29565 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWFINO r., . . BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 29565
•BUILDING ADDRESS: , SANITARY APPLICATION SU
Bp
M1I'RAL UATFD % "M�U� `� A /
OWN17R'S NAME ;I ( PHONE: IS CONTRACTOR ✓`-4�
I i GINFiR. I CNONIC CON]
LIC NOADDRESS ❑2
ry"in
C1oNTACT 1 PHONE: BUILDING PERMIT INFO
JIM-y� � nin6tilit -Zp's."5444 ❑ Consultant Fees Paid by Applicant(Initial) Blpc ELECT PLUMB MECH
LICENSED CONTRAC'WE'S DECLARAION QTY ELECTRIC PERMIT FEE ,�
T
1 hereby alarm that I am licensed sneer prevision,ar Chapter r v( omma-g JOB DESCRIPTION
Z
OR Section 7006 of Division 3 of the Business and Prafe,mr,Ctrs,and my license is p
{+1100 in a PERMIT ISSUANCE 3J-
F full lone and effect. SPUWL [I KITCHEN IIEMODEI.
aFVZV [cense Class Contractor
APPLIANCES-RESIDFMIAL ADDITION ❑PLUMBING RE-PIPIT
N60. Dam Cnmmcwr
F.
ARC]111 DIiC1.ANA'1'ION PANEIS MULTI-UNIT ❑STRUCTURAL.
Z 0 m Z 1 undimmed my pl...hall be used as public records MODIFICATION
CZ-, UPT0200AMPS ❑INTERIOR 0CHIMNEY REPAIR
P 4Ir 41 licensed Prol xi,ional 2111-1001AMPS IMPROVEMENT
lyE� OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR (]DEMOLITION
M W G I hereby affirm that 1 am exempt from the Contractors License Law for the
yx O W V following reason,(Seton]031 5,Busineca and Profession,Code Any city or county SIGNS HLECI'RICAL ❑OTHER _
al�+0 a, which requires a permit m eonswet.aha improve.demolish,or repair any swewre
hiOg prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
,> that he is licensed pursuant m the provisions of the Contractor's License Law(Ch-, -
a
p5<0 (commencing with Section 7")Of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:' P ties
W25 a o E�� that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEWJ BLDG/ADDITIONO ❑DEMOLITION
N Section 7011.5 by any applicant lin a pcmtit mhjcae the applicant to a civil penalty of POWER UF:VICIS 11Tgp CrT /I
C1 FOOD SERVICE
❑
t mme Nan five hundred dollars($SW). IMP Em"
I.as owner of the pmpeny,or my employees with wega as their sole compensation, SWIMMING POOL ELECTRIC
p.,E=C will do the work,and the ntmmure is not intended oroffsred for sale(Sec.7044,Business r�aTHER n
ail and Promxsinns Cade:The Contractor's License Law does not apply to an owner of OUTLE"LS-SW I TCHES-FIXTURES
6 3- properly who builds m impmvea thereon,and ilm does such work himself or through • C/Y!/A'n
his own em Inycea,building that such iso pmvemen NEW RESIDENTIAL ELEM
p os arc not intended i offered for
sale.IL however,the building,rimbmvement is sold within one year,f combldinn,the � $Q.14,FLOOR AREA S/SQ.FT.
