29269 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
RTINO ' . BUIDING-ELECTRICAL PERMITTING.CITYOFCUPRAPPLICATION/PERMIT BUILDING PROJECTIDENIION
-29269 DIVISION PLUMBING-MECHANICAL
IFIC
BUILDING ADDRESS AI
SANITARY NO. 7VL1IN SUBMII'1'AL DATE
4-^ Ca l v G�, T C �i S o It �
OWNS 'S NAME: - PHONE: - CONIRACTUR'S NAME: • LIC NO:•
N/C CONTROL#
RCHITECT/ENGINEER: LICN : ADDRESS: ❑ 'r
-ONTACE - - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB. M17 IT
❑ ❑ . ❑
LICENSED CONTRACTORS DECLARATION QTY ELIECTRIC PERMIT FEE
' I hereby fir the,I an licensed and provisions
' ss of C ,A
or
O�Z en PI 9( ,nn nc ns - '" - JOB DESCRIPTION
with Semo ]000) fl) 3 fthe Bmi e:.cool ksinn.Cd d ylicemes RESIDENTIAL:
f�,OO r. - _ PI:RMI'1'ISSUANCE � -
full f and effw
4U j License Clan Lic.Jr ❑SPDWL ❑PLUM IN RE-PIPE.'
Dare Contracmr APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE-PIPE
=y ARCHI'I ECT'S DECLARATION PANELS - - ❑MULTI-UNIT' ❑STRUCTURAL.
FF.
Z 1 unJemanJ my Plans shall he useda's public recoNs MODIFICATION
OZ—, IIP TO 200 AMPS (]INTERIOR. ❑CHIMNEY REPAIR
r�nF41 Licensed Pndession°I ' 201-I00OAMPS IMPROVEMENT
"
a s❑,-,J�J OWNER-BUILDER DECLARATION
Thereby affirm that I Lm exempt from the Contractor's License 1.0.ter the OVER 1000AMPS ❑BATH REMODI?UREPAIR ❑DEMOLITION
O6V followingreason.(Section ID31.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
which requires a permit to construct,alter improve,demolish,or repay any struaore L 1
pit... 't ` Jso y d ppllc-If 11 ....itr file .g dsimenra SPECIAL CIRCUITIMISC. t'
�<Ffear he licensed prament to the Provisions ofth Connector a LieLa (Chapter 9
�QO frnn y thS cti n]11(1(p tD :in J fm a ss eP f ns CoJc)nr 'TLMP.METER OR POLE INST COMMERCIAL,
It.q ca 2' that he is exempt thercfmm and the basis liar the alleged exemption,Any violation of ❑NEW.BLDG/ADDITION. El DEMOLITION
i� 4th, Section 7031.5byonyapplicant fora peru it,mbjec,deapplicant his civil penaltyof POWER DEVICES ❑TF,NANT FOOD SERVICE
Spnot mora than five hundred dollars(55 W).
Las owner of the properly,or my employees with wagesustheirsnlecompemmion, SWIMMING PCOL ELECTRIC PROVEMEN'1'
�= willdo the work.anJ@eswcture is nm imm�ded ornlrered for sok(Sea]tUJ,Business 0 HER
¢1 and Professions Cn It:The Contractor's License Law does not apply m m,owner of OUTLETS-SWITCHES-FIXTURES _
properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc nm immuded ar offered for NEW RESIDENTIAL ELECTR SQ Pf
side.If,however the houndingor impm,rixnt is sold within one year of coinuction,lhe - SQ.FT.PCUOR A�I EAY $/SQ.ITL
owner builder will have the burden of proving that he did not build lar improve for par- - -
Poseofsale.). - _ I�� 24 .
