25271APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY ON CUPS RTINO BDH:mNGT.1,1.1;
PLUMBING-MFIIAN
BUILDING DIVISION APPLICATION/PERMIT IiCAI
BUILDING PROJEC11DENTNICATION
PERMIT NO.
25271
BUILDING ADDRESS:
SANITARY NO.
APPI.ICATIONSUBMITI'ALDATE
1
f •r Gcxs UNIT# LOT art
�� 3
O ERS NAMii: PHONE: chop^ ^—
CONTRACTOR'S NAME: LIC NO:
N/C
❑
CONTROLp
C 2� nfu
c- .S f7otJo
IARCIII-C'IyIiNGINF.F.R: LIC NO:
1:G
CONTACT: PHONE:
ILP.CTRIC
s
a '
PERMIT FEE
$
BUILDING PERMIT INFO
BL L0 PLUMB M
E
PERMIT ISSUANCE
K U
OI
LICENSED CONTRACTOR'S DECLARATION
I hereby abinrnhat l an licensed underprovislons of Chaper9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
j Section 7000) of Division 3 of the Business and Professions Code, and my license is in
- full force and effEL i/
s Li{�vens Cle Lic.p �ru 116
^ ^
i DidC.mranm 5'S
UPTOMAMPS
,
201 - 11)00 AMPS
I ARCHITECTS DECLARATION
1 1 understand my pians shall be used as Public ame rds.
OVER 1000 AM
SQ. IT. FLOOR AREA
S/SQ. n
SIGNS_ CAL
i hicemeJ Probational
OWNI?R-BUILDER DECLARATION
S 1 IRCUIT/MIS
1 hereby am. shat I am exempt from Nw
e Conctota License Lawfor the
BTER
following reason. (Section 7031,5. Business and Professions Code: Any city or coon
I which reyuires a permit m e.ns.me6 alter, improve, demolish, or repair any eweturo
prior to its issuance, also reyuires the applicant for such permit o file asigned alinement
OWER DE
j that he is licensed pursuant to the provisions of the Convector's License Law (Chapter
• 9(commensing with Section 7000).(Division 3 office Business and Pmfessions Code)
or that he is exempttherefrom and the basis for the alleged encmption. Any violation.,
Sermon 7031.5 by any applicant for a permit subjects the applicantOUTLETS to a civil finality of
IMMING ELECTRIC
alr�
VAI UA7IDy'(�//
`I�yn
VV stVJJ�
--
SWITCHESFIXTURES
n
1 of mare than five hundred dollars (SSW). ❑ I,asownerofthepmpcny,mmyemployemwithwagesulheirsolecompensation,
NEW RESIDENTIAL ELE
STORIES
TYPF.CONSTRUMION
will Jo the work.and the structure isnot intended oroffered Console (See, 7mul, Business
71
and Professions Cade: The Contract.,', License Law does not apply to s n owner of
Q JJ
Impiety whohuilJsorimpreveslheuoq mewhodeassuchwork himselfor throughhie
own employees, Provided that such impmvemmtsmanw imendedoroffered burials. If,
OCC. GROUT'
RES. UNITS
„ TOTAL,
however, the building orimprovemem is sold within one yea ofeempletion, the owner-
builder will have the burden of Curving that he did act build or improve for purpose of
QTY. PLUMBING PERMIT FI?E
sale.).
❑ I,ssowner ofthe prnpeny, an exclusively contracting withlircnsed conwclonm
FLOODZONE
APN
construct the project (Sec. 7644, Business and Professions Code:) The Contractor's
License Law does not apply m un owner of property who bulk a tar improthereon, and thereoanC
PERMIT ISSUANCE
who contracts fnrsach projects with acommemr(s) licertsed pursuant.ths Conameme.
License Law.
ALTER (FA)
FERSUMMARY
❑ 1 am exempt tinder Sec. , B & PC for this reason
BACK FLOW PROTECT. DBVICIi
SID. Ila:
SANITARY Y N
RECEIFI•p
Owner Dam
pRA1N5-F100RROOIrAREACOND.