.1-t wilder will have Ne bonen of proving that he did not build or improve for par. cla %,% 2
Issue or sale.). ` ��� -o J
❑ I,as Owner of the pmpeny,oto exclusively tenanting with locn.aed contractors to TOTAL: �2 �yy., +��f
construct pmject(Sec.7044,Business and Pmfcasions Gale:)The Contractors Li- J jgCj \ \J (,4 .Its
cence Law docs not apply nr an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE T
who contracts for such projecss with a csntracmr(a)licensed par,com,,the Commerce,
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this rezwn
Owner Tale ALTER-DRAIN&VENT-WATER(EA) VALUATION
WONKEN:SCOMPENSATION
one to
BACK'LOWPROTECT.DEVICE k �A ��k/w
1 hereby orlury tiby u[Eunder Isenalty o[pof the Edlnwing declomtion �f•
❑'have andwill for by Section 37W oftheLNor ode.surefor Worker's Comf fie DRAINS-FLUOR,ROUIa.AREA,GOND. STORIES TYI'Ii CONSTRUCTION
ration, r provided for by Section 3]00 of the lain Cade,for arc peHormance of the
work for which this maintain
is issued. I'1%TURES-PER TRAP
❑I have and will ode,f n Workers Compensate w Insurance,h required by Section
3700 of ohs LaMsrCMe,for ohs perfonnerme of the work for which this permit is issuW. GAS-FA.SYSTEM-]INC.40UTLE1'S OCC.GROUP AI'N
My Workers Compensation Insurance carrier and Policy numher am:
Carries Policy No: GAS-ITA.SYS'I'EM�OVI:R 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INS U RANCP. BUILDING DIVISION'FES
(This section need not he completed it the permit is for one hundred dollars IS l W) GREASETRAP
or less.) PLANCHECK FEE
I ceni fy that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
nut employ any person in any manors,.,to beja
cn or-1 uoohe Workers'Compcn. ENERGY FEE 2CL-Z C
O Z sari..Lows of California.Dae WATER HEATER wNENT/ELECTR GRADING FEE
.Z. O Applicant
NOTICE TO APPLICANT.If,after making this Cenificam,f Facmption,you.ahmld WATER SYS91iMO RERIING r
I--' 7 become mbjeet oo the Worker's Compensation provisions of the Labor Code you must SOILS FEE
Wo-., foohwith comply with such provisions or permit shat[be deemed revoked WATER SERVICE
= z CONSTRUCTION LENDLNGAGFNCY NEW RESIUENTIAI.1'LMB. SQ IT. PAID Dam Receipt#
U 0 work
whofOnn ohntherc iso ted(See
agency for the performance of
Umework for which this permit is i.anucd lSec.3(19].Civ,C.)
Lenders Name 143 41 TOTAL:
M Isnder'u Addmss TOTAL:
} G.1 BUILDING ME Qrllo°6
LL Ionieoco1have Mad this
ty anic county ordinances
thnt the above
srelating is
F h anrcn.l agrcemcn,and wdha ammornd mm�osencolcti Of and suite entretingm Q'I'Y. MECHANICAL PERMIT PEElik lite.
U z building construction,and hereby authoriec mpmsnutives of this city to enter upon the SEISMIC FIiIi
abovomemin sed pr.,Oy for inspection ImOsOws. PERMH'ISSUANCE
(We)agree to save,inde unify and keep harmless the City of Captious,against ELRCTRIC FEIi
liabilities.judgments.costs and expense,which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE 1 's
in emeequeme of the granting of this permit.
APP AN'f ON DER STANDS AND WILL COMPLY WITH LL NON-POINT AIR II ANDUNG UNIT(To I0,gq CFM) •�1
50%C i iGU MS, �I Q CONSTRUCTION
'CTI.FEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signolure of ApplicanbC tractor ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION M-H
I IAL RDOUS MATERIALS DISCLOSURE.
Willtheopplitiod or future buildin,eccupantstemor lmndlaho...mu,material HEATING UNIT(TO 100,000 BTU)
as definM by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(u)'I HEATING UNIT(OVER 100.000 BTU)
❑Yes C]No PAID
VENTILATION PAN(SINGLE RGSID) pate Receipt#
Will the applicant or future building aecuprat use equipment or devices which
emit hocardous air nnmmitunts as dcC ed by the Bay Arca Air Quality Mawgemeno BOILER-COMP QHP OR 10,000 BTU) TO'T'AL:
Dmtuclt BOILER-COM''(OVER 100.01i BTU)
❑Yes ❑No
AIR CONDITIONER
1 have read el hazardous materials 5,2553 =i under Chapter h.95 al the Call � ISSUANCE D
AT
fomia Health&Safety Code.Setons 25505.is my and 25534.I to nonmwd that if the NEW RESIDENTIAL MECH. SQ.tT.
building does notcurrently have atom,pthat o ismyo,of. co mnotifythe ocupunt
of one rcquiremenu which muco he met prior to i.asauwe of a Cemliaum of Occupancy.
Owner or amh,szod agent Dam TOTAL: ISSUED BY
OFFICE
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