S 3949APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
0
OFFICE
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELS PLUMB MF.CIi 11,
"KJ
LICENSEDCONT CTOR'S DF.CI ARATION
1 hereby affrm that 1 am lacers I under Provisions of Crap r, 9 (commencing
wish Scction]Wf) of Division lofshc Business and Professions Cade, and my license is
in full force end effect.
License Class Lic.p
Date Contractor
Qfy - ELECTRIC PERMIT !FEE
_ _ _ -_ ,
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. [I KITCHEN REMODEL
❑ADDITION I] PLUMBING RE -PIPE
C1 MULTI -UNIT [I STRUCTURAL.
MODIFICATIONypyZ
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
C1 OTHER
;(" O
PERMIT ISSUANCE .i
APPLIANCES -RESIDENTIAL
I ECI'S DECLARATION
rt e nseds public s
Lkeze essto -
O . LPI111.Dh:S DECLARATION
I hereby affrm t a um exempt form the Contractor's License Law for the
fallowing rcvam. (Seed all s, Business and Professions Coda: Any city or county
which requires a perm to construeh alter, improve. dnmalish, or repair any structure
'her (.,Islssuanva,Nxooe"mustheii,licant humid, pemth(. fileoslgne ,tenement
PANELS
UP702WAMPS
211.1000AMPS -
OVER 1000AMRS
SIGNS 1!LL'CTRICAL
SPECIAL CIRCUIT/MISC.
d ¢�
CUCI
that he is licaoal puraton to he provixionxol'the Contractor's License Law (Chapter9
(conunencingwhh Sectinn]IxNgnf Dlvlslon9nithe BusinesNond Profoeslons Code)or
TEMP. METEROR POL1i INS'I'.t
MMERCIAL:'
that M1c is exempt ahcrair oan nnJ the ,axis for the iJlegeJ exeonption. Any violation of
EW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
SWIMMING POOL ELECIRIC
iC 4.
6❑I,mowner
Fce
`a�a
Secure 91111 5 by any applicant I... o permit subjects the vppliroul lr a evil penalty of
n erre ban fve hunJrcJ Jollurs (SSlllp.
ofshcprnpeny, ormyemployers with wages as Weirsole compensation,
will do the work, and she mmaturc is not intended or offered for sale(See 70,tL Business
and Prefessinm Code: The Contractor's License Law does not apply to an owner of
propcny who builds ar improves themrn, and who does such work himselfor through
ENANT ❑FOOD SERVICE
PROVEMENT -
THER
OUTLF,TS- SWITCHES - FIXTUSI
his own employees, provided that such improvements are not amended or offered for
sulc.If, hverventhe huilding or inlprovemnnt is sold wilhimoneyemofmmplefon, the
NEW RESIDENTIAL. ELECTS
SQ.FT.FLOORAREA
S/SQ. ET.
owner builder will have the burden of proving that he did not build or improve for put -
Five of sale.).
❑ I, as owner of the property, con earl wsively contracting with licensed contractors to
nswct the project (Sec. ](114, Business and Professions CodcU The Cammm o s Li-
� - ,
cevul.aw does not apply m an owner of property who builds or improves thereon, and
Qw, PI,IIMBING PERMIT FEF,
woo rommcts for such projects with a mmmcmrts) lic<nsed pursuem to the Commcmr's
PERMIT ISSUANCE
License Low. ---"""'1
❑ I nm exempt uncle ,-��"""� &P C for Nis reumn
...H
c r Da
ALTER - DRAIN A, VENT -WATER TEA)
VALUATION
WO I 'S COMPENSATION DECLARATI N
I hereby afforNit PPPI'eec�rjuryV08launders:
BACK FLOW PROTEGE DEVICE
D O Q
DRAINS-FI-t�SR, ROOF,AREA, GOND.
I have and willmai t in CenlliiaxyInsL�n forrcth pc oro ace olfRihe
sation, as provided for , eai, a
work for which this peissued.
STORIES
TYPP. CONSTRUCTION
FIXTURES - PER TRAP
❑ 1 have and will mai i o Wa laces Compensation Iremnce, as ,,at d by Section
37W of the Labor Code for pruomunce of the work for whir it i.z issued.
