S 3341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIJPRMrINO BUILDING-ELECTRICAI, PF. IT No,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3341
HUH.DING PROJECT IL1EN"PIF'ICATION
HUILDING ADUHr:55: SANITARY NO. APPLICAI'IUN SUCH M1jIITI'ALQDAI
R'S NAMIi. HONE �/ C kA lk'S , , LIC NU:
Z �y o NIC CONTRULa
,,CHITECDENGINEIiR": ' LIC NO: ADpN1•y;: ❑
- 1—, l0if/6ir/ 6 Q
CONTACT: PHONE: BUILDING FERMI'TINFO
❑ CDngultant Fces Paid By Applicant(Initial) LDG ELECT PLUMB MIiCII
❑ ❑ ❑
LICENSEDCONTRACIOR'S DECLARATION QTY ELECTRIC PERMIT FEE
In ny It ntI r dad,,p - .- f Chafer,9(attncoctg JOB DESCRIPTION
OaZ 'Inti ( vet dr r:.' fyQnd�dnyfat.c ie P IDRNTI 1.:
u10p a`�d Piff- I. li/ 1'I:HMI'I ISSUANCE
aeF�� full l' dell' SFIJWL ❑KITCHEN IthMOUI]
F%0. DmL L �y'#�y�! APPIIANCLS RESIDENTIAL ❑AUDITION ❑PLUMBING BE PIPE
ARUIHICI}affil ❑MULTI-UNIT ❑Sl'RULTURAh
F z w 07,511 PANELS
ZOyz Icodes, do,plans shall be used as public records - YOIDHFICAI'ION
OZ-0 UP 10200 AMPS ❑INTERIOR J'`.^'^'^rk"'.",IF-Y Rl;PAIR
4 LltW I,arowd Proo,iunal 201-1000AMPS IMPROVEMENT SWINISH POOLS
may$, OWNER-BUILDER DECLARATION OVER DAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C Y se 1 hereby affirm that 1 um exempt from the Contractor's License I.aw for the
k3 i O following mason.(Section]031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
W LL H which requires a permit to construct,alter,improve,demolish,or repair any structure
F�0g prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
fLL} that he is licensed purstent in the provisions of the Comracloei License lvw(Chapter 9
WIY�O Icnmmemdngwith Seminn)axBofnivision 3ofthe Basi mess and Pfofessions Gaelor TEM E METER OR POLE INST COMMERCIAL
a a e C that he is exempt therefram and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmLL Seen..7031.5 by any applicant for.permit subjecu the applicant m a civil penalyof POWER DEVICES
m-rn ❑TENANT ❑FOOD SERV ICE
=O nal marc than five hundred dollars,employee,p Ib1PROVEMENT
Las mune..of@e pntpeny,of myendwithaages actheirwle 044.Business SWIMMING POOL ELECTRIC
f. will da the work,and lhmwaure is nm intended orolTeredfo...le(Sec.'/(W.Ilusinesa []OTHER
C3 m and Profession Code:'the Commtor'n License Law does not apply Ire an owner of OUT'LF.J'S-SN'ITCHFS-FIXTURES
property who hwhis or improves thereon,and who does such work himself or through
his own anployces,pnwidcd that such Improvements we not Intended or oll"'d lin NVW RESIDENTIAL ELECTR SQ FI�
sale.It,however,the huild ng nr intpnwenenl issold valimnne Year of completion.the SQ.FT.FLOOR AREA $/SQ.Irl'.
