30806IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
O BUILDING - ELECTR
APPLICATION/PERMIT PLUMBING - MECHA:
❑ Consultant Fees Paid By Applicant (Initial)
1 hereby affirm that I um licensed under provisions of Chapter 9 (commencing `
OZ with Section 7")of Division Soflha Business and Professions Code. and my license is
W r in full force and, c .
U License Cla •�n�^,' �`//�� Lm
ConN a Dalc ' I A�." DEtOf
Z O' t T' AR HITELTS D[CL TI N
y I understand my plain shall be used m public rec
OZYd� ars
Licensed Professional
Oen I am exempt
from
DECLARATION
1 thereby affirm slut I em emmpt from Ne Contractor's License Low for the
ipyp5�.0 of U following reason. (Section 7031.5, Business and Professions Code: Any city or county
4i 4 C which requires v permit to construct, eller, improve, demolish, or repair any structure
m prim to its issuance. also requires the applicant for such permit o file a signed statement
0that he is licensed pursuantin the provisions of the Contractors License Low (Chapter 9
0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for v permit subjects the applicant o a civil penalty of
z H not mom than five hundred dollars (5500).
pO ❑ I, as owner of the property, or my employees with wages as their sole compensation,
j� will do the work, and the structure is not intended or offered for sale (Sm. 7014, Business
G�' send Professions Code: The Contmnmrs License Law does nm apply to an owner of
property who builds or improves thereon, end who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
side. If, however, the building es improvement is sold within one year of completion, the
wncr-builder will have he burden of proving that he did not build or improve for pur-
pose of sale.).
❑ I, ea owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Cade:) The Cmumeem's Li -
move Law does not apply to an owner of propcny who builds or improves thcmon, and QTY.
who contracts for such projects wish a contractors) licensed pursuant to the Contractors
License Law.
0 l am exempt under See ,B& P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby aIErm under penalty of perjury one of the following dcclumions:
❑ I have andwin maintain a Cenificam of Consent to self insum for Worke'sCompen-
sation, as provided for by Section 37M of the Labor Cud, for the performance of the
Ye�5work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
37W of the Labor Gude; for the performance of me work for which this permit is issued.
f My Wor��kS(e� �CCom nsa nInsurancec 'er and Policy nyp be e
Card
er:plPRJ� Policy Nn.:\I['�A'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hernmpleled if the permit is from, hundred dollars IS 100)
or lase.)
Icenify Nat' the performance of the work for which this permit is issued, Lshall
not employ any pc an
ry m r es m bm
ecoe subject w Ne Worken' Compen-
0 z rolion Laws of Cul' ia DamIf
O Applicant
1A NOTICE TO AP C T: If ter making thi a ificate of Exemption, you should
"os
a� hunme mbje the sCompensudon+nvisinnsof the LnMu Code, you most
W forthwith
,OAP,
with such provisions m this permit shell be dttmed Invoked.
0
7z CONSTRUCTION LENDING AGENCY
(.% Q l herebywhich
this
Pe mere is sued ism.
3 lending agency for performance of
F
me work for which Nis pemrit is issued (Sec. 3097, Ci, CJ
Lenders Name '
L4L I<nderI minify
I m,me thn 1 have read this application and site thin the above information mining is
Z) 4 c building
I agree c comply with all city riz county ordinances and store laws relating m QTy.
U'Z athavengeonsued construction.deadherehy vumnrixereoses. Lives of thio city to enter upon the
above-mentioned propene for impaction l keep hs.
(We) agree m save, indemnify and keep ha, in ar, the City of Cupeninn nguinnt
incon ex nce of tecostsand expcnuswhich may inane way cecina against raid City
APL;CANT of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
ZARDOUS MATERIALS DISCLOSURE
Will the up p ant or forum building occupant store or handle haxallous material
les fined by she a oma Municipal Code, Chapter 9.12, and me Health and Safety
Cad Smoot 25532(a)?
❑Yea ❑No
Will the applicant or future hui Wing occupant use equipment or devices which
t hezudme, air contvminanu as defined by the Bay Arca Air Quality Management
stoic@
❑Yes ON.
1 have read the mount materiels requimments under Chapter 6.95 of the Cali -
Evans Health & Safety Cade. Sections 25505, 8533 and 25534.1 understand quit if the
building does not currently haveamna t that it is my responsibility to notify the occupant
of Ne mquipnprt �friclyryr�{hynr pHor to issuance of a Certificate ovk�p9r(fy�
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP FO 2110 AMPS
201-1"AMPS
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELEM SQ ff.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR, ROOF. AREA. COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM.I INCA OUTLETS
GAS - fi. SYSTEM -OVER 4 (EA)
GREASEgNDIISTRL WASTE INTERCEPTOR
SEWER - SANITARY- STORM EA. 200 Fp.
WATER HEATER WNENTMLF.CTR
WATER SYSTEM19REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER I0k000 CIM)
EXHAUST HOOD (WOUCT)
HEATING UNIT (TO 100.0100 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP UUM OR 100,003 BTU)
BOILER -COMP (OVER 100,0100 BTU)
AIR CONDITIONER -
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
TOTAL:
FEE
JOB DESCRIPTION -
._....... -. _. JUVU
SANITARY NO.
APPLICATION SUBMITTAL
C3 PLUMBING RE -PIPE
❑MULTI -UNIT
2 44-`6
NIC
MODIFICATION
CONTROL Is
❑ CHIMNEYREPAIR
IMPROVEMENT
-
❑ BATH REMODEUREPAIR ❑ DEMOLITION
BUILDING PERMIT INFO
BLDG
ELECT PLUMB . M�,-E-CC�ffH
ID
E:1 ❑ ICJ
JOB DESCRIPTION -
RESIDENTIAL,
IASFDWL
11 KITCHEN REMODEL
❑ADDITION
C3 PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
O INTERIOR
❑ CHIMNEYREPAIR
IMPROVEMENT
-
❑ BATH REMODEUREPAIR ❑ DEMOLITION
OTHER QFIY a/c'M�(�"A�LSIP
❑NEWBLDGIADDITION [)DEMOLITION
UTENANT ❑ FOOD SERVICE
9 �
i�uIILHDmDk'IMDPagiBYs
ENERGY FEE
PAID
Data R«xipt p
TOTAL:
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICALFEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID
Data Receipta
TOTAL: