S 2467APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'RRTINO HUII,DING - ELECTRICAL PERM] F NO.
JUlU11NG U ISION APPLICATION/PF.RMIT PLUMBING -MECHANICAL S 2467
Ck,4&4- rto 361 - O �''I
LICENSED CON' I'RACI'OR'S DECLARATION
I beach, add n ded I am licensed under provisions of Cnamer 9 (commencing
with Smion]nnlpof Dl ,km 3ofthe Business and Profession, Cale, and my license is
in tat face and effect
License Claes Lie.#
ARCH IECTS DECLARATION
Z FphZ Iumkr,unJ my plan, shall he used m public record,
oz=o
� W Incensed Prof sionul
❑ Consultant Ethics Paid by Applicant (Initial)
QTY ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RFSIDENTIAI,
PANEL S
UP TO 200 AMPS
Q, 2-1 OWNER BUILDER DECLARATION
C C 4 I bcreby affirm than l van mmatpn trent Ilio Comnmmr's Licen,c Law tin the
X3 L F foll wing nest.. (Smfion 7031.5, Bu,mr,s vad 11.. c.,,ions CWe: Any stay or county
ftW y LL w which requires a permit to construct. alum, improve, demolish or repair any structure
.F.. �Q ......toils fnr_mch p -mil fiI a,igm-dewmmmot
nhabcixlicensed punuannonheprmisionvDhe Comracmh License Law (Chapter 9
Wa 0 0 Ievnmencing whir Srainn 700(Oof Division 3 of be Busincs, and Professions Cale) or
L G e IY that he n c rna'a bmoor rand the best, lin It, alic,d c,ran,alon. Any v'adaio 0 of
xH Section]031.5 by any applicant for a permit mhjov, the applicant 1.. a civil penalty of
TSCnot more than Evc hundred dollars ($500).
❑ Lae owncrofnhe proper,, or my cmployces with wages as their,ofe con,mmalmn,
F will dolhework,and mcmruaure is not intended oroRered for sale Ncc.]U44, Busing,
W e m taut 11 ficxxinnr Cafe: The Comnlnor'x License Law aces not apply set an owner of
d 5 propcny who builds or iniprmes thereon, and who does such work himself or through
his own employees, provided that such impmveemnt, am not intended or oOfered for
sale IL however, the building ser intprovemcm tx sold wdhi a one carol annplaka. the
ter -Wilder will have the burden of proving than he did not build or improve far pur-
e a, tax nor ).
of Thr Senpany. a n xn,%, ad ro.(c,,i ng Cath greased rnnnmanrx i-
K Lawdproject(Ser.]fanoBusmen,andrywho buil, orJ'me,esthe on, nd
mhrwdttesnot ch apply utan with
a cormiciary ficeowhhorintpmvee mcrennand QTY
who annn¢u for such projects wi%t a umtrunor4sl licensed Punuuun to the Comnswr'x
License .4sp
❑ I c rpt ander See . B & P{C/t{a fln � �JYn
O Dmc _
WOR KIiIt'SCDMP[i .'ATION UECLAItATION r l
I hereby union under penalty of perjury one of ate following declamliun:
lei ❑ I have and witl maintain a Cenilicam of Conserv ntson. imure ror Wa Km', Campen-
xmam. ax provided for by Stain 3]1X) of the LaborCade, fo i1w performance of the
work for which this pemtit is issued.
❑ I have and will maintain Worker's Compensation Insurance, os required by Section
371X1 ofthe Labor fide, Ibr the porn m muse of lire work Ibr which this permit is i,surd.
My Worket's Compensation Insurance carrier and Policy number are:
Cutin: Policy Na:
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
Cfh'n m<Ou 0 need not hecntnptcied it the permit is barons Itnndmd dallam($100)
toy any that inthe any muse ,, thework for which this permiti,issued.
...m -
no( employ any ryrcson in any treater sn as in bPconwmbjea m ILcworkeM Coulpen-
O z cation laws of California. Dam
Z Applicant
% NO] ICE 10 APPLICANT I If, after making thin Corowi m of 17 scmplion, you should
� ? become uhmm In the Workers Compensation provision of the Labor CWe, you most
t'orh ath comply wait such pra„tans- mi, permit shall he doemcd em -ked.
a0
7 7. CONSTRUCTION i, a coast
LENDING n,,nAGENCY
V forwhich his
In;.,momia..ed(ri.3( len ding agency La the performance of
Ethe work for which this permit is issued (Sri. Jfhl]. Civ. CJ
W I,enders Nurse
IsJAm
ndcrx Are
fr" I certify than I have read this application and state that the above information is
h correct. I agree to comply with all city and county ordinances and state laws reaming m QTY
L) z, building murneclienert hambyauMorlmreprexnnnniven ul this rely In unmrugm airs
above-mentioned propertyresimanpkeepha
(We) agree ,.,m,l, indemnifyx,ant keep ny many
the City e0 Catmint ad City
liabdilica,juegmffficca andofmi, Pxwhich Inuy in any cavy accrue against saiACity
in asequence of the RS ANDS
to N permit.
