28946APPLICANT717 FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISIONAPPLICATIONIPERMIT
IILDINGADDRESS:
OFFICE
ARCt�TE ISIGINEER: LIC NO:
cS�
ADDRESS: J - �, /-�
6oak put LPIr71'S
❑
CON�TA�CT�. s � j� kL ' �y�PHONE:
Ik�L1Ci1F�-Q� V /P>"'�0� l*6 -�*- it'
Drl—jC X 1"
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG , ELECT PLUMB MECH
� X-
LICENSEDCONTRACTOR'SDECLARATION
1 herchy affirm that l run licensed under provisions of Chapter 9 (luminescing
wm Seen.. 3 of he Basinessund Professions Cod,maimylicenseis
mfulltomeand eBem.g�� 3({e11(p-3
License Cl s 1 -ick
Date Conus N
QTY. ELECTRIC PERMIT FEE
JOB, DESCRIPTION -
R SIDFNTIA -
❑SFDWL ❑KRCHENREMODEL
[]ADDITION ❑PLUMBING RE -PIPE.
QWzth
Y 00
C 4Vr
-
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
�<h
80m
ZOZ-�
C< .
C �
Spa�, W
0 M U
-❑MULTI-UNIT ❑STRUCTURAL
' MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELBEPAIR El DEMOLITION
❑OTHER
'
_L%
s ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
s,
PANELS
UP TO 2W AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
a I hereby affirm that I am exempt from the Contractor's License Law for due
following mama. (Section 7031.5, Business and Professions CWc: Any city or county
201-1000AMP5
OVER I(N10AMP5
SIGNS ELECTRICAL
W
IJ a V,
�"il0
}
uu6 y e o0G
yYl7 lay
which requires a permit to construct, vai r, improve, demolish, or repair any stmcmm
prior to its issuance, also requires Ne applicant for such pemuuo file a signed smmment
thath encienmd Sectinuotheprovisioi.o3.f Cammmmr's License Law(Chapder9
(commencing with Seatinn]IXNI)af Divisian3af the Business andP ficA ' ns Code)or
ec he is exempt any a ora and the basis for Ne cts the pplic n. Any -Inion of
Sectinn]03156y any applicant fora permit suM1jcros the applic noecivil any of
Section
SPECIAL CIRCUIT/MIST.
_
TEMP. METER OR POLE INS!.
0NEW FIL AL:
❑NEW BLDG/ADDRION ❑DEMOLITION
VENgNT ❑FOODSERVICE
POWER DEVICES
FZ6
G
3..
t more than Eve hundred dollars (8500).
❑ Lasowner efthepropeny.orilmaimoyeeswithwvge.-Iheirml.7(A,L nm n,
inrendW oroO for awnlajSec. a.. .ire.
will do Nsrans, andthe he Contractor
and Prnfessinns Csdc The Cnnvecmr's License does not n an owner of
papery who builds or impaves Merton, a does su1, dmself m through
his own employees, provided that such pmvmnems am t mendedo, offered for
sale. If, however, she building or imp emem late" within r mofco motion. the
IMPROVEMENT
OOTHER
SWIMMING POOL ELECTRIC
OUTLL•'fS-SWITCHP.S-FIXTURES
NEW RESIDENTIAL RLECB SQ FT.
SQ. PI'. FLOOR AREA
SISQ. hT.
owner-builderwill have the buNe fPrsing that id himi fmrpur-
posemsm,.).
I, as owner of the pro y, am exclusively comraz i licensed con is 1.
construct IN project IS .71Nq Business and Profession C Th o pact
cense Law does not appl un nwne prop�.v qqho builds ovcxl d
Omhptoje
TOTAL:
p
A •0
��� ^
PLUMBING PERMIT FEE
whocnmrnms far with co tm&a7ksTlicen. 'u uothe nn.
License Law....//�Wy \
8
����
PERMIT ISSUANCE
❑ 1 um exempt under Sec. H & PF r this as on
_
ALTER - DRAIN & VENT -WATER (FA)V
ATI
V 1 Ur 1n,.pL4„ P.�
Date
Owner
WORKER'S COMPI'sNSA EGLARATION
BACK FLOW PROTECT, DEVICE
�Dlhomand
1 hereby dorm under penalty of perjury o f the allowing dee tions:
will m.inuina Cenifcam of Cnn num -i ore fared ken's Co.,,..
tion, as pmvided for by Section 3]00 of th Labor Ccsle, domance of the
woHn for which fs permit is issued.