,, , .
WORKMAN COMPENSATION DECLARATION
SCHOOL. TAX Y N
❑ I hereby affirm that l have a cernficdc ofconsenuo self -insure, or a certificate of
Workerx'C.mp,nsation Insurance or a candied copy thereof(Sec. 3800, Lmi which
FIXTURES - PIER TRAP
- RECHIFTA,
PARKFEE YN
covers tall emfilnyee'e und<nhia permit.
Policy Is
GAS-EA.SYSTEM-1 INC.40IITLETS
RECEIPTp
BUILDING IftVISION FfiiF.S
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PIANCHCCK FEE
❑ Petrified copy is hereby famished. .
GREASEANDUSfRL WASTE INTERCEPTOR
GRADING HE
Certified copy is filed wird the city irupeetion division.
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GRFASETRAP t
SOILS Plii?
SEWER -SANITARY -STORM FA. 20(1
ENERGY Ff:E
(This section need not bewmpleted ifthe permit is forone hundred dollars (1100)
orless.)
WATER PRATER W/VIiNT/ELECTR
I certify that in the perfrmtaacsofthe work for which thio permit is issued, Isball
not employ any person in any manner so as or become auhject no the Workers
PAID
Compensation Lawsof Celifomis. Data
Applicam
WATER SYSTEMIMEATING
)a Reeipop
NOTICF. TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FI'.
TOTAL:
become subjectto the Worker's Compensation previsions of the Lahr Cade, you must
forthwith comply with such firoviaiom or this pewit shell be deemed rev.ked.
B D GFEE
CONSTRUCTION LENDING AGENCY
19EISMN FEE t
I hereby of firm that Nem is a construction lending agency for the performance of
the work for which this pewit Is issued (Sec. 301 Civ. C.)
Lender's Name
TOTAL:
ELECTRIC IEE
Lender's Address
QTY. MF?CI IANICAL PERMIT FEE
PLUMBING FEE
I certify that I have mad this application and state that the above information is
nett. l agree to comply with all city and county ordinances and some laws reading ca
PERMIT ISSUANCE
MECHANICAL FEC
buildingsonswNon, and hereby safariu representatives ofthisciry toenter upon the
abu onneantluned Property for inspection purposes.
ALTER OR ADD TO MECH,
CONsTCQcriONJAX
(Wc) c 1, xuv , indwnnify and keep hurmlaxs the City of Caperton against
liangue tad anos,csts andexpenu.which..yinanywayacc.,,.i.,t,.id City
AIR HANDLING UNIT (10 ht" CFM)
in r./q.71 ofthc ing.f permit.
�� /^09��
AIR HANDLING UNIT (OVER IO,ODII CFM)
Signa of ApplieantlComracmr I/:•/• Data
EXHAUST HOOD (W/DUCI)
PAID
CHEATING UNIT CFO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt It
Will the applicant or future building occupant store or handle banumus material
as Aclined by the Calendar, Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNI'I'(OVEit I(p1,0o0 BTU)
Code, Section 25532(a)?
11 Y. Nor
{
1r
VEST ILATION CAN (SI NGLE RESID)
Will the applicantorfuwebuildingoccupant uta uipaten tordevicexwhich emit
ey
BOILER- COMP(3HP OR 100,(100) BTU)
IS ANCF. DATE
hasaJom sentimentlity air sentiment ss defined by the Bay Am Air QuaManagement
Titanic?P
. ❑ Yw Nn
BOILER - COMP(OVER 110,000 BTU)
p I D
fi
NEW RESIDENT IAL MECH. SQ. FT. �
1 have read the h Atom materiels requirements under Chapter 6.95 of the
Califiron Hcalt Safety CNq Senium 25505, 25533 and 25534. 1 umderataaA Nat
ifthe buildi of curently havemm�um, that it is my resixmsibilirymn�tify the
eyuiremen
�UN1)9
the whit et be me or to issuance of a Certificate of
oc.Fan
ma ey. l t
TOTAL:
O e r nhonted agent Date
ISSUED BY:
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