S 3204 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUI'IiRTINO ..... ars-ELECTRICAL Pit]
BUILDING DIVISION APPI,ICKPION/1'F,RMI•F I'LtIMItINI:-MI!CIIANICAL v 3204
BUILDING PROJECT 1 FIF'1 ,'II(.
BUILDINGADDRESS SANITARY NO. APPLICATION SUBMI FIAL DAI'1'.
OWN17K MF' HUNG CO TRAC AME: LIC NO:
pN/C CONTROLp
ARCIIIIEC19ENGINEER: / LIC NO: ADDRESS ❑
CONTn 1': 2 IIUA:, (/lyHBUILDING PHRMIT INFO
r �/// `" � ❑ Consultant Fees Paid by Applicant(Initial) L G ;LECr PLUMB MIiCH
LICENSED CONTRACTOR'S DECLARAI ION QTY 17LECTRIC PERMIT FEE
I hands aif....that[;at,licensed under ,pmdshms of chapter v(commencing JOB DESCRIPTION
O ISSUANCE
witltSnyiun 9B(NII of Division Iol'thc Hu.InassnnJPmtcsstm C+ a.imd illy license Ts R IDENTIAI,;
W zz PIEHMI'f
CWF + full force unJ Cllcn.�s 1,0 �SFDWI. ❑KHCHFNRHMODHI,
QUU License(' lir Lica / ' / APPLIANCE[.S-RESIDENTIAL ❑ADDITION ❑PLUAIBINCRIT-PIPE
H z W Oath �� JContrn< —a`
rn<6 CTS DECLARATION [:IMULTI-UNIT El STRUCTURAL
~.z I understand my plans shall be uml a%public mN
o
cns I'ANGLS MODIFICA'T'ION
OZ=O UP TO 2M AMPS ❑INTERIOR [I CHIMNEY REPAIR
Liccmcd Pmfcssional 201-11XItIAMI'S IMPROVEMENT SWIMMING POOLS
C C Q 1 heathy alTinn OWNER BUILD Gam the CommlON emr's Liccnu Law fnnhe OVER 1010 AMPS �BATH It13MODIB/REPAIN ❑DI?MOLITION
q W y city or county SIGNS ELECTRICAL ❑DTFB?R
iC 3�F Mch following rearm.(Section111911.1 L5,Bnsineas and Pro&scrods Codex, t t
lin which reyuircs a pernnt to mnslmcl altar,improve.demolish,or rcpuir any awcwre
0.1 prior, t: 1 rel th ppfc tf such pc tl fl 6 dwhanand SPECIAL Cl RCUIT/MICC.
E , that he licensedr a (I r Db C t t r L 1' (Ch Ptcr9
ta+1 001on b ihS,, 7SXp fllJsi 1 til B . exe dP m,,i 'Cxlxlor DMI'M.Et FR OR POLI:INS'I PR 1 1
6601' that he+ c pt therein and the bill (h allged exemption.+t./uy ailed(of of ❑UiMOLI'
Xm_W Section VB31.5 by any applicant for a proud subjects the applicant m a civil penalty of POWER DEVICES 1'I' ❑F(R)UIS F:
W notmorcthan five hundreddoll...S500).
F'SdLus owner of the n la 'mwvs punsa imt. 1 VIr.MEN'I'
L ❑ � Props y.unny clop Ycas wtt 6's ns their lulu tato t SWIMMING,1'UOI. .LIiCTRIC Of +R
E. rill do the work,and theamcmm limit ntended ors+Bcted for sale(Sec V(W,Moines
jLjjj
Lam Pro
and fessions CtNThe e Contestersos
License Law ds not apply as an owner of OIfIT.LTS-SWI'I'( F -FI IBES
property why builds ry improves thereon,and who deo such work himself or through
his own anployev,Provided that such itnpmvi n oaf,are nal intended m ot'lered lar NEW RESIDIENTIAL . R SV k'1',
sale.If.however.the Wilding or improvement is sold within one yoridvarnpletinn.the IS(}PC.II.Uf IR ARI?A 5/S .I*r.
Ely
ser miller will have the burden of proving that he did not build or improve for par-
posxin malal
).
