B0280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
BUILDING-ELECTRICAL PERMIT NO.1?0 2 8 O
CITY DI CUPVISION PLUMBING-MECHANICAL L VX
BUILDING DIVISION I APPI,ICATION/PERMIT xlnl,lHNc rxDJEcr uH:NTIelcrcDUN - SOQ�I
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
118-3 1 Lk 0&
I OWNER'S NAME: PHONE: COQg ICTOk:S NAME. LIC NO:
1)ll NIC CONTROL#
�.ARCI HTECT/ENGINEER: LIC NO: ADORES
❑
46
CONTACT: �uT+6tif L(4.S)U //-�/- PHONE ILDING PERMIT INFO
HU .
-r1Jr(6i ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB .MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT
I hereby affirm and I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z th Section 7(XX))hf Division 3ofthe Btamassand Professions Code,and my license is RESIDENTIAL;
LL100 sen PF,RMIT'ISSUAYCIi
F-E,. in full force and dTcd _ ❑SFDWI. ❑KITCHEN kIiMODF,I.
<UU license Class Q 1.ic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIS PIPE
F Z W Umc Camracmr
`ae 4 cc ANCHITECFS DECLARATION MULTI-UNIT ❑STRUCTURAL.
I.p m PANELS MODIFICATION
Oh Z I and...land an,plans shall he used ns public records
Z=� UP TO 21X1 AMPS ❑INTERIOR PUIUMNEY REPAIR
I-�E"u: Licensed Pmfessiunul 201-IgM1AA1P5 IMPROVEMENT Ej SWI.NMING POOLS
y•.LTJ
OWNERBUILDERDECLARATION OVER❑)(M)AMPS ❑BATTI REh10DEUItIiPA1 !❑DT:MOLITION
C C d I bemhy iffiem mat 1 vin exempt from the Comracthrs Lkense Law for the
apu1U 1-1 OTHER 7- .
3U.Ffolk g (Section'In315 ct dP n Code:Any ua county SIGNS L'LI CTRICAI.
m¢ which q pe I I I nt all r p e J m F.h p' a y.t cmrc �-
C•�0J Exch t t m F qurt th pplc (for uch pc uo nears rda meta( SPECIAL CIRCULDMISC.
9gp p. Ihuth 1 dp rsu ml 1h p un ftM1 C t t L W (Cha mr9
IyC�p Isom ncrettgw'th Section 9(XXp ufDsision 3 ofthe Business and lrhfevsion.Ctole)or TEMP.METER OR POITIH COMMERCIAL'
d
a2 C Ihat he is emmpl lhmefmm and the basis per the allege)exemption Any violation of [D NEW BLDG/ADD["PION ❑DP.MOLI'I]ON
�-m Section 7031.5 by any applicant for a pertnit subjects the applicant)a civil penalty of %NEWRE
ICES El TENANT ❑FOOD SERVICE
not more than five hundred dollars(551X1). IMPROVEMENT
E=O ❑ I,as owner of the property,or my employees with wages as their sole compensation, POOL -.ECTRIC [I OTHER
p. will do the work,and the structure is not Intended om0iad for sale(Sac 9044.Business
W m and Professions Code The Contractor's License law does not apply 10 an owner,of CHES-FIXTUR
e. Exropeny,who builds or improves thereon,and who does such work himself or through
Itis own employees,provided that such improvements are not intended or oxeted for NTIAL ELECTS Il'.
sale.If,hooter,the boldingor impo mincnlissold within mr,ycounf,enlumion,the SQ.FT.pLO�SR x SISQ.FT
owner-milder will have the burden of proving that he did not build or improve for par-
pi fsale} �I�1c
1.as owner of the property,ant exclusively contracting with licen.md contmmurs m TOTAL: JUL U 7 EN
c ntsouct the project(See"10,14,Business and Ponessi^ns Code:)The Commemr's Li- -
t nc Law J«s not apply tit xn owner nlpmpeny who hnlIds crimpeoves thereon.and TY. PLUMBING PERMIT
whatonoansfn"ach projects with a contractors)licensed pursuant mthe Comearturs CITY OF Gurrfu It-0-
License law. PERMIT ISSUANCE _- -----
IT I am exempt under See. ,B&P C for this reason
ALTER-DRAIN&VENT-MINE PH(EA) VALUATION
Own^= Dale ..p
W'ORKER'S COM1IPIiNSAT10N D[CLARATION BACK FLOW PROTECT.DEVICIi / /_L✓��
. I hereby affirm under penally of ExcrjuO-one of the following Jeclamti^ns: (� /
❑IM1uveonA will mamminu Ctnificatc u(Cohsenut)srlftittsure fur Worker's Compen DRAINS-FLOOR,RUDE.AREA,COND. STORIES 'fYYP.CONSTRUCf10N
s^ti^n,as provided for by Section 37 W of the Labor Code,for the parforntaneo of the
work for which this permit is issucal. FIXTURES-PER TRAP
I have and will maimain Worker's Compensation Insurance,as required!by Section
3700 of the Labor Code,foram perfommncr of me work for which this pe-it¢issued, GAS-ISA.SYSTHiM-I INC.4 OUTLEC OCC.GROUP N'N
My Wnrkets j�p��en��''''li�n lnsu n rand Policy y�bh1ar'
Cumco_�TZa2(a� aY,�nnir Policy No.:nL '��I I`I S, GAS-IiA.SYSTEM-OWR4fl?A)
CERTIHCN£OF EXEMPTION FROM WORKEEpRS' 7(�/q qk GREASIANDUSTRL WASTE FERCEPfOR
(This section need me brearmleted fhIFION N�mRpNis fonm�fid'W�d(SIW) BUILDING DIVISION IVES
e GREASB'fkAP PhnNC1IECK FEE
or less.)