1 hove'and will mvimud. Worker's Cm penmtim. Insurance, required by Section
3]Wofthe Labor Castle, for the perl'or cc ofthe work for which is'noblsissued.
DRAINS- FLOOR. ROOF, AREA, COND.
STORIES
TY PE CONSTRUCfIOls
FIXTURES - PER TRAP
GAS -EA. SYSTEM.) INC. 4 OUTLETS
-
OCC. GROUP
'APN'
GAS -EA. SYSTEM -OVER 4(EA)
My Wmker'iCa�mg a�mi n 1 mranarer anc c d Policy number
Carrier: `Ik'arKlD Policy No.:
GREASMNDUSTRL WASTE INTERCEPTOR
CERTIFICATE EXEMPTION FROM WORKER
CO ENSATION INSURANCE
BUILDING DIVISION FEES
GREASETRAP s
PLANCHECK FEE
(Thissectiourt do ecnmplemilifthepermitufmune hondor nllau (EI W)
or IessJ
I cenify Nati epMonmance afore work (nw hispcmnid it is ed.l shall
not employ any on In any manner sn as to becomes. t m the Workers' Compen-
'EWE -SANITARY-STORM .200 FT'
ENERGY FEE
GRADING FEE
O z
F ti
w
Q
V
0 U
0.
�•' N
U %..
avtiun Lawx o dif rina. Datc
Applicant
NOTICE APPLICANT. IL after making hi erifcate f Ilion, you Should
became su 'act m the Wor a's cation p sin of r Cade, you must
forthwith, mply with sac moralis pe shut mind invoked.
CON TRU /N�Q11 ENCY
Iherc yaffmnthatthcrcisa or l'YlC mgagrncyfonheperformanceof
e
Ne work far ich this 't' s e. Civ. C.)
Loder's Name
Lender's Addree
1-ttl cenify th I -aJ Nis a ration and sire that the above information i.
carrrn.l egrce sac ly with dlc' and coumy ordinances and one laws relatingm
fuiTmg con slmetion, dhercby thorize represemadives o(dhis city to enter upon time
WATE E
WpTEE
WpTE
McWr and
NEW
omissions an-
d 6hAL.
QTY.
aaasn�laaV
A I Date Receipt
Date
-
OTAL:
.
BUILDING FEE '
SEISMIC FEE
ELECTRIC FEE
bee -mentioned pope tori pneuma purposes.
PERMIT ISSUANCE
(We) agree m save,' emnify and keep harmless the City of Cupenina against
liabilitiesjudgmems, costs anti expenses which may in any way.acme ugainstssid City
ALTS 12 mECH
PLUMBINGPEP.'
m conxcqu ndem -f the grantiag Nthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNR(TO I FM)
MECHANICAL. FEE
AIRH V
TAX
SOURCE REGULATIONS
/l%«avLl..d bl'� 10/1V /-l5
Signature al'ApplianVCgtracmr-oVr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplirontm future building oecupant stormlatndle hmardous m.terial es defined by the Caperton Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532()T
HOUSING MIT'IGAF�E
OOD(W/DUCf)
NIT (OVER 100.000 BTU),
ON FAN(SINGLP. RFSID)
❑Yea ❑Nm
PAIDDmcWill
the applicant or future building locator use equipment or devices which
haoccous air emnummunts as defined bythe Bay Area Air Quality Management
OMP (JHP OR 1 Wp00 BTU)emit
7(W
District!
OMP(OVER 100.000 BTU)
❑Yes ❑No
TIONER -
I have mad Ne hauNous materials requiremems under Chapter 6.95 of the Cali-
ENTIAL MECH. SQ. R.
fea. Health & Sdny Cade, Sxtions 25505,25533 and ]5534.1 understand dud if the
building does not curendy have a tenant, that it is my responsibility to notify the occupant
of the requirements which ..at be met prior m issuance of a Cenificate of Occupancy.
-
, DTAL:
ISSUP,D BY:
Owner or subsidized agent Dam
OFFICE