29441APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -
ONLY
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BUILDING DIVISION APPLICATIONIPERmn PLUMBING -MECHANICAL
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❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION QTY
I hereby offirm that I am licensed under provisions of Chaluer 9 (commencing
with Section 7")of Divicien 3oOhe Business end Profession Cor, it an, license is
in full force mal effect.
License Class Lic.N
Date - Commcmr
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Ismicaaioml
OWNER -BUILDER DECLARATION
I hereby nfRrm that I it. excmpt frons the Csmtmmor's license Law for the
following resort. (Section 703).5. Business and Profession Code: Any city as county
which acquires a permit to construct. site, improve, demolish, or repair any swcmm
prior to its issuance sets. requites the appI icon for such permit m me a signed statement
that he is licensed pursuant to the provisions ofthe Contractor's License Use (Chapter 9
(commencing with Section 701 of Division 3 of the Business and professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applivol for v permit subjects the opplleanl It, c civil penalty 6f
0 mom than five hundred dollars ($500).
fas owner of the property, or my employees with wages as their sole compensation,
ill do the work, and the smtcture is nal intended or offered for sale (Sec. 7114, Business
and Professions Code: The Contractor's License Law does not apply to an owner mf
property who builds or improves themon, and who does such work himself or through
his own employees, provided that such improvements am not irmadedmr offered for
aide. If,how er,the buildir,amrpmvemen0issold within mneycemsfcompdeuon,thc
owner -builder will have the bunks of proving that he did not build or improve for pun
pau clime).
❑ I, as owner or the property, am exclusively contracting with licensed cram curs to
cons epru3 IR4, Business and Professions Code:)TheContractorsLi-
< law Jces nm vpply ns, ter of pmpecry who builds or improves Merton, enJ QTry
{�Ira cu far larch projecu hacont r (s) Inertial pursvom m me
the Commr's
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I hereby affirm under penalty of perjury one of the following declamtions:
❑ I have and will maintain a Certificate nfCopsenuo self.in.sure for Worker's Camper
action, as provided far by Section 3700 of the Labor Cade, for Ne performance of the
work far which this permit is noise.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Lahr Cede, for the performance clubs work Por which This permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
Obis union need nm be completed BNe permit is formic hundred dollars v$ [all)
or less)
1 certify that in the Performance of the work for which this permit is issued.I shall
not employ any person in any mmner u as to become subject to the Workers' Campen-
0 z moan laws of enllr ..mi. Dat-
z 0 Applicant
L4)NOTICE TO APPLICANT. If, dice making this Certificate of Exemption, you should
(~ biome subject to the Worker's Compensation provisions of the latter Cale, you mat
forthwith comply with such provision or this permit shall be deemed reveled.
CONSTRUCTION LENDING AGENCY
V 0 thereby affirm Etat there is a consomrimn lending agency for the performance ml
!Ta f•' the work for which this permit is issued(See3097, Civ, C.)
0 U Lender. Name
W Leadvea Address
1 certify that 1 have read this application end smic That the aheve information t
r0./] cumin.Iagreemcomply with allcity and county ordinances and storhoe eat relating a QTY.
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building construction, and f..herebyal etin. authorize representatives of this city to enter upon the
above -(we) oodgreproperty hu Imnify an keephe.
(we)agreem save. indemnifyandkeep harmless the
City
p .1=n1oagainy
liahimPo,mr..1 he amand expenseswhich may in any easy accrue against xaiJ City
A PLIC NT U the UNDERSTANDS
g of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signature of Appdicant/Cormustor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant an future huilding cecupnnl entre or handle hmxardeuc material
as defined by the CuNnina Municipal CWe, Chapter 9. 12, and ate Health and Solely
Code, Section 25532(a)?
❑Yes ❑No
Will the applicant or future building eacupant use equipment of devices which
emi0 hnxardons air conmminmms as deOnW by the Bay Area Air Quality Management
District?
❑Yes ❑No
I base read the hamNoue materials requimmems under Chapter 6.95 of the Cali.
forma I mlth & Safety Code, Sections 25505, 25533 end 25534.1 understand that if the
huilding does mrcumtnly have a tensor. that it is in, mspensibility to notify the cecupant
of the requirements which must Ise met prior to of it Ceni firms of Occupancy.
Owner ser aathoriaed sgenl Date
ELECTRIC PERMIT FEE
PERMITISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPTO 21X1 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE 1
POWER DEVICES
SWIMMING POOL ELECT
OUTLETS— SWITCHES—
NEW RESIDENTIAL MU
PLUMBING PERMIT
PERMITISSUANCE f'1
ALTER — DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF, ARG, COND,
FIXTURES — PER TRAP
GAS — EA. SYSTEM -1 INC. 4 OUTLETS
GAS — EA. SYSTEM -OVER 4 (G)
GRGSIVINDUSTRL WASTE. INTERCEPTOR
GREASE TRAP
SEWER — SANITARY— STORM F.A. 200 FT,
WATER ItEATliR WNENI'MLECTR
WATER SYSTEMITRF.ATING
WATER SERVICE
NEW RESIDEMIALPLMIL SQ. FT.
MECHANICAL PERMIT I FEE
PERMITISSUANCE
ALTER OR ADD 10 MECH.
AIR HANDLING UNIT TO 10,100 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD(W/DUCT)
I(EATING UNI"T (Ter 100,000 BTU)
BEATING UNIT (OVER 100.000 RTU7
VENTILATION PAN (SINGLE RESID)
BOILER—COME' OHP OR 100,000 BTU)
BOILER —COMP (OVER 100.00 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
0
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
XATH REMODEUREPAIR El DEMOLITION
OOTHER
COMMERCIAL:
❑ NEW BLDG/ADDITION
❑TENANT
IMPROVEMENT
Q OTHER
❑ DEMOLITION
❑ FOOD SERVICE
%1 x
-'1
MAR 1799
I V VAI,UAT[ON
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STORIES
OCC. GROUP
TYPE CONSTRUCTION
0
BUILDING fIIVISION RLS
PLANCHIECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Ren tN
TOTAL:
BUILDING PEG
SEISMIC IEE
ELECTRIC FE
PLUMBING FEE
MECHANICAL FE
CONSTRUCTED AN
HOUSINGMIT ATIONFEE
PAID
Dare Receipt g