S 1641 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF cuPFRTIN0 BUILDING-ELECTRICAL PEg IT No. 1641
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL CJ
BUILDING PNO.DrCr LDENTIFICADDN
BUILDING ADDRESS= SANITARYNO. AI'1'LICN'IUN SUI1Mfl'IAh UATI
WNIiR:I NAME'. _ r.(,. 1'Ul E: CONTRACIOR5 GAME, LIC NO: N/C CON'I'ROLX
V_Z
• ARC]II'fE ENGINHER: /C�� LIC NO: AD RL S: ��� �� ..�`�� ❑
COMACT PITONI;; �L BE ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ' NIECII
LICENSED CONTRACTOR'S DECLARATION ry ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with$Cetinn]IXMI)of Divixinn3af the tlusines,and Prnfc,sinns Gds,..m arylicenseis RESIDENTIAL:
W O PERMITISSUANCE
W in fill liuccand clYn',^136 . /fin//0/ ❑SFDWI, ❑KITCHL'N k1iMODE1.
Q,UEGkcnxc Clvw 1, Lies# -i C�-f->_r�_ APPLIANCES-RESIDEN'T'IAL OADDITION ❑I'hUYIBING
BE PIPE
y<i nam Cnnmanor
>,n ARCHITECTS DECLARA'T'ION X r2A
LS ❑MULTI-UNIT [I ST
F-,n Z 1 understand my plans shall be used as public records MODIFICATION
OZ`=S 200 AMPS [I INTERIOR C]CHIMNEY REPAIR
W Licensed Po'ccsinoal XXIAMPS IMPROVFM17NI' SWIMMING POOLS
L
OWNER-BUILDER DECLARATION OVER IIXNIAMi'S BATH REM )Ii1lR11 AIR nD'YIOL'
tE C w Q I hereby a(fimt IM1w I am exempt from the Cnnlrachv',License Law for he
X 3 d U following rcamn.(Seaton O(IJLS,Bminccs and Pmfaziom Code:Any city or county ELECTRICAL
ECTRICAL ❑(IIHER
W W y which requires a permit to construct.alter,improve,Jcmolish,or repair any sweure
�J pro t t L 4 IM1applicantr M1pc n flsignedLt¢memAL CIRCUIT/MISE
y� thatl I Ip a the p r- t of'he C I' I' (Cl 1p¢,9
6W ad6d6'
that he r,exempt
t]INX))of ll'v ii Tdlhclius'nen dP :fu.c:n,Qdc)o, TEM MI:I I3 BOR POLE INST COMMERCIAL:
W_ g t themfront and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DIiMOLIT'ION
ore
Section 7031.5 by any applicalLfor a pewit subjects the applicant to a civil Penalty ofR DEVICGS ❑TENANT ❑FOODSERVICE
n marc than five hundred doll ors(b5N)). IMPROVEMENT
I,u,nwncr of the pogwny.or my employees with wages us their vale aampenxmion, MING POOL ELECT RICill do Ie work.and shear re snot intenlyda,Owndl ou le(So,,n1IIa,lne,e OODIER
W3ae and Prowsion.v Code:'Ibe Contractor's License Law docs not apply to an nwncr ofE'I'S-SWITCHES-FIXTURESmpeny who builds or improve,Iherenn,and whodoe,such weak himmlfser through
his own employees,provided that wch impmrcments art net intended or offered forRESIDPMIAL ELFTR � SQ FT.sole.If however.the building or impervmnent is cold within oney ear of completion,theSQ.FT.PLIXIRpAREA SISQ.FT.cr.ht rider w ill have t li:burden of proving that he did not nada or oupmvc far par- PM / npo cid'ala N TOTAL CIO 1.nv owner of the prapenn am exclusively contracting with licensed umnecmrs mCogmn the Project(Sec.]IIW,Business and Pmravinn,Cade:)The ContralloGc Li-
c se LawJtesnotapplytoanownerofPmpenywhobuildsorimator,hcrcun.andPLUMBING PERMIT F F E ,' AY 11 ANS'D
whocontracts ror mvh projects with a vontnemas)licensed po„uam to the Contractors N�I r
Liccn,e Law. PERMIT ISSUANCE. UIE
j ant CxetnI,under Sec. .B X P C'Ill Ihis wosnn
ALTER-DRAIN&VENT-WATER(EA) VAI
Own Doc
Owner WORKER COMPENSATIONDECLARATION '
BACK FLOW PROTFCIDEVICE
hereby affirm under Penalty ofTI one of the following declarations:
I hmmnW will intention 1.CcniGcum TI Consent n.nreforWorkernCotnpen-
DRAINS-FLOOR,RODE AREA,CONK STfIRDLg 'TYPO CONS'i'IXUCTiOp
ration,un
work fwhich Npis Permit
d for Section 9]1X1 of IM1e Lebed CnJc,lin the pcJ'nnnuncc of the
or mi t is izwed. ITXTURIS-PER TRAP
O 1 have and will maintain Workers Compensation Insurance as required by Section
37100 of the labor Code,for the of the work for whivIdto pent is issued. GAS-i!A.SYSTEM-I INC.J OUTLETS OCC.UROUP MIS
M`Worker.NC�pcn,alian lnp/ran,tc(.a yl1liy Noand :
Q31��- 0 �7 GAS-PA.SYSTEM-OVER 4 EA)
tYCXTw- CLRI-11C,C,I E OIIffiimlll ION FROM WORK KERS' Y GRIIASUINDUSTRL W'AS'rE IN'FERCEVI OR
COMPENSADON INSURANCE BUILDING DIVISION FEFS
(bisection need no,becomplemd tater.pewit is for one hundreddallan,151011 GREASETRAP
or
less l PLANCHF.CK PER
lefilythamlhe peformall.of the work for which thispruni,N o,unl,I shall SF,WER-SAN]TARY-S'TURM EA.200 FT.
an enploy any person in any mmaria11-1r m becmnc rabirelethe Worker.C( 1pcm ENERGY F1717
OZ ,alio..laws of CaliGmti..Dere WATER 1117.A1 ER WNEN'1'/IiLECTR GRADING PDI!
Applicant
Z = NOUCH TO APPLICANT:If,after making this Cenifivmr of Exemption,You should WATER SYSIMMITRi61'INC. SOILS FEE
f-' bev r .bjc.to the Worker,ComPcnstaian navoilm,ol'the Lava,Coda you must
y ronhwith comply with melt provisions or his permit ship IN,deemed revoked. WATER SERVICE
W Q PAID
CONS ThemUCT10N LENDlNGAGENCY NEW RI3SIUI!NTIAf.PLMIi. SV FT. Date Receipt#
LJ work
which
thi shroud i iisummmctionlending agency forthc Pcrfowance of011)
W F^ the work lar which this permit is issued(Sec.J(19].Civ.C.7 TOTAL.
pU:nder's Name
U
W lender',Adder, BUILDING Plili
r
r G 1 ceniry that I hive read tel,upplleudan and ante taw the above Information Is
F" UJ ctrca.Iagmem comply with all city and county ordinances and state laws rclaing u+ QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building construction,and hereby amhodre exparemmivevdthis city loemerupon the
above-mentioned pmPeny for inspection Purposes. PERN111'ISSUANCE
(We)agree I,,save,indemnify and keep aamdeas the City of Capeoull against IiLECfRIC r
tj
IDabilities.judgmenta,cnslsnnd CXpenses whiuhmay inany vaytic'nre against said City ALTER OR ADD TO MECII. 1'1.(JMB C !I;
I. nwynene,of Iegl ndng of Nis I'll"
API, C N'1'UNDERS'E,ND NO LL COMPLY WITH ALI.NON-POIN'P AIR HANDLING UNIT('I1)I(kIl11BCFM) MECHANICAL Pf !
SOUR iREGULFTIO
Sf / AIR HANDI.JUO,ING WTIOVER IO.(XX)CPMI HOUSING,NY(, TAX
gn to of APPL HAZARDOUS
I)am BXHAl1S'I'1100D IWlDUCr1 HOUSING, I'ICATIUN PCI:
IIA%ARDOUS Mdon,ot P.6S DISCLl,nere SURE
orfuture lCadr.Chapter 9.12,handle hb,,ith ad Safety
HEATING UNIT(TO IIXI,gX)BTU)
as de.Se i the Cupeninn Municipal Ctdc.Chapter 9.12,and the Ileallh and Safely
Coda,SCc_ Ii�5321af! HEATING UNIT(OVER Rp.(NXI BTU)
s E]No VEN'I'I I,A'I'ION FANS I NGI.Li RCtiIO) PAID
Dale Bocci,#
'. Will the aPplicamor future buildogoccupant use...her em or device,which BOILER-COMP(111POR 100,0XIBT
emas it hazardous air contaminants defined by the Bay Arca Air Quality Management UI PETAL
Dora BOILER-COMP(OVER IIXkIgO BTU)
gj F]No
I leavened'he hileduus mmeriulxrc t,link,Causer IT or he Cut, AIR CONUI'I'IONI3N ISSUANC )ATC
25533 n p
fomiv Ilcuhh ffi Soley Gde,Swtinns j55(I5.25533 vnA 255111 unJerstanA tem date NEW RISIDENTIAI,hfLCll. SV.FT
builJinF does not J f. :titismyacspmsibility m entity the occupml
tlth/m hi oi,e once nfv Cenificae of(kcaPane)'. V
lnw�iwr ur uulhon lagent Ulm 'T(1'1'ALI ISSUED BY
OFFICE