AI'PLf(irt!NjI1NUER5'I'A:JUS AND WILT. COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the upphcnnl or lumrc building ocupam store ser M1undlc h cauchme ntmenul
as defined by the Cupenino Municipal Code, Chapter 9.12, and the Health and Sandy
Code. Sudan 25532(ml
Yes
Will the applicum or Omar, buildn" occupant nuc cgmpnmm or device, which
,) r hamrdoue air contaminanl> as defined by me Bay Amu Air Quality Management
Uimriny
❑ Vcs
I have real the haearduue :nater eb, res dremems under Chapter h95 of the Cali -
I ame Iteeth k Salcey Oslo, S .ions 255%5, 25533 and 25534. 1 understand thus d be
SIGNS ELECTRICAL
SPI',CIAI. CIRCLE I'IMISC.
'I EMR. MIUTR OR POLE INST
POWER DEV ICES
SWIMMING POOL ELECTRIC
OUTLI:I S -SWITCHES - FIX1U RES
NEW RESIDENTIAL ELECTR SQ IR.
PLUMBING PERMIT FEE
PERMIT ISSUANCE
^
Y
ALTER -DRAIN A, VENT- WATER (EA)
O SIrlmI
BACK [LOW PROI'PC'E DEVICE
❑ADDITION
DRAINS- FLOOR, ROOF, AREA, COND.
❑MULTIUNIT
FIXTURES -PER TRAP
GAS - HA. SYS UEM-I INC. 4 OUI LIC S
❑INTERIOR
GAS- ITA. SYST1fM-OVER n (EA)
IMPROVEMEN"P
GREASI%INDUSFRI. WASTE INTERCEPTOR
D HATH RFMODEI/REPAIR
GREASETRAP
D OTHER
N
SEWER -SANITARY -STORM EA. 200 FT
/
WATER HEATER WNENDELECfR
WATER SYS"IEMOREAFING
By -
WATER SERVICE
NEW RISIDEN"l L PLMB, SQ, 1
G
MECHANICAL PERMIT I FEE
PERMr1 ISSUANCE
ALTER OR At)]) TO MECH.
AIR HANDLING UNIT LTO 111,01X1 CIM)
AIR HANDLING UNIT (OVER 10,01X) CFM)
EXHAUST FOOD(W/UUCP)
HEATING UNIT ('10 I(q,00011'IU)
ABATING UNIT (OVER BALSE I BTU)
VENT H VF1ON FAN (SINGLE BESIDE
BOILER -COMP (3111' ON I IX%(XX) Ifl'U)
HOILFR-COMP(OVER 100,0001H DO
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, FP
_ 9q-19
El
BUILDING PERMIT INFO
HLDGELECT PLUMB MIiC11
❑ 11❑
JOE DESCRIPTION
RESIDENTIAL:
ODEMOLI'UON
O SIrlmI
D Ki UcHEN REMODEL
❑ADDITION
ID PLUMBING RI; -PIPIT
❑MULTIUNIT
OS'I'RUCIURAI,
MODIFICATION
❑INTERIOR
OCHIMNEYREPAIR
IMPROVEMEN"P
OSWIMMINGPOOIS
D HATH RFMODEI/REPAIR
❑ DEMOLITION
D OTHER
N
/
COMMERCIAI.
ONIiWBI.DGIAUDITION
ODEMOLI'UON
D FOOD SERVICE
e0ANT
IM PROVEVIF,NT
D OTHER
SQ, IT, FLOOR AREA
S/SQ. ET.
ENIHtGY IgiH U
GRADING PEE
PAID
Ilam _
PLUMRI !G FEE Q
MECIIA ICALFEIi
CONS rRUCr1ON TAX
HOUSING MITIGATION FEE
PAIII
Dae Receipt #
ISSUANCE DATE
/-a-y'-4'P
ISSUED BY: