99100004APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
PHONE: CONTRACTOR'S NAML LIC NO:
��oor
Stgnamre of ApplicanUCmIreemr Dale
HAZARDOUS MATERIALS DISCLOSURE
CONTACT: J�� PHONE:f p3�)/
Y f
Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT' INFO
BLDG ELECT PLUMB MECH
Will the upplicum or lumrc building nwupvnt xinrc nr handle bu"a meter'
as Jelined by the Cupemmo Municipal Code, Chapter 9.12, and the Health anJ Saf.
Code, Section 25532(x)?
,FAT INO UNIT (OVER I W.000 BTUI
❑ ❑
LICENSED CONTRACTORSS DECLARATION
1 hereby affirm that I am licensed under provision. of Chapter 9 (commencing
Ih Section 7fN1(B ofUivdion3 tel the Businesstmd Pr�fessionsCude,undmyllecmci'
wt ��ac,
in fall (thee erW 7/� �u G
Liccnsc Class !� Lic.M
Date�D Cnmrvmorato
ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RF ID NTIAL
❑SFV WL ❑KITCHEN REMODEL
❑ADD[TION ❑ PLUMBING RE -PIPE
[]STRUCTURAL'FJ
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
ED BATH RE UREPAIR 0UEMOL,ITION
PIiR l'ISSUANCIi—
PLIANCIiS- RESIDENTIAL
' ARCHITECI"S DECLn A ION❑MULIhUNIT
1 understand my plans shall M used m public records
PANELS
UP'f0200AMPS
I,Ic,owd Podes.lonal
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Connector's License Law bade
lidlawing reason. Seel It 7031.5, Business and Proessionx Cude: Any city or county
which rcquims a pit ermw eonslmm, eller, improve, demolish, or npair any wroth
primo its ismence.alta requimcthcapplicam forsuch pctmilm fleasic.Mocacm r
that he is licensed purmannu the provisions of the Cnmmcmh License Law (Chap¢
(commencing with Section 710X) of Division 3 of the Business and Professions Code)
that he is exempt therefrom and the basis for the alleged exemption, Any violation I
Section 70315 by any applicant for a permit subjects the applicant to a civil )Noah of
201.1000AMPS
OVER ILY!BAMPS
S JNS ELECTRICAL
BW RESIUEN'I IAI. MECiI. SQ. i'll
E
SI iC1AL CIRCUR/SIISC.
IliMPME'1'LR ORPOLE INSI'.
R
❑NEW BLDG/AD IT -ON ❑ D/.M_qLLITION
(]TENANT SERVICE
POWER DEVICES
Y
Sa
W'F.0
Wim
nm rmne than five hundred dollars ($51X1).
0Lo the work. the pestructur myemployeesintended wiWenal fowages vhei(Sm. cumpeasiness
will dolhewons and the structure i.nt's License awdoes not apply to an, Business
andprofessionsCode: The Comment's License lawdre.notapply toanowner of
his own who yers. or improves thereon, and who Joei meb work himself or through
his own cmplayccs, Provided that such impmvatxnts art not intended or olfcrtd for
sale.If,however, the building or lmpmvcmcnt is sold within ane year of It the
IMPROVEMENT
❑OTHER AtW
SWIMMING POOL IiLEC TRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENI'IAI. ELECTR SQ F
SQ. FT. FLOOR AREA
LSQ. F1'.
ow soba ilder will have the burden Of proving that he did not build or improve torpor -
prose ofsala).
❑ I, as owner of the property, am exclusively comrxting with licensed contractors to
A
onstioct the project (Sec. 9114, Business and Pmfeasons Code) I it Contraclnh Li -
mire LawJcevnrnapplyat an owner of pm No, who holds or impmvcc thereon. a ad
QTY. PLUMBING PERMIT E
who contracts for such pmjeets with a etmo-amar(s) licensed purivanllit the Communes
PERMIT ISSUANCE
License Law.
Ej lam exampuutdcr See. ,B& P C lot 'his reason
mer UIO
WORKERCON PI7NSAT10N DECLARATION
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
Q �/ C�
BACK FLOW PROTECT. DEVICE
under penally of perjo of the l'nsure for d
p
I hand
! a�
willlrainma a
meet Worker's
❑I haveomas and willtrainmanSe Certificate of thenar Code, sure far Workers Cumpen-
moire, provided for Section 77W of the ichor Code, for the perfotmancc of the
DRAINS - FLOOR. R(KIE AREA, COND.
gTORI'
TYPE CONSTRUCTION
work for which this permit i. issued,
r a
IgXTURTiS -PP,R TRAP
❑ I have and will maintain Worker's Compensation work li Insurance, squired by Section
¢u(rhe k forwhich this Permit is issuers.
J]37Wof the Lane, Code,(robe performance
GAS GAS - FA. SYSTEM -i INC.G OUTLETS
pCC. GROUP
APN
Ca Wnrkcrs✓At � onon lnsA Jceµ cy Nc f mh';r n/ g
Carrier: l Y O �. v
�,a-
GAS -EA. SYSTEM -OVER
GHEASEIINDUSTRL WASTE INTERCEPTOR
FROM WORKERS
CERTIFle PI'IINN FROM WORKERS'
'' ''
COMPENSATION INSURANCE
9UILDIN DIVISION FELS
('Thicsociionnced not be contplelyd iflhe permit is for one hundred dollars (SIN)
or less.)
GREASE'rRAY
PLANCIIEC,K PEE
t
SEWER -SANITARY -STORM EA. 200 FL
rformccofthe workforwhichthispermit oi... ed. Ishall
Ieenifyihminthepean
not employ any person in any manner so as to became subject the Worker, Compcn-
ENERG IFE
WATER HEATER W/VENT/i?I.1.MR
GRADINEiF
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QLenders
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ration Laws of California. pace
Applicant
NOTICE TO APPLICANT: IL afar making this Cenificac of Exemption, you should
he,on a nubjc,l pr the W..cars Cont unn f the labor Code, you must
I In'nxa pmmun°aO
forthwith eomply withsuch pacismnnsorrM, pc— it shall her deemed ravoled.
CONSTRUCTION LENDING AGENCY
hereby effort that them is a aon.unaiun leading agency fur IM1e perlimntmce nl
the wadfor which hispermit is issued (Set. 3007. Cie C.)
Name
WATER SYSTEMG`REATING
SOILS FEE,�J OCTT .I
ell C1 1
WATER SERVICE
PAID rsate Receipt M
F(
NEW RESIDENTIALPLMB. SQ. FT.
TOTAL:
Leader's Addie.
BUILDING FEE
1 certify mal I have read mi. application and stale that the raise information is
correcr.l agree mComply with all city and county ordinances and stale laws rtlmingto
building construction, and hereby authorize representativeso(this city toentcr upon the
MECHANICAL PERMIT FEE
SEISMIC FEE
PP
MI'1'ISSUANCIi
ELI3CTRIC FEE
ahove-nrenUoncJ prapeny t in nmpcm'mn Iampascc
(We) agree nr save, indemnify end keep hannlesn the Cny of Cupcninorgan
ALT ER OR ADD TO MECH.
PLUMBING PEE
Iiabdhies.juJgmenu. costs and expenses which may in any way accrue against said Ct
im cegncnce of the gtanlia, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (1010.(XX)CFM)
MECHANICAL PEE
AIR HANDLING UNIT (OVER 10,000 CFND
CONSTRUCTION TAX
Stgnamre of ApplicanUCmIreemr Dale
HAZARDOUS MATERIALS DISCLOSURE
HAUSTHOOD(WMUCT)
HOUSING MITIGATION FEE
HATING UNIT (TO IW.OIXI NTU)
Will the upplicum or lumrc building nwupvnt xinrc nr handle bu"a meter'
as Jelined by the Cupemmo Municipal Code, Chapter 9.12, and the Health anJ Saf.
Code, Section 25532(x)?
,FAT INO UNIT (OVER I W.000 BTUI
VENTILATION PAN (SINGLE RES] Of
' C)Yes ❑Nn
PAID ,
Rncipt p
BOILER-COb1P(JHP OR IW.000 P'IUJ
Will the applicant or future building Occupant use equipment or devices which
mit hazardous air cuntaminanu as defined by the Bay Area Air Quality Management
T
RXLER-COMP (OVER 100.(X)0 BTU)
Di.uiefl
0Yea ❑No
CONDITIONER
I have rad the hw.ardous materials requirements under Chapter 6.95 t the alt.
ISSUANCE D
BW RESIUEN'I IAI. MECiI. SQ. i'll
E
fomite Health & Surety Coke. Sections 25505, 25533 and 25534. unJerstat that M1c
building d«xnat currently haveamnanh thmit is my resrymcibiliry m notify emcupa
of rhe rtquiaments whit mus be rota prior nt issuance of a Certificate of <upmcy.
ISSUED BY:
TOTAL:
Ov.'nenmamhorizeJ agnl Dam
OFFICE