My Worker's Conifersa'o(3hIurance
Comer:
.RO
GAS- EA. S YSTEMI INC. 4 OUTLETS
OCC GROUP
APN
I
GAS- EA, SYS I'EM-OVER 4(EA)
CERTIPIC ION WORKERS'
OFMPE
OE
SATIONIONFRAN
COMPENSATION ol11NSATIONINSUm,is ha
(This section need vol he complcmJ if thapermit is lar ora hundred dollars ($1 00)
or Icss 7
GRE!ASF/INDUS'1'Hh WASTE IN'I'ERCIi
IT
BUILDING DIVISION F2ES
GRF.ASETRAP
PLANCHECK FEE
SEWER-SAN11' -STORM EA.2Bl Ff.
I certify that In the purfomolae of the wark awhich this permit is ksueQ 1 shall
am cm la vn
reello, Y person in any memo so ns m M1ecnme suhjuat to the Workers' Camper-
ENERGY Fy
WATER .A'PRRW%VRN'f/HLIFCI'It
Oz
Z Q
ai r^
fli r.
Ll
H
sation Iowa al'Culll'orniao Umc
Applicant
GRADING EE
NOTICE TO APPLICANF: IL nl)er making this Certifcnm nl'fexemption, you should
become subject to the Worker's Compensation provisimtx of the Labor Code, you must
forthwith comply wilt such lovision—, this pimtit that hedeemed revoked.
CONSTRUCTIONaconst ].ENDING AGENCY
thattherei insued(Snetiunleading . agency for she performance of
khereby for which
the forwhich Chia permit is issued (Sec. 3191, Civ. CJ
F.R SYSTEM/BPA'I'ING _
WATER SERVICE
SOILS
PAI
ate ReceiptM
NEW RESIDENTIAL I'LMB. SQ.IT
p
WLenJefI
rte. 4c
U Z
Lendses Name
Address
TOTAL:
- TOTAL:
I certify that I have read his application and lee that the aMve information is
amen. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby uathnrirc representatives ofthiscity toemerupon the
-
QTY. ,+ MECHANICAL PERMIT PEE
BUILDIP FEF.
SEISM E Q
PERMIT ISSUANCE 3 T
ELECTRIC E Q
above untenanted pmperty for inspection mr,som,.
(We) agree m save, indemnify and keep hmmless the City of CuPenino against
liabilities, judgments, costs and capehoes which may in any way starve againm said City
incamcquenecofihegoom/m of fit".,
ALTER OR ADUTO MELE. -
PLUMBING FEE
AIR HANDLING UNIT(TO I0,000CFM)
MECHANICAL FEL 3
APPLIC U RS la - AND WILL COMPLY WITH At , NO POINT
SOUR ' Fj.. IOL. /
L�
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCDON TAX
Sgn r r APPA nt n Date
EA O US MATERIALS DISCL.OSU E
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO IW.000 BTU)
Will she applicant r are huilding osteopath store or handle hazardous material
as defined by the Cupeni Mumc: al Code. Chapter 9.12, and the Health and Safety
Cale, Section 25512(a)7
HEATING UNIT' (OVER I W 000 BTU)
❑Yest
Will the applicant ( future building occupant use equipment at devices which
lit hazardous air contaminants as deli ned by the Bay Area Air Qual My Management
isvict? /�
❑ Yes �, .
/—
PAID
Date ReceiptM
VENTILATION CAN (SINGLE SE
POILER - COMP (7TIP OR W,fNlfl RTU)
A
BOILER- COMP (OVER I Ig Ind
AIR CONDITIONER
I hove rwJ the huomlotw t els myuireancnas under Chapter 6.95 of the Cali-
ptaer 69
ISSUANCE DATE
NEW RESIDENTIAL MI!CH. SQ, fN.
toe 1s1'
tic Il ofmy S 255115.25597 mat 25514. I m that 'the
huiWing Jq t 1r t hav th; ole my resq�nsihiliry to mai thea pant
a'
O T E
��--C
oft nc l r t t• soft Certifenm f'Su aylay�,�
��f ✓] /
ISSUED BY:
Own rt�r el�i inn ad ogee m
TO
OFFICE