30352 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO. �O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICA'T'ION
352
I �DRESSyI �Lb` is
SANI'PARYNO. APPLICA'I'IONSUBMfRALDATH
U NAIvtF / ; �'BD .: _ CONTRACTOR'S NAM^ LIC NO:
NIC CONTROL#
ARCHITECT/ENGIN:F:R: /`/�I S..LLIIICC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby anion that 1 that IicensW under provisions of Chapter 9(commencing JOB DESCRIPTION
G tYz with Section 7000)afpsition 3,fmw Business end Fiction...Cadc,amdmylicenseis
cW, O PERMIT ISSUANCIi RESIDENTIAL:
F. in one Class
effca' ❑SFDWL ❑KITCHEN REMODEL
�VpLL.I1 License Class .Lie# APPLIANCES-Rh'IDENTIAL
a� Date Coniruear []ADDITION El PLUMBING RE-PIPs.
aM ARCHITEC'PS DECLARATION ❑MULT4UNIT []STRUCTURAL
P� I understood m tans shell bt used blic recmd, PANELS
[F.. YP, as Pu MODIFICATION
OZZ
UP-02A VS ❑INTERIOR ❑CHIMNEY REPAIR
[=4F� Licensed Professional 201-I PS IMPROVEMENT
OWNEon exempt
DECLARATION
I hereby,(Sect on 1 um exempt from the Contractors c,Amyx Law for no OV I 'S - ❑BATH REM h 1
G U following reason(Seaton 7031.5, t, i et,imp Professions h,or Any city nr county SI LGCTRI ❑OTHER
Owhich rcyuires n permit a uirms the
applicant
improve,demolish,or repair any mssnm �SS n 0V-
that heor to slits cenedp...onreyuiresmopplrno the wchractor mBleneLa (statement SPECIAL CIRCLE'i/ �d �6-OV-
that
`
thm he is licensed pursunm mthe provisions of the Contmcbr's License l,uw lCM1apser9
u1p00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.M O 'OLEI T. COMMERCIAL:
L 6 0
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
-,so Section 7031.5 by any applicam for o permit subjects she applicam toe civil penal,of POWER D Cay
} rot more than five hundred dollars D5W). T" ❑TENANT ❑FOODSERVICE-
e D 1,as owner of the pmpcny,or my employees with wages as their sole compensation. SWIMMING POOL. LE IC IMPROVEMENT
O will do the work,md,h , ui isnot imamdalor offered for mle(Sec.7044,Buslnws ❑OTHER
mad Professions Colc:The Cuntmctar's Lnemm Law does mol n,ply no un owner of OUTLETS-SWITCHES- UR S
" property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvamcnts are not intended or offered for NEW RESIDENTIAL.ELEC R SQ FT.
sale.IL however,the building or improvement is sold within oneyeonofmmplulom,the SQ.FT..IRAORAREA- S/SQ.EL
er-builder will have Ne burden of proving that he did not build or improve for par-
, pose of sale J. ,
❑ L m,theer of the Sitepro,cory,704 am exclusively matauding with. ...licensed comc.-s 1. TOTAL UG J
erose La the es project(Sao. o an owneBusir
of nope property
won
o hatar,Code holua C,almaon,and
V V 7,
cense Lawdoesrnapply man owaaon not or
a uccnuc Wsrsuant to the thereon, rd Q'PY, PLUMBING PERMIT FEE ss�
who contracts fur such project -nnvucnr(s, icensed pursuant the Contractor
License law' PERMIT ISSUANCE
❑Ire exemplum ,9&YC for this reason
.Owner Date ALTER (I!A) AN 12 '199-'TION
WORKER'S COMPENSA'HON DECLARATION BACK FLOW PROTECT.DEVICE
Ihereby affirm under penally of perjury one of the following declensions: sr s 1
❑ IM1uveomwillnniintoinuCusiticnm nl Cnnxenno sdGinsure iia W,rku's Comput- DRAINS-FLOOR,ROOF,AREA,COND' � "'S,pONIPS� 'I'VPII CONSTRUCTION
sml.n,is provided for by Section 3710 of the Lahor Code,for the performance of the
work far which this permit is issued. FIXTURES-PI!R TRAP
❑ 1 have and will maintain Workers Cumpemsution Insurance,as required by Section
370).f me Labor Code,forthe perfomwnce,fthe work for which this permit is issued. GAS-EA.SYSTEM.]INC.4 OUTLETS OCC.GROUP qPN
My Worker's Compensolion Insurance carrier and Policy number am:
Cartier: Polity No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEM PITON FROM WORKERS'
COMPENSATIONINSURANCE GREASFANDUSTRI,WASTE INTERCEPION pUI1.DING DIVISION IrRF",5
(This section neuJ not he completal it'the#,roll is(ornate hundrW Jnllurn(SI 007
or less.) GREASE TRAP
PLANCIIECK PEE
Loy anylhoninthe,my summer
the work Car subjectch io#,noir ikes'Compn- SEWER-SANITARY-STORM EA.2X1 FT.
