S 325340
WS
ZWZr
UU
W
O�
F�
"4
�U
W I'�
O
h
O�
m
�a
Sp
APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPVRTINO' BUILDING - ELECTRICAL
BUILDIN9,DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PER/'f'v.1IT NO /�
5 3
L V
J 3253
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ` � t ` LOA ` ` t
SANITARY NO.
APPLICATION SUBMITTAL. DATE
PHONE:
O RACTOR(:SNNAME:1r_^1 ��" �TICC N/gi
S` j. I�L ', `CLJ-U-Iy� ` YO(J//may
SIC
❑
CONTROL# .
,vRCHITECT/F.NGINEEk: LIC NO:
AD /
-zS 1v J
�A 6 t
CONTACT: PHONE:
BUILDING PERMIT INFO
/] �'f
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MUCH
(/
1
❑ ❑ LK ❑
LICENSED CONTRACTOR'S DECLARATION -QTY.
I hmchy affirm that am licensed under provisions of Chapter 9 (remonstrant,
ELECTRIC PERMIT FEE
JOB DESCRIPTION
wish Sec))inn 7000) 111 ofth Business and Professlore Code, and my licenses
inf�I*ce'inligJef 2�Ljv _
License Cl Lich
Date Contractor I =
PEkMIJ'ISSUANCE
RESIDENTIAL:
CSFDWL El KITCHEN REMODEL.
CADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall be used as public roods
PANELS
Up'r020)AMPS
1-1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
[I BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm the 1 am exempt from thee Contruetor's License Lev, for the
following reason. (Semon ]031 5, Business and Professions Cade: Any city or county
which requires a permit to conmmet,.iter. improve, demolish, a repair any snucmre
201-1000AMPS
OVER 1000 AMPS -
SIGNS ELECTRICAL
prior to its issuance, also requires the applicant for such permitto rile a signed statement
SPECIAL CIRCUIT/MISC.
that he s licensed pursuant to the previsions of the Contractors License Law (Chapter 9
TEMP. MET FIR OR POLE INST
COMMERCIAL:
(commencing with Section 7000) of Division 3 of the Business and Profession, Code) .,
that he is exempt therefrom and the basis for the alleged exemption Any violation of
CNF, .DG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7(1.315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars OiNkd.
C Las owner of the property. or my employees with wagesnn their sale compensation,
will do the work, and the structure is not intended or correct for sale (See. 7aaq Business
,NANT El FOOD SERVICE
IMPROVEMENT
C OTHER
J7 A7
SWIMMING POOLE IC
and Free .... a, Code: The Cannot License Law does not apply ,, an owner of
OUTLETS -SWITCHES- VrXT
pfaperty who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended or offered for
NEW RESIDENTIAL P.LECTR S
SQ. FT. FLOOR AREA -
$/SQ. IT.
sale. If,however, the building or improvement is sold within one year ofcomplotion,the
owneclouilder will have the burden (if proving that he did not build or improve for pur-
C 1, as owner M Ne prtp¢ny, am exclusively contracting with licensed contractors to
TOTAL:
m.load the project (Sec 7044, Business and Professions Code:) The Commctors Li-
useLawdoesnmapplytoanownerofpropertywhobuildsorimprovesthereon,and
QTY. PLUMBING PERMIT FEE
who rmlmtn ferateh p jecu with awmmmogs) I iunsed puraaamm the eommetors
PERMIT ISSUANCE
License Law.
E]I am exempt under Sec. ,B&PC farina reason
ACI'FIR - DRAIN & VENT -WATER (EA)
,ne-,
, Data
VALUATION y,
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
DRAINS- FLOOR. ROOF, AREA, COND.
❑lhweandwll tnelm.InaCmaf eros of Ctnawun self -insure far Worker's Compen-
tion, as pmvideJ for M1y Section 3](NI of the Lvhor Code, fur the performance tri the
S IES
TYPE CONSTRUCTION
fur which this permit is issued.
FIXTURES - PER TRAP
Q'1 have and will maintain Worker's Compensation insurance, as required by Section
_
3700ofthe Labor Gale, fort pednnn,nce the hir,work for which his permit is issued.
MyWCarrico, rsI mpensn n mote wm PoaetVLMio t -I(2
CERTIFI TE OF EXEMPfIIO_N`icyFROM WORKERS'
OMPENSATION INSURANCE
(Tha,mationneed nnlbe rampldadifthe Permit is forone hundred radius ($100)
or less.)