Dol.as owner of the papery,am exclusively connecting with IicenneJ eontmanm m 1
construct the ponpan(Sec.AW.Businms and Professions Cast The Comc¢'mr's ra-
cc,,v Law does nmnpply a+ten owner of prolixity who bind.%or improves thereon.and QTY PI,UMBINGPE IT FEE
who conamclsfor such pmjecis with u comtramoos)licensed puruanuo the Gmuae(ors /
Llccmc Lon, PERMIT ISSUANCE
1 an,exempt under Sec. .B&P C for this reason
ALI'17R-DRAIN&VENT-WRIER(IEA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DIEVICE
hereby nl'Brm under penalty of perjury one of the follow ingdarker' ns G•
�IM1uvumJ will mainluina Ccnifculwtl Concent n+uclLlnsurtfrWnrkcrs Gmtpcn- IIRAINS-IsLOOR.NOIIF,AREA,COND STORIES 'I'VI'Ii CONSTRUCTION
sution,as provided for by Section 37110 of the Labor Code,for the pcA+mtance of the
wink fill which thin Pcm ,is ism al. FIX -PLR TRAP
el 1 have and will tnairoun%Walker's Cwnpennatiun Imurxnce,an«alai red by Section
permit is i....e GAS-EA.SYSTEM-1 INC.401ALFIti
my n(me Ledo Coxla.for(hc perfurnm cxof(hu work for which this d UCG(J2DGP AI'N
My N'n�q;r a tlnsurnnce brole,Isicyn M� Z GAS-EA.SYSTEALOVER 4(EiO S
Cu a Policy Nis `1 Y�
CER'1'IFICATIi OFF ;.ME]ION FROM WORKERSGREASIVINDUSI'RI.WASTI:IN'II:RCl11'IY)R
COMPE1QSAfION INSURANCE? 13111LUING UI SIONfyilE$
frEff-cetionneednot hicaut ctcd ifthe .it is fore.hundred dollars(SIM) GREASE*1'RAPPLAN +C 2 r
or lcsx.l ' � .
I eeae nify that in the perhanniaofthe work lixwhich this Perini(is issued.I shall SIEWER-SANITARY-S'FORM EA.200 Ff..
not employ any poen many manner so as m Wc.,.,ubjcctlo the Worker'Compea- li ' OY F.'
.ween Lnws til Calih+mia.Il:nc WATER BEATER W/VEN LELEC
Z B O ANTImiml G DI .FEE
N(XIICE rO APPLICANT.If.after making this Cenificaw of Exemption.you should WAIER tiYS'1_N oTRHXITING SOIL.' THE
become subject o the Wodcrs Compansmion pmyNmas of the WMsr Cote,you inust
�+
her hwith comply with such provisions rat this pernnt shall be deemed moss n{. WA'T'ER SERVICE
D Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDWNTIAI,I'LMH. SQ.ITT
I' )
"U- 'x - [ending pli Uatx Hxceiptp
UO If..wlaftirm that there 30 lcndin for Hnmwnce of
CI. F the work rat which this purtni(is IssntJ[Sec.31101,Co.Cd nal:
Icoders Name
V Icndch AJJms I-I ox
r I«nify that I have real this application and state that the aMwe information is BUILDING FEE
o-F-t y umceLlegmc lu amply with all city and comity oNimurtcs and.ewmlaws nitningm QTY, MECHANICAL PERMIT IEE SBISMICFI'
U building aonsteaction.and hereby mutnormarpresentativesafthis city toemer upon the
above-motionedro
pperly for ire"'inacn....... PERMIT ISSUANCE IihE F '
(We)agree In save lndenmify and keep harndess the City ul'Cupenino agnlrrst
hahll'nies,judgments.casl�and expenses which may in any way accrue against said City ALT ER OR ADD IT)MECH. PLUMBING FEIi
in nsegaence of the granting of this Permit.
APPLICANT'IINIIF.H STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IBW0 CFM) MEiCHANICALFEE
SOURCE REGULATIONS.
AIR ItANIILING UNIT(OVER 111.001 Curl) CONS'1'HUCf10N 'AX
Si, PP mnnUCnntraanm Ilam EXHAUST HOOD IWIDUCI'1 HOUSINGMITIO TIONITEE
HA. S MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle Ir...Wommaterial HEATING UNIT CIT)100.00011 I'U)
;is Jutined by Om Cuperti no Mmnicipul Code.Chapter 0.12,and the Health and Safety II EATING UNIT(OVER IgUXXIBTU)
Coale,Section 255320)1 rtY
i�Yes yC'^ VIENfILATION PAN(SINGLE RI&SID) PAID
�a time Raeipt x
Will the applicant or Emum building occupant use equipment or devices which BOILER (HIP OR 11X,100)Ill U)
mit h:oarJous air asmmormots as dc0oed hY the Bay Arco Air Quality Managumcn( 'Idyl'
District! BOILER-COMP(OVER 101,100f)HTED
❑Yen
1 have th mad the h all,Se tions 2 5 5,1553 To under Chapter 6 to ill(he Call h
AIR CON A I ION 11114 ISSUANCE DATE
Inuld Health on Safety Code,Sections 25505,25,ay teed a,dmI 1 understand that if the NEW RISIUfiNT1AL M1tECII, SQ.ITT.
of me radocsnoncuncnth must n met prior
istryre.gn+.ilan we ofytheoccupant
of rtyuimn¢n(s which mus(he nrtl prior m issuwm ill n Cxnilicmc of Occupancy.
Owner or all rved agent Elate ISSUED BY:
FICE