27001APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
COPY OF CUPER,PINO lo-nCri - 1,CKC I RICAE
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION BUILDING PROJBCTIHEN'FIFICAI'ION
PERMITWO.
^ 00
L
BUILDING ADDRESS
I,OTpMITI'ALDATH
SANITARY NO.
APPLICATION SUB
,1— L —`
ERSN M.: PH(lNli:
A TOE'S NAME: LIC NO:
NIC
❑
COMROLK
' A CIIITIiCI'piNGINGF.R: LIC NO:
UR 'S —
=,
D E s u
CONTACT: PHONE:
QTY. - ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE J
BLDG ELECT PLUMB M[CH
❑ 75- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hemby affirmd due l am licxmed underpriommns afamos 9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section rce a II creel, el, on 3.1 'Ne Business and Profusions Cede, and my licence is in
fill
nseCndeffect.
� License Class lisp
Date Contractor
PANELS
UPT02WAMPS
1 J
201 - 1000 AMPS
_ ARCHITECTS DECLARATION
I undersand my plana shell be used m public records.
OVER 1000 AMPS
SQ. M. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Profesxbrall
J OWNER -BUILDER DECLARATION
I hcrcby affirm that 1 am exempt from the Contractor's License Law for the
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
o following mason, (Section 9031.5, Business and Professions Code: Any city or county
which requires it permit ns comtrvct, alter, improve, demolish, or mash wry structure
prior to its issuance,:dno re9uima'he applicant for such permit to file ilmmdsammenl
j Nm he is licensed pursuant to the Provisions of The Commoner License Low (Chapter
s 9(commencing with Section 9000) ofDivision J of the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Semon 7031.5 by any applicant for a permit subject applicant ml
the applicano a civil perty of
not mom than Eve hundred dollars ($500).
mneeswiNwagesNc0mpie
1:1 I, w
The work.and the soetweisnmintended offered for e(Ser. M, Business
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FlXTURES
NEWRESIDENTIALELECTR S QFC
STORIES
TYPE
CONSTRUCTIONwlldo
.at] Professons Code Joe Cwtrnos License Law does ind apply us
'an owner of
properly whubuildaorimprovea thereon, and who lues such work himselfoe Nroughhis
own employees, pruvicEd that such improvements are not infrared reoffered for sale. If,
OCC. CROUP
RES. UNITS
however, the building or improvement is sold within one year ofelandetlon, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
QTY. PLUMBING PERMIT FEE
mlc.).
❑ Las owner afthe property, amexclusively contacting with licensed conflanrrs to
HOOD ZONE
APN
onmmct the project (See. 7044, B-ines, and Professions Code:) The Contractor's
License Lxwdrcs not apply to an owneroPoTery who builds or improvesthercon,and
PERMIT ISSUANCE
who conflict for such projects with a contmetor(s) licensed puarom to the Comwass's
License Low.
ALTER-DRAIN&VENT-WATER EA)
(
FEE SUMMARY
❑ 1 am eminpt under See. , B & PC for this mason
BACK FLAW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
Owner Dam
yys
�, BF EAj1CON s I
DRAINS- i, 11 �. ,r -r
RECEIPT M
WORKMAN COMPENSATION DECLARATION
' ❑ Ihercby affirm that lhave acenificute of conxm mmlLinmre, oreanificam of
Workers Compensation Insurance ora cenilied copy Hereof (Sec. 3800, East CJ which
null employee's under chis permit.
Policy a
SCHOOLTAX YN
RECEIPT#
FIX.LUR-1iFN,1.RAF �a
;\ /1 (i I m I'..'
_
I'ARKFEE Y N
RECFIIT#
GAS- F,A.SYSTFM:IANC. JQIJTLETS�1 U
BUILDING DIVISION FEES
Grapier
GAS - PA. SYS 'M FR4(F
GR[iASFJINDUSTRI. WASTE IM'ERCEYTOR
IIANCIIECK FEE
GRADING FEE
El copy is hereby famished.
❑ Ccnilied copy is'filed with Ne city inspection division.d
CERTIFICATE: OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
("is section need not becomplemd if Ne Pounds is for one hundrMd00ols(S100)
less.)
SEWER - SANITARY - STORM EA. Judi
ENERGY FEE
I certify that in the performance ofthe work for which this permit is issued, I shall
WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject t0 the Workers'
Compensaurn laws of Celifomia. Dam
Applicant
WATER SYSTFM/1'REA'TING
PAID
Date Roto
NOTICE TO APPLICAN'1:If, arm, making this Cenificam of Exemption, you should
become subject to The Worker's Compensation provisions of Ne Labor Code, you mum
NEW RESIDENTIAL PLMB. SQ. FIE
- TOTAL:
BUILDING IEE
mammoth comply with such provisions 0r this peon most he deemW revoked
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby allirm That there is a construction lending agency for The perfomrance of
TOTAL:
ELECTRIC FEE
The work for which his permit is issued (Sec. 3099, Civ. C.)
Letal l Name
finders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify Nm 1 have mad this opplic#ti0n and sate that the above informoned is
PERMIT ISSUANCE
MECHANICAL FEE
conoccl. I agree meamply war all city srdemaryordommassandsum laws mlmingm
building cudomel on, and hereby ambodze representatives of this city teenterupon the
above-mentioned property for inspection owPoes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We)agree tower, indemnify anV,— Nc Ciry of Cupcninn aguinmhabit uev,yyyWWW000 corns expensey vyarcrince,wro said City
AIR HANDLING UNIT('TO 10JB0CFM)
in L"n enr�e Negr g idip
AIR HANDLING UNIT (OVER IO000 CFM)
/
roam of pphewill cmc or Dam
E%HAUS'FHOOD(W/DUCn
'
PAID
HEATING UNIT (TO 1(10,(100 BTU)
IIAZARDOUSMATERIALS DISCLOSURE
Dam R«c;pts
Will Nc ier mum
furorebullringde,
or handle hHealth
Camstem
The Cope i
Cdefined io T25CupeninO Municipal Crdq Chapter 9.12, and the Health and Safety
ad Safetl
Code, Sermon 255321v)P
HEATING UNIT (OVER IW.0009I'U)
VFM'ILA'TION EAN(SINGLI3 RESID)
❑Yex 0 N
Wil, building
aconfirmatt lattice
Air Quality
BOILER - COMP( IP OR 100,oW BTU)
ISSUANCE DATE
ai
harrder? air contaminant as Jelined by Nc Huy Arta Air Quality Management
a, by 'he Bay A . Management
fDisuia? ❑ Yes ❑ No
1T /� I1 p'p
`_ A
SEP
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDWI IAL MECH. SQ.IT.
I hove read Nuiremem
e Iwombitn minimal, rcqs under CTapmT 695 of the
l i 1Q"�
994
California l 1pahh&SafetyC de, Sections 25515,25533 and 25534. 1 understand That
dies not currently have alen:mT.Boit is my respnnsibililymnotify the
"lir
Oche cupant'.
occupant of the requirements which must he met prior to issuance of v Certificate of
Occupancy.
V V uf"Cn lOV l
ISSUED BY:
Owner nr oriented agent Dole
TOTAL:
OFFICE