99080187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U
CITY O F.CL{PERTINO I BUILDING-ELECTRICAL PER ff N
HIIILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SGBMFUFAL DATE
o /U eu - Zf`JQ
04.MER'S NA. F: PHONE: C T ACTOR'S NAM': LIC NO',
' NIC CONTROLp
�. ARCHI I'BCI'/IiNGINEER; LICNO: A DRESS'y , iA El
CONTACT: PHONE: 4vt �t2S BUIIAING PERMIT INFO
i
❑ Consultant Fees Paid by Pelican[(Initial) ELECT PLUMB BCH
a 30 Z BL ❑ �/M❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alum mat 1 OO am Bsd eenmade,provisions Of Cooper 9(a mmecing JOB DESCRIPTION
O a'z. with Section VU(XBof Divisina 3Ofrhe Business and Professions Code.and PERMIT ISSUANCE my license is RESIDENTIAL,
W
F u:^
in fucls and efTca. OSFDWL [I KITCHEN REMODEL
aVU hicemc Class Lac. APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
[-Z M Da¢ feather.
mQa ARCHITECTS DECLARATION 0MULTI-UNIT ❑STRUCFURAL
z 0 vs ; I and crswd my plum.hall be cared oa public records PANELS MODIFICATION
m_ UP10200AMP$
OZ-p EJ INTERIOR L1 CHIMNEY REPAIR
F��W Licensed Professional 201-1000AMPS IMPROVEMENT E)SWIMMING POOLS
�s1�; OWNER-BUILDER DECLANA'1'ION OVER IIXXIAMPS ❑BATH RE DE! ❑DEMOLITION
C C Q 1 hereby aiGn that 1 am camth
cpt form e Counsel,L.Ice.m Law for the
3 a H following reason. n(Section 703 I.S.Business and Professions Cols,Any city or county SIGNS ELECTRICAL. ❑OTHER
wh,ab requires a Permit u,eoncma,alter,int.nwe,demolish,or cotton,any%tmcwre
F-�Oci
n prior to its issuance.also requires the applicant for such permit to file a signed smrenmnt SPECIAL CIRCUIT/MI SC. _
� } that he is licensed pmrsuuatit)me provisions Of the Contractor's License Law(Chapter 9
W SAL
OD (commencing with Section 70)(I)OHAvision Jofthe Bumme,nin, Profucsinre COJe]or TIiMP ME'ITfR OR POLE INS'L 1
Ca.a of that be Is exnnpt therefnnn and the basis lin the alleged exemption.Any violation of C NEW BLDG/ADDI ION DFMOLITI
x se,N Section]031.5 6
y anY applicant Grtapennit subjectsthe applicant toacivif penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
an more than live hundred dollars 155(9. IMPROVEMENT
�zQ [] L.,owner of Lou propeny.ranry employees with wages as mairsole,rmtpeosution, SWIMMING 11001,ELECTRIC en
will dothework,and menrunure,is notinammindoroffctM prime(Sec 1814,Business [-]OTHER
W.
and Prnmssiom Cde:The Contractor's License Law docs not apply to an Owner of OUTLETS-SWITCHES-FIXTURLS
propeny who builds or improves thereon,and who dues such work htmrelf or through
his own employees,prmiJd thm such improvements arc not intended n of ted for NEW RESIDENTIAL IiLECTR Q FI'.
sale.If,however.the building or impowemcm is sold within one year Ofcumpletion,the SQ.FT.FLOOR AREA 95Q.FT.
owner-huilder will have the burden of proving that he did not build Or improve for por-
sof sale),
O 1.as owner of the propeny.am exclusively contracting with licensed contractors to TOTAL:
,mama the project(Sri.70,14.Bunions,and Pmfcasions Code)The Commcmr,,com law d.esnot apply to as owner of profanity who builds or improves thereon,and QTY. PLUMBING PERMIT 00,
who contracts for such projects with u contractor(%)licensed pursuant to the.Contractors
Lee—law. PERMIT ISSUANCE
I am exempt audit,Site .B&P C I'or his.,am
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WOR KP.kSCOM I'ENSjuaryo DECLARATION BACK FLOW PRQI'T:CF DEVICE ?