nr-builder w111 have rbc harden of pr,w,that he did nor held or imprnva I o but-
�
a moal
❑n 1 of the propertY,a selueively imraini,wish Iacono]comm torn to
nsnnat the envico(Sec.](N4,Bre and Profes ns Code:)'Ibe Cnntmaora IJ-
c aLawdoclu n
s Too nowncrofprupenY who builds or intpnrvm mrr..n,and QTY. PLUMBING PERMIT fl?G
,hoe....hunts fart such proyas with a commends)berried punuant to the Contractor'%
License law. PERMIT ISSUANCE
lam exempt under See ,B A P C for this reason
ALTER-DRAIN&VENT-WATER(EA)Owner DaVALUATION
Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under Penalty of perjury one of the folhaving declaration%:
Iha.candwillmuinmina Ceniucateof Conwntlowlf-insurefor Workee%Compen- DRAINS-FLUOR.ROOF AREA,GOND. 5 ORIFS TYI'Ii CUNS'1RU Ie
titin s Provide)for by Section 39IX1 of die LaWr Cale.far the performance o!the 2
f 11 hich Chia(error is areae). FIXTURES-PER TRAP
me and will maintain Worked Compensation Insurance,as required by Section
%poflhe LrMm Ctae,fordo,pef11 +fwwv of tine work for whicbthis Perim'.. call. GAS-EA.SYSTEM-1 INC 40UTLErS 0C . 'ROUP AIT(
My
Currier'.. �Inxu{ c yNo.Y GAS-EA.SYSTEM-OVER 4(EA)
CHIG IFICATE OF EXEMPTION FROM WORKERS' —1 _q'�l/�\L+L�yy
41m,
COMPENSATION INSURANCE GREASrANDUSTRL WASTE INTERCEPTOR
(Thais section need nal her...oplened if thepconil is Rnonc btmdred dollars($100) BUILDING DIVISION IBES
or less.) GREASHTRAI'
PhANCHECK FEE
lanifylhalo the penlnnnr,io bwmkforwhich thisphe Wakis es ed,IfiallContain- SEWER,•SANITARY-STORM EA.200 FI'.
not cnnploy any pcaon in unY m:unto ao Ian m become cuM1)a:1 m the Waders'Contain- ENI? PP.F,
(] z 'inion U."of Collfomia (lac WATIII11[EATER W/VENT/H1.IiCfR
Z 0 Applic'anr GRADING FEE
(/) NOTICE TO APIVI.ICAN'1:11;tiler making%hie Cerlficme mf Exemption,you sh...dd WAI'13R SYS9'P.M?RBATINC
a ; be come.'i,hj.,n,(he Worker's Cn openadion provisions of the Labor Cod,you n usl SOILS FEE
W forthwith unnply withxuch pni,nans or his parnlshall be deemed revoked. WATER SERVICE
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
IJ 0 eipt#
0.1. the work to,,which this permit is issued(Sec.3097.Civ.C.)
Q Lenders Name I TEAL:
Leeder's Address TOTAI-:
Fr^ y 1 verify that 1 have mud this applicmion and state that the aWve infarmminn is BUILDING FEE
y correct.lagrec to comply with all city and county ordinances and slate laws relining us QTY. MECHANICAL PERMIT FF.E
V Z building construction,and hereby ruthonee reprcsemaive%of this city to enter upon the SEIS M IC FEE
abatse-mentioned property for inspection pure,e 1
(WO agree to save,indemnify and keep harmless the City of Cit,wo nn asdnstJAILTER
ERMIT ISSUANCE - - ELECTRIC FEE
Imbduar,pid• s.costs and expenses which may in any way revive against said City OR ADD TO MECH.
in move meat e6mming rf this inti, PLUMBING FEE
APPLI NT DERS'ANDS i' WILL COMPLY WILHALL NON-POINTIH IIANDLINC UNIT(TO IO,fYJfICFM)
SOU MECHANICAL FEE
./ IR IIANDLINC UNIT(OVER 10.001 CFM) CONSTRUCTION TAX
Siynamrcof Applican C."ohnai Umv X11AUST HOOD(W/DUCT)I IAZARIX )SMATP.RIALSDISCLOSURB HOUSING MITIGATION FEE
Will lhwgrplicaut or future handingoccupantsmn:orhandle husanlens nacrialEATING IINI'I(TO I INI,000 B'TO)
us defined bythe Caperton Man I Cuda Chapter 9.12,and the Ilealh:uul SafetyCndc.Semon 25532(x)'! iA'I ING UNIT(OVER 100,000 B'IU)
El Ycn
V17N'I'II.AI'I ON FAN ISI NGLE RESID) PAID
Will the a livor,a fnture buildin t use e 1 or devices which Dam Remipl#
40 pp goccupan yuipmcn BUILBR-CGMP(3HPQR 100.gN1 BTU)
'nit haralloun air condo nu is defined by the Bay Area Air Quality Management,,net' til'
E3 Yes o BOILER-COMP(OVER 100.000 BTU)
I have read the hwa Zsmurtrialsrequimmemsunder Chup¢rh95nf1he Cali- AIRCONDITIONER ISSUANCE DATE
Imihanldn vend e.Semio %5505.25533 and 2553J.luWeat td aha ifthe NEW RCSIIIENTIALMECH. SQ.F1'. ,Q ^ -2
huilJa rent have n ,thatitie myresponsibilityl citifytddawifm
ohne eAms— ceofa Cenir vd Geo y
Ow er or au l a".
to
ale / TOTAL:
ISSUEDBY
is
OFFICE