S 0197 (2) CIIFFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
TYOF CUPRT NO
ItUILIHNG-KLEC1'RICAL IIiRkE r NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0197
BUILDING PRUTEr IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(J In/gebI , er4j'n0 GR, 950/4
OWNER'S NAMEPHONE: cowritAcrolt'S NAME: LIC NO'.
Rio r r 6 2 G / Q 37233 NIC CONI'ROLp
•ARCHIIEC'UhNGIN ER: LIC NO: ADDRESS:
ES ` `t ❑
0DR 1 , J
CONTACT: PHONE: BUILDING PL'RMI'I'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LI.11 PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECrRICPHRMIT •E
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing
JOB ESCRIPTION
QW004Z with Sectinn]Ilfl()of Divisiun3ofthe Bu.sinessand PreferrinusCde,and myliccnw is RESIDENTIAL;
III p PERMIT ISSl1ANCli
QWWU infullClass add effect. CSFDWL El KITCHEN RIiMODEI.
U�j License Class Lie. APPLIANCES—RGSIDEM'IAL ❑ADDITION O PLUMBING RIS PIPE
F.ZZ W Datc Conuocmr
Va 2, CMUI:1'I-UNIT El STRUCTURAL
Om ARCHITECPS DECLARATION PANIi1S
O p 7n. I i nderamnd u plans shall he used as public records MODIFICATION
O Z�p UP'f02f1(IAMPS ❑INTERIOR El CHIMNEY REPAIR
r lot Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS 0 BATH RF.MODEUREPAIR 0 DEMOLITION
5 Q 1 hereby uf0nn that I roes exempt from the Contractor's License Law lin the
WU following remon.(Section]031.5,llminesx and Professions,Coll.:Any city of county SIGNS ELECTRICAL ❑OTf11iR
which requires if Permit m construct,alter,improve,demolish,or repair any structure
HBO prior to its issuance,also requires the applicant for.such Permit file a signed nmm
eent SPECIAL Cl RCUIT/M ISC.
E} net he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
CA (commencing with Section 7M))of Division 3 of the Business and Professions Core)of 'TEMP.METER OR POLE INST. COMMERCIAL:
6 d c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDL'fION 0 LEMOI.I'I'ION
IA Scecion]O315hy any applicant fora permit subjects the app to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
FZqnot more than five hundred dollars(S500). - IMPROVEMENT
I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
SS will do the work,and the showhem is not intended or offered finsmle(See 1014,Business HER
ul
m and Professions Cade:Thc Commcmr's License Lew Jces net apply m an owner of OUTLETS—SWII'CIIF.S—EIXTl1Rli5
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvcmems are not intended sur oRernd for NEW RESIDENTIAL ELECTR SQ FT.
nate lf.however.the building or improvement is cold within one year efcompleticiLI SQ. I'.hhODR AREA USU�FT
ownecbuilder will have the burden of proving that be did not b ild or improve for puts
E,sm]1 of smeJ.
0 I, f rne.). of the prnpeny.em exclusively convecting with licensed cnmmmnrs m TOTAL'
construct no projoet(Sec.7044,Business and Professions Gde:)The Contrdcntrs Li-
cense
i-c se law does not apply to an owner of property who builds in lmprovesthernm,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a communist licensed pursuant.the Cnmracuse, s
Licerae Law. PERMIT ISSUANCE �/ Ca
0 Iain exempt under Sec. .B&P C for this reason F/
ALTER—DRAIN&VENT—WATIiR(f•A) /
AT ON
weerOW
Du
KER'I COMPI!NS 10 LARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations.
O l have and will maintain a Cenifice.of Cnnseni to elf-asurc for Worker's Compen- DRAINS—FLOOR,ROOIy AREA,CONIC. STORM /�Q 'TYPE CONSTRUCTION
ration,ex provided for by Section 3]00 of the labor Cade,for the perfamance of the '1•
work for which this permit is issued FIXTURES—PER TRAP R�
0 I have and will maintain Workers Compensation Insurance,os inquired by Section a
37Wofthe Labor Cede,for the performance of the work for which this permit is issued. GAS—PA.SYSTEM-1 INC.4 OUT LES OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number are:
Cerner, Policy No: GAS—EA.SYSTEM-OVI:R 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GR BASFJINDUS'fRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section fired not he completed if the permit is for one hundred dollam SH10) GRT:ASETRAP
it less.) PLANCHECK FEE
I cmtifythat inthe pefornare.fNe work for which this permit is issued.I shall SEWER—SANITARY—STURM HA.20F IT.
not employ any Person in any manner so as to become subject it)the Workeri Compen- ENERGY HE
Z
sation Laws of California.Data WATER HEATER WNENT/ELECTR
z Applicant GRADING FEF:
NOTICE TO APPLICANT:IL intrinsical;this Certificate of Exemption,you should WATER SYSTEMTREATING
become object ,,the Worker's Compensation provisions of the labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
{J 0
CONSTRUCTION AGENCY NEW RESIDENTIAL FUME. SQ.IT. PAID
f0n
]z (hereby mn that
em isixaconstruction lending agency for the perfnrmawe n( Uma R ciplN
U� the weak for whichmis per mit is ixsued(Sce,3097,Civ.C.)
I" E" lenders Name 'TOTAL:
O Ulenders Address TOTAL:
LL I rectify that I have read this application and since that the atone information is BUILDING li
fA v.,l reportto comply with all city and moot,ordinances and scam laws refining. QTY. MECHANICAL PERMIT FEE
(.> building construction.unit hereby authorize mpresemhnivexof this city mother upon the SEISMICFEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree 1.swee,indemnify and keep hamlexx the City of Cuperim,against ELECT RIC PEE
liabilities,judgments,mast and expenses which mayin any way accme against said City ALTER OR ADDI0 MEC H. PLUMBING
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10AX)CFM) MECHANICAL.FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.011)CFM) CONSTRUCUONTAX
Sigamme.1A,10,11faCcuorwhar tat EXHAUST HO)U(W/DUCT) HOUSING MITIGATE) EE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam m fmure building nwupanl s..c or handle hsmolis s material IEEAI'INC,ON IT(TO I00,N)(I BTU)
as defined by the Capitation Municipal Cods,Chapter 9.12.and the Broth end Safely
Code,Semmes 25532001 HEATING UNIT(OVER 100,"BTUI
O Yex -1 No VENTILATION RAN(SINGLE RESID) PAID
Data RmciplN
Will die applicant or fmure building mecepted use equipment of devices which
emit hazardous air contaminants as deOnM by the Bay Arcus Air Quality Management 110I1.ER—COMP(3HPOR 100,0)BTII) 'TOTAL:
Dcs.at^ BOILER-COMP(OVER 100,000 BTU)
El Yes Fl No
I have and the locaudnns materials requirements under Chapter 6,95(if he Cali- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code,Sections 25505.25533 and 25534.1 understand that it the NEW RESIDENTIAL MVCIL SQ.ET.
building does not currently have a tenant that it is my responsibility to notify the occupant
of the requirements which must he met prior to issuance of a Cerifico.of Occupancy.
Owner or authorized agent Doc TOTAL ISSUED BY:
OFFICE