GAS - M.SYSTEM-I INC. 4 OUTLETS
� p
/
_
APN
GAS -fiA. SYSTEM-OVER4(F,A)
GREASFJINDUSTRL WASTE INTERCEPTOR
BQI4DBSGD ISI FEES
GREASE TRAP J
I candy that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any manner so ave become subject m the Workers' Compen-
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEF.
WATER HEATER W/OP.NT/HLECTR
seem Laws of California Date
Applicant
GRADING FEE
NOTICE 9Y) APPLICANT: If, after making this Cenificate of Exemption, you should
become subject m the Worker's Compensation provisions of the Lobo, Cade, you most
WATER SYSTEMn BEATING
SOILS FEE
forthwith comply withsuch Provisions m Has permit shall be dermedrevoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby aflimuhm there is acorcumation lending agency for the pamareome of
NEW RESIDENTIAL PLMIL SQ. PT.
PAID
D a Receipt If
the work for which this permit is issued (Sec 3097, Cie. C.)
Lenders Name
TOTAL'
Lenders Address
TOTA
BUILDING F
I cenify that 1 have read this application and state that the above information is
sect. I agree to comply with all city and county ordinances and state lawn relating to
building connotation. and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT -E
SEISMIC FP ,
PERMIT ISSUANCE
ELBCTRI E
above-mentioned p,open, for inspection purposes.
(We).goach, save, indemnify and keep ha,mleas the City of Caledonia against
ALTER OR ADD TO MECH.
PLUMBI G EE
liabilities,judgments, costs and expenses which may inany way accrue against said City
in asequence of the grunting of this permit
AIR HANDLING UNIT (TO Io(V0 CFM)
MECHANICALuE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE GULATIONS,
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUCTION TAX
J
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
Signature ofAppleamUCantimicaur � t Data'1
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO I00.0(g) BTU)
Will the applicant or fmure building occupant store or handle hazardous material
as defined by the Cupenit, Muticlpol Code, Chapter 9.12, and rise Health and Safety
Code, Section 25532(a)'7
HEATING UNIT (OVER 100.00) B U)
FAN (SINGLE RESID)
0Ye.VENTILATION
y/
Will the applicant,comor furore building y the Bay Awal it Qu or devices which
'emit huzaNnus air usnmminunts ae defined by the Bey Arca Air Quality Management
IDistrlet
❑ Yes
PAID
Dam Rweipt#
BOILER -COMP (3HP OR I W,Dq B'rU)
t,1
T2A6. C/
BOILER-COOP (OVER 100,000 BTU)
AIR CONDITIONER
1 have rove the h.znMtus materials requimaumns undo Chapter 6.95 of the Coli-
fomiu Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
ISSUANCE DATE
NEW RESIDENTIAL MML SQ. FT.
of the requirements which mum be met prior to issuance of a Certificate of Occupancy.
ISSUED BV
TOTAL:
Owneror saidmized agent Date
OFFICE
3LI
20U
O.1
30U
3GI
Selo
:011
m21
mu
1011
2!9
ti-
2Wi
tat!
xmt
311! 1 218 1 2121 1 1113 1 1.! 1311➢ I Sul 12W
221
110 121N 1 1147 1 241 1 2111 I' 21371 2U9
„•1 1 !I 22L
nl1
320! :2p1 :3Qi
2V!
3.9]
1.61
�� 5.61 1612 a� iW
41
331 31m /' 1711
121]
3.J2 1119
222! 7127 II19
r Z:m
cC
rM RC 44101: TN THE CITY 08
�^ i� MIT1110 CrM3S lIf itiD/OR/DINA/N}CEepS
2]" I This set oil P caacns mual
u�i,e kept or a , "1 I :ones and it is un
'lawful to c`I.a, • I;;`G or alterations
no camrn{;i ,'g,6:rscion from
I the bu.,OM 4 "- r G:ye,
1pe The:.r+tmPof a s,zsifioations
l ( Ie, u , Pc ^,it cr to be an
n of a,i',' Provision'
St1B Law,
II 3U,I2UY iVt I SUl l ibl I:u7 2W 13� SQY 2P1 :.19 124] 1.211 2.21 I ZUY 13.17 13.r! 12.O I :.11 :6G II
Loco tion CO3 -
1NOR ir1 Iy111 Valm Panay
�� ✓
CA ISCII
T V':'� L" Gcc-'0c-,'
.1— ..
}
4-
M.a
P�
w
o;
�.
� 0
10-16
-/ -1 * U-pb
LA
Lj
Ll