not employ any perm in any manncr.w m m hccnme subject m the Workdre'C,mpcn- ENERGY FEL?
0Zvishmewsof Califomia,Done WATER HEATER WNE-NT/ELECTR
z 0 Applicant GRADING Isl!1!
yyy NOTICE TO APPLICANT'.If,eOer,making this Certificate of Extinsi,n,you should WATER SYSTEM/TIY 1!ATING
a [^ to o err mhjeal o the Worker's Compasmlo,pooislons of the Labor Cole,y.0 mol SOILS FTSE
Ft1 G f,nhwith comply wishsuch provision,or this pdo it shall be deemed revoked WATER SERVICI!
Q
0.
CONSTRUCTION LENDING AGENCY NEW RESIDEM'JAL.PLMB. SQ,FE PAID
L)0 Ihereby affirm thenhere is ac.nstmctinn lending agency for the performance of Date Roca 4
Us P: the work for which this permit is issued(Site3097,Ci,C.)
0 Lenders Name If TOTAL:
Wlender's Address TOTAL:
I certify thin I have read do,.,,I cal iot trod stone thnl the above bfoi
de ,n is BUILDING FEE
V0.') correct.I.,ow to crnnplywllh all cityand....nly onfinances and swm lows relatingro QTY. MECHANICAL PERMIT FEE
U Z building cricancsion,und hetebymwhoniou epresenmtivesafthiscity to enterupon the JMFOATION
above-mentioned pmpcny for inspection stipends.
(We)agrce kouc,indemnify and kap harmless the City of Catania.against I'[RMITISSUANCE llabilities,judgment,costs and expenses which may in any way accrue against said City pt.TER OR ADD TO MECH.
I.consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IQ(KKI CPMI
SOURCE REGULATIONS,
AIR HANDLING UNI'P(OVER 10,000 CFM) 'PAX
SignatumofApplicanVConimnor s Data EXHAUST FOOD(W/DUCD ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicat or future building com,n to..,handle hamN.is mmerial HEATING UNIT TIO 100,0010 BTU)
os defined by are Colombo,Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 255320? - , ORATING UNIT(OVER IW,f10B BTU)
❑Yes FI No VENTILATION FAN(SINGLE RESID) PAID
Bute Receipt p
Will the applicant infurore building by the muse ea AirQn.rdeviceswhich _
;mithazanlous air contaminant as defined by the Bey Area Air Quality Management BOILER-COME(3HP OR 100,000 BTU)
District? TOTAL:
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
I have read the hazuNous maleoielsm requirements under Cho tar b95.f the Cali- AIR CONDITIONER ISSUA E DATE
q P
Tornio Health&Safety Code,Sections 255115,25533 and 25534.I understood that if the NEW RESIDF,NTIAI.MECH. SU.Ff.
of hitthisog does nalss hirh have atenant,that it ismyce ofosCeniycteof. the oacu,am .�
of the requirements which nmst he met prior h:issuance of a Certificate nl Occupancy.
OwnerorauthnnrcJ a gent - Data 't ISSUED BY:
OFFICE