23646 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
�
Building Address: qV �� �� - 23646
wry 254 s 00i "
CITY / � ,
ctntrasar. � �Ty t.No: APPLICATION I PERMIT �p
M-� S� "(0 1#.
BU[LDING-0SCTRICALPLUMBINC MFLHAMCAL CATEGORY CO (_
Archlfed/ gleser. Lie.N. N 7
QTY ELECTRIC P JOE BUILDING PERMIT INFO
Address: PFRh9TISSUAN / "i PLUMB MECH❑
LICENSED CONTRACTOR'S DECLARATION
I hereby a(lirtnthallam lkmsed underprovWans of Chapter9(commen APPTJANC6ENTIAL JOB DESCRIPTION
ingwlth Seelon7000)of Dlvltlon3ofthe Ru sl freacnsCode,andmy
license le In 1uB force and dies. §9 K PA
N /ate_ �
Limy—Clp� CHI �7y U.
POD Dat f`�J� Contraamr
ARCHITECTS DECLARATION 1-1 A.
�qq�uu�$ (understand my plane alull be used upuhkc mrordw OV^ DO SQ. .FLOO1R AREA 5/SQ.FT.
k 201 Licensed ProfessionaleSI 5 TRICA
i<Qh. OWNER-BUILDER DECLARATIONLC T/MLSC V' PTI■
ZI.., .7i I herebyafflren that l am exempt from the Contractors License LA.for the
qqq following reason.(Section 7031.5,Business and Professions Code:Any dtyor
rountywhich requuarsa penNt rococo[run,alter,Impmve,dcnnWh,orrepair MTX OR POLE INST.
anystructure prierto its issuance,alsorequires theapplicant forsuch permit to POWER DEVICES
0. file a signed statement that he is licensed pursuant to the provisions of the
�Ow Contractor'sLicense Law(Chapter 9(mmmencingwith Section 7000)ofDial-
0S sioa3ofthe Business and Pmf.hmACode)mthat he Is m d exempt therefroSWIMMING IDOL ELECTRIC VALUATION
the bean for the alleged exemption. My violation o!Se tbn elect
cr anyapp0171,2( SN7.7.CHI&FIKTURFS 5--�
G2 five hundredt for dollars 5500), the applicant to civil penalty dnot more than N
five 1,as o ner of he pr, NEW RESIDENTIAL ELECTR SQ.Ff, BTORI-S TYPE CONSTRUCTION
�n ❑Las owner of the property,or my employees with wages r there sole
C compensation,Busio the ness
and weak and thes Code:rehnol intended License
d for Law
5' q ale(Sec.7Wy Buelnees end Protealotu Code:The Contragofe Lkenx hw
�9a docs not apply to an owner of property who build,or Improves thereon,and 0 KI UNITS
whodacasuchworkhirruelf orthrough hisownemployees,providedthat meh
Improvements are not intended oroffemd!.rule.If,however,thebuilding or
Improvement bsold wlthmoneycarotcompletlmy theownerbullderwill have
the burden of proving that he did not build or Improve for purpose ofsaln). QTY, PLUMBING PERMIT ��yyy p APN
F1 L as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE / �� {�Ar9
contractors to construct the proper(Sec.7044,Business and Professions Code: ` / !�
The Contractor's License Law dm nor apply to an owner d property who ALTER-DRAIN&VENT-WATQt ) As
Wilds ar Improves thereon,and who coanncts for such pWJects with a
cgBjlactor(e)licensed pursuant to the Contractors License I. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reasonOUTSID
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Date R7LE3PT N
WORKMAN COMPENSATION DECLARATION Fp(TURI51ER TRAP SCITOOL TAX Y N
❑1 hereby or( m that 1 have a i rtnue of consent to pytheure,ora RECEIPT N
3SMmfti" teo(Worken Competwtlonhuurance ora mttlfled ropy lM1ercof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS
Policy ab CJ PARK FEE Y_ N
Polley N RECEDING DI N
Cam any CAS IA.SYSIT7d-0VFRd(EA) BUILDING DI VISI 'EES
[,�CertiOed copy is herebydwith the city GREASE/INDUSTRL WASTE EPTOR PLANCH FEE L ► L,
❑CcrtiOed copy h(Pled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID _
COMPENSATION INSURANCE SEWER-SANITARY RM EA 200Fr. a Remi t
(fhissectlon need Act b completed lithe permit h(or one hundred dollars
tslro)orlytha WATER HFA /vENT/ELECTR EIjE EE Y
!certify thatln�hepedorminanyance of hsonerse work oastobthispenult is Issued, ��
I shall not employ any person N any rrunner w as to become subject to the WATER SY • /TREATING �
Worlicn Compensation hors of GII(ornla.Date PA
O Z Applicant
Z O NOTICETO APPLICANT:If,oiler nuking this Certificate o(Exam ption,you DINTIAL PLMB. SQpy. Date eml t#
Hshould become subject to the Workers''CompevaHon provWosi of the Labor T TAL:
c W Code,you moat forthwith comply with such provblooa orthb permit shall be G L
�j deemed mvoked. But
0- CONSTRUCTION LENDING AGENCY SEISMIC .
[hereby afBrmtlut there h a construction lending agency for the perform,
Z an¢of the workfor which thispermlt is Issued ISM 3097,Clv.Q TOTAL: E•LE�TRI E Z
UQ IerWers Name PLUMB GFEE
LL � LAAdera Address QTY. MECHANICAL PERMIT FEE MECI ICAL FEE
O W Icertitythat i have read this appllcatlomnd entethet theabove lafornutlon
Iscormct.I agree to complywlth a0 city and musty ordinan¢sand patelasys PERMIT ISSUANCE FEES PA
} IL relating to building construction,and hereby authoder representativn oflM1h
I—
In
city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMECH,
55 _ (We)agree to save,indemaity an d keep harm ess the City of—paRmo .Date Recei t#
against liabilities,Judgments,"sand expenses which may in anywayacerue AIR HANDLING UNIT OD 10,000 CPM) SUBTOTAL:
galnst said Cit�In conxquen the granting of thispermit
AIR HANDLING UNIT(OVER t0,000CFM) CONSTRUCTTON TAX
Signature of pp
lean
t/Cohire
s pate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: I
HAZARDOUS A RIALS DISCLOSURE
Will the appllcanl or forum bulldln ocntpant afore or hanrichavrdous HEATTNGUNIT(TO100,000BTU) Date Ci
rmterlala,definedby the CupertIn uhldp.ICode,Chapter 9.12,and the -
IleahhandSaf&yCodeSeslon 2(a)7 HEATING UNIT(OVER 100,000 BTU) T A
❑ Yes No
Wllltheappllcanl or uW.bulldlog ocavpantuxequlPment ordevim VFNOLATION FAN(SINGLE RFSID) ISSUANCE DATE -
which emit harardou,air roma minors es de0ded by the Bay Area Air
Quality Management DIshis7 BOILRR-CAMP 0HP OR 100,000 BTI))
4 Yos rl No
have read the hada Rus meiertals requirements under Chapter0aof 110MER-COb1P(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
rapoto Issuance
of aCeify heompantccupanof the equlremente which crust be met
pdormlssuanct o(a CettlOatc of Occupancy. f s�
pd � Q
Owner or authorlred agent Data I�upl�it
OFFICE COPY KI��U