or offered for
sale. IL r. fine building or improvement is sold within one year of completion, the
Q. FT. FLOOR AREA
LSQ. Ff.
-builder will have the burden of proving that he did and build or improve fon pur-
neofsule.)
TOTAL
L
w
p�r
❑ 1, us owner of the prmpenY, am eadusivelY amtreaimg with sed cumeacmrs 1.
PAI D
construct me project (See. 7064, Business end Professions Code)'Ire Contractor's ].I -
carve Low mss not apply to an owner of progeny who builds Or improves memo, and
ocmmmcts for such projects with a contfactor(s) licensed Toroidal to the Commeo's
QTY. PLUMBING PERMIT FEE
MAY 12 ANSI
PERMIT ISSUANCE
License Law.
I am exempt under Ser, ,B& P C for this reason
Owner Date
ALTER - DRAIN & VENT - WATER (EA)
OF Gul"t- HAU
WORKER'S COMPENSATION DECLARATION
- BACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of perjury One of the following declaration,.
I have and will maintain a Certificate of Consent loself-insure for Workees Compen-
DRAINS- FLOOR, ROOF, AREA. COND.
STORIES
TYPE TION
cation, os provided furry Section 39(0 of the Labm Ede, lot the performance of he
work far which this pcmait is issued.
FIXTURES - PER TRAP
❑ 1 have and will maintain Worker's Cmngsens:nion Insurance, as required by Section
3]Wofthe LitherCale. far the perfmmanceofthe work for which his permit i, iaued.
GAS -FLA. SYSTEM -1 INC 4011'TLF.'IS
OCC.GROUP
APN
GAS-EA.SYS'I'EM-OVHR4(EA)
My Worker's Con)-mamm mucrony�oficrom Policy mmmbernrt:
Carrier: L.�Se_ Policy No.: AfwL111M87-03
GRIiASOINDUSTRI.WASTF.INTERC[zfOR
// CHRTIFIC TI! OFEXEMPTION FROM WORKERS
COMPENSATION INSURANCE
BUILDING DIVISION FEES
GREASE TRAP
PLANCIiBCK FEE
Old,w"tionneed no( Mcmmpleted ifthepemail is Froue hundred dollars ($100)
or less.)
SEW17R- SANITARY -STORM EA. 210 FT.
ENERGY PEE
I sen ity that in he performance of the work for which his permit is issued, l shall
not employ any person in any manner wax to become subject m the Wmke.i Cmmpen-
WATER HEATER WNENT/F.LMTR
GRADING ItiE
uorion laws of California. Dam
i Applicant
NOTICE TO APPLICANT: It, after making this Cenificate of Exemption, you should
become subject o the Workers Compensation provisions of the WMf Cade, you must
WATER SYSTEMIfNEATING
SOILS FEE
4 forthwith comply with such provisions or this Permit shall W deemed revoked.
WATER SERVICE
f CONSTRUCTION LENDING AGENCY
L hereby affirm that there is u concoction lending agency for the performance of
he work for which this #email is issued (See. 3197, CO. C.)
Leader's Name
PAID
Date 1#
NEW RESIDENTIAL. PLMB. SQ. FT.
TOTAL_
69
Lender's Address
BUILDING I'E
4 L sentry that I have mad thin application and state and the above infornmtion is
0 forte". l agree ba comply with all city and county ordinances and sate laws relating to
building construction, and her" by authmfixe representatives of this city or enter alum the
QTY.;HANDLING
NICAL7CFM)
SEISMIC FEN 7'si
EELECTRIC
IEE
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep her less the City of CmIrtin, against
FE'
Iiabilinesjudgments, costs and expenses which may in any way accrue against said City
MECH.PLUMBING
in nnsequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
NIT(TO 1MECHANIC
.FEESOURCE
REGUWTIOONSS'
(OVECONSTRIIC
ON TAX
SJ9d�NIT
S Imre of pplicant/Cuotmaor Dot
EXHAUST HOOD(W/DUCT)
HOUSING MIT \ATION FIA:
HAZARDOUS MATERIALS DISCLOSURE.
Willmeapplienlimlulms building occupant sore Or handle hmardous material
as defined by the Caperton, Municipal Code, Chaptcr 9.12, and the Health and Safety
Code, Section 25532(a)T
HEATING UNIT (10 100,000 BTU)
,
HEATING UNIT (OVER I111i BTU)
VFFO [LATION FAN (SINGLE RESI))
❑Yes El No
PAID
Dam Rcceiptp
'Will the upplicum or futua" huilofmg xcopnm use equipment Or devices which
mit hazardous air o m a inane, as defined by the Bay Area Air Quality Management
BOILER -COMP UHP OR I00JX0 BTU)
L:
BOILER - COMP(OVER 100,1100 BTU)
District?
❑Yes ❑No
AIR CONDITIONER
ISSUANCE, DATE
I base mad the haeallous annedds eltimments under Chapter 6.95 Of On Cali-
NEW RESIDENTIAL MECH. SQ. IT.
Fonio Hcnith & Safety Codc. Sections 25505, 25533 it 25531. 1 understand that if the
building does not conically have a mount, that it is my resism ibility m notify the Occupant
of the mqulrements which must be met prior ba isenonee Of a Cenificate of Occupancy.
TOTAL:
ISSUED BY:
Owner or mthariaedagent Dote
UFFICE