25739 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,e CITY/�F CUFF,RTINO BDIGEnNit.- T,EL I.,,A. PERMITNO
�! PLUMBING-MECHANICAL, 25739
BUILDING DIVIS ry APPLICATION/PERMIT
11 BUILDING PROJECT'IDEN'T'IFICATION
BUIL DING ADDRESS JU I
'/g /0 SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
UNIT p Z LOT p O L 1,
(W ERS E: UK-VIRIS
NIC CON'I'RO
ARCHI'TEC(I NGINEER LIC NO: A R --g I` .n
PHONE: ����//�� c V` ` BUILDING PERMIT INFO
�lN F IMMQTY, ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
yy Ihcmby affirm l.. la ddheH 'Ill er'd Pri°ns°fChapter9(commencing with 1 RDES> ION I
00F Sectlon11300)af fthe Hu es dPro license is in PANELS l/Jylr lo /��,�_�_cI'(F��(�^''711(p''
UU full forte eml of vi lIP TO 2010 AMPS
.4- Li CIazs�GL1L Lic N
y4'4 Dam Candrecd 201-1000 AMPS
Fyy ARCHITECT$ ARATION w �F' DO �e 5/SOFT.
Z O'r+y 1 understand m I h II od uxA pu lie records. OVER 1IXIo AMPS /L_46 'vl
CZ-0 ypamsse
FyFw SIGNS ELECTRICAL
Q Y�'j Licensed professional 1
Xeg�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOyU 1 hereby uffimt thin I am exempt from the Convectors License Law for the I
W 3 R y following reason.(Section 1031.5,liminess end Professions Code:Any city ter county TEMP.METER OR POLE INST.
F"�'O which requires a permit to construct,slat,improve,demolish,or repair my sweture
prior itsissuance,almouse:m the applicant for such from,to file.signed sucromm POWER DEVICES J
that he is licensed pursuant to the provisions of the Commandoes License Law(Chapter
4 p,a� 9(commencing with Section 1000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
XW—H or that be is exempt hcmfrom and the basis for the alleged exemption Any v:olmion of OUTLETS-SWrfCHES-FIXTURES
F Z Q Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
nm more than five hundred dollen($5110).
SSSS❑ NEW RESIDENTIALELECR _SQ.FT. STORIES TYPECONSTRUCHON
� � ❑ hhe mlro Uthedpnry.army<ndeoyed.,mmoges...Ic(sulecom1,Bminm,
Y will dnthewons and e:The Contractor's
mot's License
a se Lae doesaff not
apply to an Business
and ROress:ons Code:The Contractor's License how Jces not npply to an owner of
property who builds or improves thereon.and who does such work himselfor through his
employers.providel thmsuch improvementsme not insmadedoroffcrd forxle.If.
OCC.GROUP HES.UNI'TS
however,the buildingm improvement is sold within one yearufcompmetion,the owner- TOTAL:
builder will have the burden of Pmving that he did not build or improve for purpose Of
sale.). QTY. PLUMBING PERMIT FEE FIAODZONH APN
❑ Lasowner ofthe property.amexclusively contracting with Bormdnonwaurato
conswet the project(Sec.1044,Business and Professions Cade:)The Convector's
License Lawd«sore apply to an ownerefpropeny whubuildambralrovesdammon,and PERMIT ISSUANCE
whourntnctsfursuehpnsjeets with o contractor(s)licensed pursuant°Ne Crops
..or9
License Low. gL'fER-DRAIN&VENT-WATGR(FA) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reawn OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF.AREA,GOND. RECETPI'p
WORKMAN COMPENSATION DECLARATION SCHWL'fAX Y N
9I hcmhy stew thnJ havencenifcxofennscnuo self-' sum,macenificaleof FIXTURES-PER TRAP RECIiIPI'p
, rm'C xsinn In c nr co y ( '.380QLm C.)wbich PARK FEE Y N
RECEIPX
Oro. AS-EA.SYSTEM-m INC.INC4 OUTLETS
BUILDING DIVISION Ii1S
Polcy p
Compan y GAS-EA.SYSTEM-OVIiR 4(EA) PLANCIIECK FEE
Cc. d y i,he
.[�Cenife copy:- dd with Ne city inspection division. GREASFnNDUSTRL WASTE INTERCEPTOR GRADING FEE
tICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE'
COMPENSATION INSURANCE
Int (This uctinn need not Ee completalifdie permit is for one hunJrd dollms($I0(0 SEWER-SANITARY-Sq'ORMEA.21XIFT. ENERGY FEE
or less.)
I certify dam in the perfomwce of the.,it for which shin pewit is isnot,I shellWATER HEATER WNENT/ELECTR
nm employ any person in any manner x as to become subject to the Workers PAID
Compenxtlon Lawsof Califomis. Date WATER SYSTEM/IRFATING Date Receipt IT
SII p z Applicant
Z
2 NOTICE TO APPLICANT:IL after,making this Ceniftcam°f Exemption you should NEW RES IAL PLMB. SQ.FT. TOTAL:
(•-' DO become subject the Workers Compensation provisions of she Lor Code,you must
� ? bandwidth comply with such previsions m mi
thu pert slam be domed mvokd. BUILDING FEE
L1. F CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 hereby affiw that is a construction lending agency for the performance Of
z' the work for which this permit is issud(Sec.3091,Civ.C.) TOTAL: ELECTRIC FEE
U O Lender.Name
0 F Leade-Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I cervi fy thin I have read this application and mute that the above information I. MECI IAN ICAL FEE
Y' moea.IaEcomm comply with all city and county ordinances and state laws rclmingm PERMIT ISSUANCE
F-' y builJingrnnswninn,un M1ereby authod.m mpresenutives of0tis city roenter upon the CONSTRUCTION TAR
(� z bovomentim d p ny or inspection purposes. ALTER OR ADD TO MECH.
e ( e)agree s ndernnify and keep harmless the City mCupenin°against AIH HANDLING UNTTU O Ig000 CPM)
IiaMlil' i,jud ems uv sa.rdexpenses ichmayinunywayanucagainstmul City
0 his it.
on slue c AIR HANDLING UNIT(OVER 10.0100 CFM)
/2 �-
Sig intr axpipharbContracuir Date EXHAUST HOOD(W/DUM PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt p
' Willtheappl:cant mfmurc building occupant score mhmtdle haaardous maxrial
as defined by the Culienina nlcida pal CoChapter 9.12,and the BaHEATING UNIT(OVER IW,WO BTU)
Health and Safety TOTAL:
Code,Section 25532(x)1 VENTILA9'TON FAN(SINGLE RESI D)
❑Ycs N°
ISSUANCE,DATE
Will thmm
eappEctorfumbuilmngoccupameem
nt useequipnt ordevices which it BOILER-COMPf311P OR IW,000 BTU)
reallous sir constrommnts defined by the Bay Area Air Quality Management BOILER-COMP(OVER m00,0100 BTU) p D
District W
❑Yes N° NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hvudoa-materials vega:remems amber Chapter ass of theC^ - 6 1993
Caliromia I lenith&safety code.Semon-2ss05.25533 arta 25-34. I udersmad dim
if the building does not currently have a tenant,that it is my mspmsibility to notify the
nccupant of the requirements which must he met prior to issuance Of a Certificate ofCI I y Jl - -TxI' Z
Occupancy. V
Owner Or authodud urgent Date TOTAL: ISSUED BY:
OFFICE