25883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
❑".11si � PERMIT NO.
CITY OF CUYESIO NO APPLICATION/PERMFP PLUMBING,.MECHANICAL. 25883
BUILDING DIVISION BUILDING Pill IDENTIFICATION
BUILDING ADIJ ESS: �I + SANITARY NO. A^PPLICA^TIONSSUBMH'1'ALDATE
pari UNIT# LOT#
O NIiRS NAME: PHONE: CO;U 'SpAny'�_ LIC NO. WC CO��—MROLIIp
4ttj
•ARCIII'IECJ'IENIM LIC NO: ADDRESS: IVfii� ❑
CONT'ACI': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
DG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
ereh ffir that l am licensed under p gwith JOB DESCRIPTION
❑CZ I hYa provisionxof Chn ter9(cointnencin
m00F geciion Jfxxpolicid.ion3 of the Buslnexa undP`4aio Code.and my llttnse is in ppNHIS
¢VU fullfarc//ewwwqqqal/nJ-►-ef`��`fercv�� �y ri �Lie.ra / UP TO 200 AMPS
RON
F,7 DaeZW n_#, IiCTSrDECIARATION 201-ItppAMPS SQ.FT.FLOOR AR S/SQ.M.
'L O os`� I understand my plans shall be used as public records. OVER 1000 AMPS r N
O'-° � NALED IN
F N W SIGNS ELECTRICAL
Licensed Professional
��a'< OWNER-RUIhDER DECLARATION SPECIAL CIRCUIT/MISC. e10—) MPU
W aU 1 hereby affir that 1 oat exempt from the Contractors License Law for Ne
TER
W3�H following reason.(Senium 9031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
f'LL <, which requires a permit to construct.alter,improve,demolish,m impair any structure
prior to its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES DATE r3lk 11n
pjCQp that he is licensed pursuant a the provisions of the Contmemrs License Law(Chapter
c—iL 9(commencingwlth Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC w� VALJ:yn '
X._iy or that he is exempt therefrom and the basis the alleged exemption,Any violation of OUTLETS �j1� {•w�,�
1_7P Section 9031.5 by any applicant for a farmitsubjeets the npplamat o a civil penalty of (,
��n not nuircthan f ve hundred dollars($50)).
props y,mmyemployaswithwagesastheirsulecompensation, NEWRESIDENTIALELEC1k 5 .Fp.
cet=5F< ❑ I,esownenifthe n Q STORIES TYPE CONSTRUCTION
wit l do the work,and the smucmre isnat intended or offered for aide(Sec.70Wl Business
and Professions Cade:The Cantnetm's License Law does not apply to an owner of
property who huilds or improves thereon,and who does such work himulforthrough his
hoemploytts,provided thatsuchimprovements me natiotendcdoroffered fmsate.if, OCC.GROUP RES.UNITS
wever,the molding or improvement is sold within one ycarofcompletion,theoweer- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑ I,asownerofthc pnipcnY.nmaadusivdyrnnnaming with littnua ceno-edors to QTY. PLUMBING PERMIT FEE FLOOD LONE APN
t the project(Set.94,Business and Professions Code:)The Gmtrador's
License Lawdres not apply toan owner ofpropenywho butilsarimprovo thermn.and PERMIT ISSUANCE
whocommcts for such projects with scoolmemrts)licensed pursuent ni the Contractor's ALTER FEE SUMMARY
License Law. (EAI
❑ 1 am exempt under See. ,B&P C For oris mason (UTSIDF.PEFS
BACK FLOW PROTECT'.DEVICE SANITARY YN
Owner Date DRAINS-FLOOR,ROOF.ARBA,CONE. RECEIFr#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
covers❑ IherehY uffir thetl haveaccnificam of nmsenno self-insum.ore certificate of RIiCE11T#
Workers' m
Compensation Lnsuoce or u cenifed copy thercof(Sec.3800,Eub C.)which PIXTURPS�PER'I'RAP PARK FEE Y N
all employee's under this peril GAS-FA.SYSTEM-]INC. OUTLETS RECEIPT'#
Policy p BUILDING DIVISION PEES
Company GAS-G.SYSTEM-OVER 4(EA) PI ANCHECK FEE
❑ Certified ropy is hereby fumLahed.
eniHW copy is Cited with the city inspection division, GREASEtINDUSTRL WASTE:INTERCEPTOR GRADING FEE
CERTIFICATE:OF EXEMPTION FROM WORKERS' GREASETRAP
OILS FEE
COMPENSATION INSURANCE
(TTissee ion nexdnotbecamplendfurthep<ritis for one hundroddallars(S100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
orless.)
l certify that in the perfmmwttefthe work forwhich this pcnnit is issuW.l shall WATER HEATER WNENT/ELE, R
not employ any person in any m mm
s
s as to become bject the WorkerPAID
2 Compensation Lawsof Califomia. DateWATER SYSTENUTREATING
Applicant Date Receiptx
O
Q
z NOTICE 1`0 APPLICANT:If.after making this Certificate of Excmptioq you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F-' L/t become subject to the Workers Comicnsation previsions ofthe Lehr Code,you must
forthwith comply with such provisions or this permit shall b,deemed revoked. BUILDING 17EE
a ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I herby affirm that is a construction lending agency for the performance of 'TOTAL: ELECTRIC FEE
U O dta work l or which this peril is isaued(Sec.309?,Civ.CJ
Lenders Name
U.
F Lender,.Address - QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I cenify that I hav ad this application and state that the above information is
armor.Ingreemca I ith ell cityontl county ordinances and atom levee rcluting ni PERMIT ISSUANCE MECHANICAL FEE
e` buildingmnswcti ,and hereby authorise ceptesentntives ofmiscity to enter upon the CONSTRUCrION'fAX
Uzi shove-memionc nipeny for Inspect it ALTER OR ADD TO MECH.
(wc7 agr ro xarc,indcmnif keep harmless the City of Cupcnino against
Fabilif - era costs node awhicM1 may in ony way accrue against said City A IS HANDLING ON]p(TO 10,M CFM)
nscq' m the gmntin it.
AIR HANDLING UNIT(OVER ILOX)CFM)
natum of ApphcunV i r a Date EXHAUST HOOD IWIDUCT)
PAID
II l UOUS MATERIALS IS .OSURG HEATING UNIT ITT)100,000 RTU) Use Receipt#
Will the applic: forlmurc M1uilding xcu ' tut -or handle hese coal HEATING UNIT(OVER 100,f1(XI BTU) TOT
as defined by the C nine Mvni<ipal Code.C a 9.12,and the HaAh and S.
c
Code.Senior 255.2(:0?
❑Yes 13 No VENTILATION FAN(SINGLE RESID) PIA rn
Will theapplicanmrfatom builJingwm
cupantuseryuipmeordevicezwBOILER.COMP(3HPOR IW
hich emit ,(pO BTU) ISSUANCE DATE
hazardous air umnuninunts::s JuOncJ by the Puy Area Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU) FEB -2 1994
• &at,-
" NEW RESIDENTIAL MECH. SQ.FT.
IuS materials requirements under Chapter M195 of the Gil Y Ut curly1IrVU
Culifo ide.Sections 25505,25533 and 25514. lundersmndthu
ily havenicna o �i anthich must be met prior to issuance of a Ccrm at of
Owner or am i ager )ae
IDEAL: JISSUEDBY:_
OFFICE