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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN nNI v
CITY OF CUPVISION PLUMBING -MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT
BUILDING PROTECT IDEYfIFICATION
P "T"° 26641.
BUILDING ADDRESS:
SANTTARYNO,
61444 -ed&) AA 6- # LOT#
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CONTACT: - PHONE:
•. -.,- --:
QTY'.:. ELECTRIC PERMIT:., FFA
---
BUILDING PERMIT [NT -0
BLDG ELECT PLUMB MECII
PFRhffTISSUANCE I
❑ ❑ Np ❑
LICENSEDCONTRACI(lR'SOECLARATION
I hcrcbYrmrhm tarn Ecenaed underprovisionofChapter9(commencin%orifi
APPLIANCE$-RFCB)P1J.I.IAL
I
JOB DES N
J Section]000)of Division3orihe Bui dProfessionsC andmylittneuN
full force an" � S 3
Licenu Class a
PANpS '
UP T0200AMP5
riDeo Contrectm
ARCHITECTS DECLARATION
1 undcrsucM my plays shall be uud as Wbtic recmda
201-1000 AMPS
SQ. Ff. FLOOR AREA S/SQ. IT.
L_
OVER 1000 AMPS
SIGNS EIECIRICAL
j Ltmsed Profcsstond
= OWNER-BURLDERDECiCRATION
� 1 hvcby affum that I am ,.eaups Tion the Connivance. License law for the
SPECIAL
I
TEMP. np�OR POLE INST.
POWEIrE EVICES
following manor, (Section 7031.5, Business and Profession Cade: Any city or minty
jwhich rcquircs a permit b construct, alcor, improve, demolish, or repair any snu[cure
priorto is issuantt, dsorequirtsche yglicantfm such pemdtnfde asigned sarcment
lVL lJ IC'r✓
j thatheis HcensedthSemon00povisiono 3 of camacnrs Licau Lawns line)
= 9(mruneisingcioncletheeioenand!hebassin,thealleedexosaMRAnyviosCode)
Semen?in thad he 316bpt therefrotnandda perne,ortheallcgedexerrucoon.Aivil ermit, f
Section than by anYappHuntrorapemdt subjects tee applitvtt na civilperrdry of
rot rtwre than five hued dollars (5500).
❑ I,uownerofthepm M,mmycmployaswffi a msstheusolcmmpe on,
will de, the work, and the structure i s nm usanded m offered for we (ser,. 7tsaa, Business
SWIMMII4GPOOLELECIRIC
OIHLEIS-SWTICHES -FIXTURES
NEW RESWIINTAI'FLOCTIR —SQ. FT.I
STORIES
TYPECONSTRUCFION
and Profusions Code: The Contraries License Law does cot apply to en owner of
pmpeny whobuilds orimpmves thereon, and whodoes such work hitnelfor through his
employces, provided that such ionpovemmed or
entsenotintendoffeml for H,
OCC. GROUP
RES. UNITS
however. the building mimpvvmient isuld withinone yema(completion,thc owner-
builds will have the buNm of proving that he did rot build m improve forpurpose IT
sale.).
❑I,asowmrofthepoperry,amexclu4velYcontractingwffilicasvdmnrncm W
washes the project (Sec. 7044, Busirtes and Professions Cade:) The Connncrar's
TOTAL:
Q,171y: PLUMBING PERMIT -- -- FEE
iii
FLOOD ZONE APN
Urens, IswdoesrrotapplyWmOw ofpropenywMb &mmprovesthmem,cod
PERMITISSUANCE
whocontrects fessuch projects with amno-attm(s) B s ipursuant ache Cannaccots
License Law.
