S 2540 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFE
NO RUILDING-ELE,CI'RICAL PERMIT NO.
N1111.U1NAPPLICIATION[PI':RMIT PLUMPING-MECHANICALS 2540
BUILDING PROJIC1'IDENIIFIGATIONHUIIIANGA QI qK q VID D� SANI'I'nItV NO. AI'P ILIO/SUIiM11 ,DA'I'li
OWNii 'S AM ' - C N'1' n 'S sit 1 CN N/C CONTROLp
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`�'rCO�ACI:
ARC IiCf/i?RCINIiIiR: LI NO: AI Dyl:" c (/L.n za 0 \ id
PHONE U n�'I VC.I BU ILDING PERMIT INFO
❑ Consultant 17ces Paid by Applicant(Initial) RL❑DO Iil.1❑?CT I'LUMH btll❑CI{
I,ICIINSIiUCONTRACIOR'SDI:CLARATION VU QTY ELECTRIC PERMIT FEE llrTIO/
1 hereby afilnn but I am licensed under Provision.of Chapter 9(commencing JOB DESCRIPTION
�Q'Zestion70XJaI DiVlslnp3onhe nuxincs.nnJ Pmrc..ion: aEc.and mylicense in RESIDENTIAL:
H C Intl tiucc.nut cRcw. PERMITISSUANCE ❑SPDWI, ❑KITCHEN REMODEL
CWF .n
aUU Licclu�CI Lica AYI'LIANCES-RESIDEN'I'I Al, ❑AUDFI'ION [D PLUMBING RIiPIPE
y<i DuudLSa J—t—� Cnmructor
ANCHITECPS DECLARATION PANEIti ❑MULTI-UNIT ❑MODCTGRAO
z o ll I understand my Plans shall he used as public records MODIFICATION
OZ�
UP*10 ❑
0200 AMPS INTERIOR ❑CHIMNEY REPAIR
M
I,iccnsull4nl'e"ionA 201-1000AMPS IMPHOVFiMI:N'1' SWIMMING POOLS
�Y�'j OWNER-BUILDER UIiCLARAI'ION OVER RNNIAMPS ❑BATH REMOOIdJREPAIR OHMOLI'IlPON
—y C W 6 I hereby affirm that 1 am exempt from,he Comracan'.License I,aw lin the ❑OI HER
X C a U fallowing reason.(Section 7011.5.business and Pmteasionr Cede:Any city or county SIGNS ELECTRICAL.
W 3 4 ya which reyuire%a permit m construct.altar,improve,denudish,or repair any tmeare
LL'
IC' C.J pour,on, I... .the applicant far such N It rile a signeda¢ment SPECIAL CIRCUIT/MISC `
Wj� mattm is wee,ed1 tt 'he p ..... f,hC r I Law(Chapter9 COMMERCIAL'
WaOC (courncreng wilh Sur.7000)ofDivision Jnfine rim aand ..
ss aPr f - lar,C,s rFMP NIHI'1?R OR POLL INS'I'.
a a e W that he is exempt therefrom and the basis for the alleged csemp,ion.Any vinialum of ❑Nli\V BLDGL\UUII'ION ❑DEMOLITION
Wim Section 7071.5 by any applicant fora pem,i,subjects meupplican,my civil penalty of POWER DEVICES 0117NANT ❑Tom SERVICE
fnot more man five hundred dollars($500).' IMPROVEMENT Z0 ] Las owner of the pumeny,or my employee,with wage.as heir anlccumpcnvtinn. SWIMMING I'OOLIii.ECi'RIC OOI'HER
will do he work,and thu.nucalm is nor mc n led..... rcJ litrmlc l5ccJIIJ4Iluwncc.
W 3 m and Pro lereions Celflie Contractor..Liana:Uw mese%nal apply or xo owner of OUTLIHIS-SWITCIIIP I'UIt1J5
property who builds or nnproves thereon,and who does such work himself or through IA S RI!SII - V
his own employees,provided,hat such improvements vee nal intended nr offered for NEW I.T.
sale.IT,however,the building or impinvelletn is sold witorran,year of completion.the SQ.PI'.FLOOR AREA 5/NQ.NI
ur-hudder will bait the burden of proving that he AIJ pro
ml build or into for pur-
Iss"of,sale.). YEA
I]L.a.a owner of,he unit am exclusively contracting with IieenuJ contractor.net
unstruct the project(Sec.'AW.liusinevs and Professions Gsle:)Me Contractors Li- !�.
x Law does not apply to an owner of property who bm
builds or impvea thereon.add QJ Y. PI,UMBING PEhYyN FEE
who contracts for such projects with a contractor(s)licenced pununnnn the ConionelaIII
Liccnsa Law, l`ERbi FIISSUANCE
❑ I an uxernp,under Sec. .R&P C for thin rc lou.