1 hereby affirm under penalty of perjury one of me humor for declarations: V
❑nc, and by eCenifcateof the Labor
ed&in Compar-of the DRAINS-FLOOR.RUDE,AREA.COND. ST IES 'I'YPF CONSTRUCTION
women,us hick thi for by Section J1tN)of the Lmdr Cde,for the performance of the
work have
and
this permiti Work J. FIX TORES-PER'I'RAP
Fl 1 hath and will ode,For Workers Compensation Imarronce,which
h required by Section
'
310X0 of Labor Cdaf nM1h performance nfthe work for which this pemtir is issued, GAS-EA.SYSTEM.I INC.4OUTLETS OCC.GROUY APN
My WmkeryCl team Insurance carrier and Policy npynobr[�rY/�� GAS-P.A.SYSTEMOVER'P Carver. 4/tit 1 S L /
CERTIFICATE OF:EXEMPTION FROM WORKERS' GREASEINUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(Th,oa,don need not becompleted Rise permit is forone hundred dollars($100) GREASETRAP
,or less,) PLANCHECK FEE
Icenifythm imine perfnrnnmce tithe work(..which this permitla i...ad,[,hall SEWER-SANITARY-STORM EA.200 F1.
not employ any Person in any manner m as to become subject to the WorkersCampton- ENERGY FEE
O O Applicant
micinN
Law,Of California.Do. WATER HEATER WNE '/CLEC IR GRADING FEE
NOTICE TO APPLICANT:If,agar making this Ccnificam of Exemption,you should WATER SYSTEMOTEATING
F' ,,r, become subject to the Workers Compensation provisions of the labor Cale,y.a must SOILS FEE
Rmhwlm comply withmeh movisinns O,this permit shall be decound evoked. WATER SERVICE
a �
.= z CONSTRUCTION LENDING AGENCY NI?W RESIDENTIAL PLMB. SQ.IT. i'AIU
U C, Ihereby affirms memo,a consuiction lending agency for the perfarnunce of Das Recei a
LL P~- the work for which this permit is i....ed(Se.3091,Civ.C.) TOTAL
0 U Lender's Name
r Lender's Address TOTAL:
y IF
I acrohy Wm 1 hast reised thapplication and once that the oMwe information is BUILDING EF.
F f!1 correct.I agree to comply with all city and county ordinances and stag laws relating to QTY. MECHANICAL PERMIT FEE
U sZ building constmaioqund hereby tmhorim represenmtivesofthis city toenrerupon the SEISMIC FEE
tMwo-mhml.nad propeny far innpeafion tmpuse%' Pt?EMIT ISSUANCI?
(We)agree a mvh,indemnify and keep hamdew the City.(Capeninn against 1.1.EC1'RIC B
habildics.judgmem¢,costs and expenses which may in anyway accrue against mid City ALTEk OR ADDI MECH. PLUMBING FEE
¢quence of the'emorg of this Krount
APPLICANT UNDERSTAND' NO COMPLY WITH ALL NON-PONT AIR HANDLING UNH'(TO I RELY)CFM) MECHANICALFEE
SOURCE REGULATIO
9 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
rcc'ignoaEXHAUST HOOD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WTI theupplicum..tame buildingtccupammore n,handle nomrdons tnmeriil HEATING UNIT(10 100,NX)BTU)
as defined by the Cesium Municipal Cook.Chapter 9.12,sad the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER into"B'N)
❑Ye.% ❑Nn PAID
VENTILATION FAN(SINGLE RFSID) De1c Rcce' t X
Will the applicant or future(wilding Occupant use equipmem or devices which
/ ba'zardon,s air contannnonts as defined by the Bay Area Air Quality Minum cmeat tlOILER-COMP(JHP UR IOO.OIK)BTU7 TO I. r
F 0"net?
❑Yes 0 N BOILER-COMP(OVER 100.050 BTU)
I have rod the hicana,unntials auntie.,Cha mr h95 of the Cali AIR CONDITIONER ISSUANCE DATE
reyuimmcn P
forma Health&Safety Code.Sermons 2550 553J 25534.1 understad that if me NEW RP_SIUF.NTIAL MECH. SQ.ET p �.- )
build'mg does urn cuncntly havcnm ani ' rmspursomility to notify the occupant !//1
Ichor ntcn O.s a se uta C�ifi tcof0 upency. .1
Tier or authorized agent 00"i Date TOTAL: ISSUED ByO
OFFICE