learinythal inose,iformanccoftheworkfnr which this penmg is iaaued.I shall SEWER-SANITAR STORM EA.200 FT.
temploy any person in any manner m subject as to become subjeco the Workers'Cnmpen- ILNERGY ME
Z caion Laws of Caliburn-Data WATER HEATF,5hNENT/E1.ECI'R
z2 Applicant ) GRADING I:EE
[n NOTICE TO APPLICANTI If,after making this Cenlficme of Exemption,you should WATER SYS .`AT REATING
become subject m p
the Workers Chme^smioo provisions of the labor Code.gnmust —ust SOILS FEE
{afJ forthwith comply with such immisiomorthis permit shall be deemed venture. WATER. RVICE
Q
CONSTRUCTION LENDING AGENCY NEW I?SIDENTIAt,PLMB. SQ.FP. PAID One ksseipt K
U O 1 hereby affirm that hem is a construction lending agency for the perfnrma^ce of
CS. F the work for which this permit is issued ISO.3097.Cie C.)
O Lender's Name
U TOTAL:
r {f-1 Leader,Address TOTAL
y 1 renify that 1 have martins application and ame that the above i^foenalion Is BUILDING Il?B _16i
F h chmm.I Ogres wct)mply with alldry and county otdi^antes and stain laws relmingm QTY. MECHANICAL.PERMIT FEESEISMICRiIi /,��
UZ building construction.and hereby uniform representatives of this city to enter upon the
above-mention it p r peny for inspection purposes. PERMITISSUANCE ELECTRIC FEE
(We)agree at save,indemnify and keep homeless me City of Cupenlnu-Inion ,
liabilities.judgmenu,eels and expenses which may in any way acme against said City ALTER OR ADD TO MECIL PLUMBING FEE
In consequence of the grunting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOORCE RIiGULN1'IONS.
AIR HANDLING ON['[(OVER 10.000 CFM) CONS-11RUCCION'FAX
Signaturcof Applicanl/Comreemr Date EXHAUST GOOD(W/UUCn HOUSING MITIGATION FEE
HA9.ARDOUS MATERIALS DISCLOSURE
Will the applicnt in furore buildingoccopanLstum or handle ra-mous nwland HEATING UNIT(101(X),00)BTU
as defnal by the Concoct,Municipal Ctdn.Chapter 9.12,and the Health and Safety
Code,Section 2553200? ` HEATING UNIT(OVER IW )BTU)
❑Yes (�'o VENTILATIONPAN(SI LERESID) PAID pate Reeeiplp
Will the ap,licom or future building occupant use equipment or devices which BOILER-COMP(3 OR IM.0 0 BTU) ,J
mit ha=arJous air ammminan s as defined by the Bay Area Air Quality Management TOFAL:
Distad^. BOILER-COMI OVER 10(1.(X10 BTU)
E]yes (➢To
have the hamrmrequire
dme, umdals is number Chapter 6.95 of the Cul,- AIR CUNDITI Nlik
rid ISSUANCE DATE.
5yk
fomla g does&Sdery tryCode.have
Sections,Him i 25533 and 2sibili I undersfanh Lha if the NEW RES \TIAL SUCH. SQ.FF.
building does norourtenlly M1ave a tenon,Na it is my responsibility nt notify the occupant
ofthemyuirent Lichnoon lmmI enol jssuunec of a Cmjfiorgrup nty.
Owner moon ug=^t Date TOTAL: ISSUED BY:
_. OFFICE