1,as owner of the property,am exclusively contracting with Ilecntmd
sed nmcmto TOTAL. 6/ ��
construct project(Sec.](k W,Business and Professions Code:)The Committees LI- 96
aaow
seas Liwdocanot apply ,an ner of'uh,ny who Thai Ids or l mpmveslienan and QI'Y. PLUMBING PERMIT FEE u
whoomerans mrsuchprojias whibscoamc i(s)I icenseepursuam mthe Gmimnnrs
License Ln PERMIT ISSUANCE yurCnrlhQ
Ownerscull under Se ,B&I'C for this rcnson
Dam AUfER-DRAIN&VENT-WATERIER) - VALUATION
W RKER'S C MPENSA'1'ION DIKE RATIONBACK FLOW PkUTECT.DEVICE,
crthy amrm under penally of perjury one of the following Jedamtioas:
I have and will maintain a Certificate of Concent to set0insure For Workers Camper-. DRAINS-FLOOR,ROOF,AREA,COND. S'--- TYPE CONSTRUCTION
cation,a,provided for by Section 3]W of the LaMa Cede,for he performance of the
work for which ibis permit is issued 1'IXTURIS-PER TRAP '
❑I have and will nutrain Worker's Comryrnntlon Inmra w,as required by Section
3700ofthe labor Crde,fomhe performance ufthe work forwhich thispemtii is issued. GAS-EA,SYSTEM-I INC'4 OUTLETS
OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Cuvier. Policy No.: GAS-FA.SYS'I'BM-OVBR4(I:A) � ,
CERTIFICATE OI'EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE ORGSF/INDUTML WASTE INTERCEPTOR
(This weimn need not be u,mplemd it permit.+forme hundreedullars is RE) BUILDING DIVISION FEES or less.) GREASE TRAP
PLANCHECK FEL• -
Icerlifyfair in the perLmv:mce ofthe work for which this permit is issued,l shall' SEWEk-SANITARY-STORM EA.21X1 FT.
not employ any person in any manner so tom become subject o live Workers'Compcn- - ENERGY FEE
Z sainn Laws of California.Date
z 0 Applkam - _ WATER HEATER WNF.NT/F.LF,CfR GRAVING IT
IA NOTICE TO APPLICANT:IL aper nuking this Ceniftcam of Exemption,you should WATER SYSTI3M?RGTING
become subject to the Worker's Cnmpenseumt proves!...of the Labor Code,you must SOILS FEE
forthwith comply wltheuch provisions or this permit shop he dcub d revoked.- \ WATEN SERVICIi. O I �a
Q6.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MR. ,.SQ.FT. PAID
V� I hereby affirm that performance,is a construction ling agency for the performanof hate .. Receina
Lks H me work far which this lemon is issued(See.3097.Civ.C.)
Lenders Nanta•UtOTAL:
lenders Address - 'I TOTAL:
1 cenify that 1 have mad this application and state that the above information is BUILDING HE
nFr,(1) o4oba.I agree In comply with all city and enontyordinerces and state lawsrelaingm QTY. MECHANICAL PERMIT FEE
UZ building combustion,and hereby authove representatives ofthiscity roemeru(ian the SEISMIC PI '
shout-mentioned property for inspection purposesPHRM19'IgSUANCE
- '(Wc)agree to save,indunnlly and kcal h...r ess the Cay of Cupenim ngainst 13hBCTk tE
Iiabilities.judgmems costs and expenses which may in any wayaccme against sail City ALTER ON ADD TO MECH,
in consequence of the goal ng of this permit. PLUM NCE'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO In10o CFM)
SOURCE REGULATIONS, MEC AL rE
' - AIR HANDLING UNIT(OVER 10,000CFM) CO U TI TAX
Signature of Applicant/Counwar Dae,,., EXHAUST HOOD(WIDUC) HOUS GMI'IGA'I'ION PEP.'
.HAZARDOUS MATERIALS DISCLOSURE " '
Will the applicant or future building occupants store or handle hicardous careful HUNTING UNI'I'(TO HM.00)BTU)
as defined by the Caperlino Municipal Code,Chapter 9.12,and the Health and Safety
-
Civic.Section 25532(0)? HEATING UNI'I'(OVER I W,tNX)BTU) •• -
[3 Yeas E]No • - VEiNTILATIONFAN(SINGLF.RESID) PAID
nam - Reeelpt a
Will the applicant orin Tatum building occupant use equipment Qu or devices which BOILER-COMP(THP OR 1(0,1100 BTU) -
mit hasadnus air contaminants as define)by,the Nay Area Air Quality Management TOTAL:
ixtrin? '. t
❑Yes E]No I BOILER-COMP(OVER IW.01x1 BTU)
.have read the hoz Nous maedals ntera under Chu terfi95 of me Coll- AIR CONDITIONER
rcquirc p - ISS ANCF,DAT
mean Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does mm currently have a warm.that it is my responobibay to notify the occupant of the requnverwa s which must be met prim u,issuance of a Certificate of Occupancy. ,
Owner or amhonced agent - - Dam TOTAL: jSSUED BY:
OFFICE ,