ALTER - GRAIN & VENT- WATER (EA)
FEE SUMMARY
❑ I ern exempt under Sm. , B ffi P C for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEESFLOW
SANITARY Y N
Owner Dau
DRAINS -FLOOD- ROOF. AREA, COD.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ IhcrtbyaR dwlhaveamtifiva of conaen[bulf-iwrrt, oraartificateM
�. Wmkers'Conµrnmtion lnumntt m a cenifced copy Hrercof(Sa. 3800. fah C.)whil
rovers Nl r s
Policya a
SCHOOL TAX y— N
RECE1PT#
FlXTURFS-PFR TRAP
it PARK FEE Y N
RECTTPTIt
GAS -EA. SYSTEM -I INC 4OULLEI3 I
BUILDING DIVISION FEES
Can [,��1�. I
GAS - EA. SYSTEM-OVER4(FA)
PLANCH;CK FEE
'fie cop byfumis d.
❑ CmifiW copy is filed with theciry impaction division
GREASEBNDUSTRL WASTE IM'ERCEPI'OR
GRADING FEE
CERTIFTCA'IE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRE4SE'IRAP
SOILS FEE
(Thissmes, need notbe completed ifthe permit isfmoae hmdreddollars(SIW)
or less.)
SEWER -SANITARY -STORM EA. MFT.
ENERGY FEE
WATER HEATER W/VENT/FLECIR
I certify teat in de, performmwe ofdte work for which IT permit is issncd, l shall
M CmplaY any person in any, mmuc so as on bca®e subject to the Workers'
Comparri, laws of Cdifmvis. Dare
Applin c
WATER SYSTEM/TREATING
PAW
Dna Receipt#
NOTICE TOA PP Le Work:IL Wmmakingthis Cwafi®u of Labor on.1. .you union
becomeh n the Workersved--elm provision of the Code you must
NEW RESIDENTIAL, PLMB. SQ. FI'.
'TOTAL:
c—P
forthwith comply with such provision or this permit shall b<deemed h,voked
cruel
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby off that there u a construction lording agency, for N, pufmmanre of
:)
-
EI.ECfRIC FEE
PLUMBING FEE
Ne work for which chis permit is issued (Sec. 3091, Civ. C)
Lendes Name
I<ndcr's Address
I certify dent 1 have read this application mon and such, that da abroc infmaes
-
,� . MECHANICAL PERMIT - _ I FEE
- `. ..,-.
PERMIT ISSUANCE
MECHANICAL FEE
rorteck lagrsncnmply wiW sllary and monryoNituvtaendsuminws relatirtgn
building mnwc is n are hereby authoneerepresnttativn of this city in enter train the
CONSTRUCTION TAX
above-mentioned property for mspemess purposes.
ALTER OR ADD TO MECH.
(We) agree on save, indemnify and keep hmruless the City of Cuperturo agarat
liabilities,judgments, mss and expenas which try To any weir accrue against said Clry
AIR HANDLING UNIT(TO 10,W)
in consequence of the granting of this permis
AIR HANDLING U. (OVER 10 CFM)
Ssg,atae of Applitant/Cone for gee
EXHAUSTHOOD (W IT I
PAW
HEADING UNIT (TO 100, TU) I
Dna Receipt#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fugue building occupant sere in handle heaso on mean,
as defined by the Cupe rino Municipal Cade, Chapter 9.12, and the Heahh and Safety
FIEATWG tINfT (OVER 1 BTU)
TOTAL:
Cale, Section 25532(a):'
❑ Yes ❑ No
VEN ILATION FAN (S GLE D)
WHIU zpplicmtmfuturtbuildin o[cupantuse
g equipment anality
BOILER-COMP(3HP RIOO.000BTII)
ISSUANCE DATE
ajorgemit
laradous au mnamiuna n defined by the Hay Area Av Quality Mara%cmenc Districtl
❑ Yes ❑ No
A
BOILER-COMP(OVER IW,000BTU) I
NEW RESIDENTIAL MECH. SQ. FI.
1 have cud the ferallous materials 5505, neva under Chalet.4,1n first of Ne
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 undersand that
1994
iflhebuildingdoesnotc By have etetunt, Dat ic6myiespunsibilirytonotifythe
occupant 0f the requ which must be mer prim n issuance of a Centiliter, of
Ocupancy.
ouch t
I VI CIs
r.1ri Utr
ISSUED BY:
TOTAL:
UttlUt