ALl'IiR-DRAIN&VIiN'I'-WATER 07A) VALUATION
Owner Dae s:
WORKER'S COMPENS AI'ION DECLARATION PACK FLOW PROTEC'E DEVICE
bendy.11"Inoa..under penalty of pa'rjury one of the following drel Worker,inn. �p��
� IhuveanA will.nnirnmm�Cenilicum of Convent b.nelhinrum for Waded Cun,pen- DRAINS-I1,00R,HOOP,AREA,C(INO. Ny f3' 'IYI S'1'Hl1Cl'[ON
,allnn,as prov.ded for by Seel or 171X,m Ill,Lvhnr Club.Ino the wrE'nrntunle of he
work for which this permit is issued. PI%'1'URIiS-PER'FRN'
I]1 have and rill maimain Weiser',Compensation hemmnec,as retained by Section
370X1 of the labor Calc,forth,pedomunttofhe work for which this Perini[I%issued. GAS-HA.SYSTEMd INC.a OUTLETS TOO) `N
My Wo -r',Ce ry:�la,yon er�Pallcy�cyyg�/ GAS-17A.SYSTEM-OVVR 4 CA) LO
ry 1 yytt a.mt .�TJi b
card,. 1� I(' h/1Pri1Ylf y RO
GEH'1Ip1CA117 OI'E%EMI'I'10. PROM WORKERS GREASI%INDUS'IG.WAS'I E ENTERCUVIOR
COMPENSATION INSURANCEBUILDING DIVISION '
('Ifii.,section need nn,be atmdeall ifhc permit is for one hundred dollars IS Ih% GREASE'I RAPPI
or Icss.)
Ioy ,,,lhm in the Ndnnna11ar-art work lot which this phe Wokes Clausen-
SEWIiN-SANITARY-S'IURM EA.2fN1 Jr,
nm e.tgtlnY unY Nn nr.y.n nann.wmbcannc nuhjcet net the Wudcn.'Compen_ IINENGV pIJi
Z ..tion l ows of C.difomiti.Data an WATER IIHAI ER WOVEN'1'/ELECTR GRADING PER
Z0 Applicant
V) NOTICE TO APPLICANT:If,after ma4.ing,his Cenibcate of Exemption,Ynu should WAFER SYS'IEM(FREAI'ING SOU-S PER
F becnnte subject a me Worker's Coupenaoinn pmvicur,of,he fahor Cede,you ma
��. forthwid,chop, th.encl, sur this Nnnil nb'ull he deemed rcvoAed. WA'll?R SERVICE
y wi p...for n
QPAID
5z CONST"RUCTION LENDING AGENCY NEW RESIDENI'IAI,FLMIi, Q.il'. Raceipta
U C) Ihereto,effimub0rahere is a vorwarainn lending agency froth.perfnmunee of
R. F 'he work for which this Nount is issued(Sec.7097,Civ.C.) 'TOTAL:
C) U Lenders Namc T(p
W I.—III',Address BUILDING Tillr
y ecnify that 1 have read his appticallon and Mate That the above inBumaion is
� too) cmrcc,.I agree no co Italy with all city and county ordinances and slate laws refining to QTY. MECHANICAL PERMIT PEE SIi1SM1 til:
U Z build.,sam,tratertior.rand hereby earhoriee repmsemalives'If this city Or anal upon the
abovcmemionel Prnp,nY for inspection purposes. PERMU ISSUANCE ELECfRI FEE
(Wc)raga,m save,inJcrnm(y unA Accp hurnilcsv,hc CitY of Cupcnino ugaina �1
Pabititics,luJgtmuI.nal.and cxpen,I,Is ich.,try in:nsy way allme algal 1111 said City AL'I'iil<(IIt ADD'10 MIiCiI. PLUMPING :I?E ( v
in vwyurnce of,he 6mming of Ibis permit,
API' ANT'UNOI?HN'I'ANI AND WILL COAfP1.Y WI'T'H ALL NON.POUTI AIR I IAN DUNG UNIT IROCICFM) MECHANICAL I,
Com`y}K( ECU LATIONS. !J� ///��I
NRIIANDLING IJNI'1'fOVF.R 1(1,1X18 CI:M) CONSTRUCTION INS
Sib. rent NppllnanVCantmcan 1 > / Ea
OOD(WMUC'I) HOUSING MI'I'I(IA'I]ON,lilt
I IALARDOUS MN"ERIALS DISCLOSURE
will he applicant or future building tmvpunuare ur handle h...rdnuxtnaerial IT(TO 100.00,BTU)
ac defined by the Criterion Municipal GNc.Chapter 9.12,and the Health unit Safe', IT(OVER IIXI Il(p BT'UICala Section:5512(0)1❑Y� N PAN ISINQ,IiRENIU7 LAID
Umc Rccei Pr q
Will the applicamor furore building uecupt use cyulpmenl nrdeviee%which MV(3HP OR IW.000 BTI))mit hazardous air cnteaminenas as defined by the Bay Area Air Quality Management District,' / OMP(OVER 100.IMX1131 U)
�Ve< IYNI'
AIR CONDIITONEIt ISSUANCE DATE
I bout wit the h0mrdon.nmarinlX rcyuimnrenN under Chupar M195 of the C-11-
morin dealt,&Safety Code.Sections 25115.25533 and 2551.1 understand that if the NEW RESIDENTIAL MECII. NO.MY
o —(
huilJin oRcs no,cuncnlly havcaamanL hOt it is mY tc.IXmsibiliry atnaily the ccuNnt
th o, moots whichm Mac,Pdur at issuance nfa CeniBcm ul(kcu
e0
r � U
'I OTA1,: ISSIIU
¢ D Ii Y:
OFFICE