28643 APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPCi RT'INO I TSU I LDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATIONIPERMITPLUMBING-MECHANICAL ,
BUILDING PROJECT IDENTIFICATION . 28643
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O 'S NAME: e- �H NE: CONTRA R'S NAME: LIC NO:
�.I 1 1 cS r_ NIC CONTROL#
ARCHITECT/ENGINEER: LIC 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 affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO
WOO with Section 7")of Doision 3 ofthe Business and Professions Code.and my license is
PERMIT ISSUANCE RESIDENTIAL:'
C W F- mcensfull elass effect. OSFDWL D KITCHEN REMODEL
Q U D License Class Lic.p
i-ZW Date Comlraclor APPLIANCES-RESIDENf1AL DADDITION [I PLUMBING RE-PIPE
F,7m ARCHITECTS DECLARATION PANELS ARCHITECT'S OSTRUCTURAL
Z O m Z I understand my plans shall be used as public records MODIFICATION
O Z En on UPTO 200 AMPS
[=�E"W Licensed Professional [D INTERIOR El CHIMNEY REPAIR
2oLIW0AMY5 IMPROVEMENT
CYz;
OWNER-BUILDER DECLARATION OVER HXXIAMPS D BATH REMODEL/REPAIR [3 DEMOLITION
1 IY c.Q 1 hereby.(tete thus 1 am exempt from the Contractor's Co License Law for the
IrXd'3 F following reazon.(Section]031.5.Business and Professions Code:Any city'a county SIGNS ELECTRICAL ❑OTHER
m which reclines a permit to consumer,aper,improve,demolish,or repair any dromme,
O� prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
} Births,is licensed pursuanua the provisions ofthe Commnor's License law(Chapteri)
llluo (commencing with Section]000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE IN COMMERCIAL:
a 0,c X Nat he is exempt merefmm and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
X m W Section]031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
[]TENANTW^w TENANT ❑FOODSERVICE
not more than five hundred dollars(3500).
[-ZP - IAIPROVF.MF
pDLasowner o(me property.or myemployees ed oiNwagesmmcirtele compensation, SWIMMING POOL ELE IC
p.. will domesions ands caesium isnotCommunes License
Law offered
not
apply to an
❑OTHER
d 3
cot and Professions Code:The Convamors License law ices not apply to if owner of OUTLETS-SWITCHES-FIX
property who builds or improves Hereon,and who does such work himself or through —V
his own employees,provided That such improvements menu art not intended m offered for NEW RESIDENTIAL ELECTR 7 Now
sale,If. wmhavet inburdenmvementisat cl hedid non build rimprove fon,mc SQ.FT.FLUOR AREA
er-builder will have the burden of proving that he did not build or improve for pur-
❑L m r of the property.um exclusively contracting with ,Insedsuahncontractorsm 'HI'TAL:
consumer dr,projector (Sec form Business it Professions Cod,UThe Connador's and
nae Lawdcesnotapply
roman Elba of mentor who baripurmmpmuse Cothemogona QTy. PLUMBING PERMIT FEE -
whoconuacrsforsuchp jcets wichaconumnor(s)licensed pursuant mthe Conaecwb
License law. PERMIT ISSUANCE
D 1 am exempt under Sec. .B h P C for chis mason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of me following declarations:
D l have and will maintain a Cerificam of Commintto self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND, I
STORIES TYPECONSTRUCON
cation,as provided for by Section 37W of the Lifor Code,for the permarrome of the -
weak for which this permit is issued. FIXTURES-PER TRAP
D I have and will maintain Workers Compensation Insurance,az required by Section '
37M inns,LabarCede.for me performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 O(/TLII'S FICC.GROUP APN
My Workers Compensation Insurance cancer and Policy number are:
Cardec - Policy Net GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR,
BUILDING DIVISION FEES
(This section need not hecompleted iffortunen genet is fortune hundaddollars(3100) GREASETRAP
or less) PLANCHECK PEE
I ccnifythat inch,pMocormucofthe work for which this permit is is.aed.Idall SEWER-SANITARY-STORM EA.200 FT.
cut name,any person in any manner wax to become subject to the WorkersCampion- ENERGY IEE
oZ sationlawsof Califomia.Date WATER HEATER W/VFJJT/ELECTR
Z Applicant GRADING FEE
% NOTICE TO APPLICANT:If,after making this Cenifeare of Exemption,you should WATER SYSTEM TREATING
become,subject m the Worker's Compensation prcritics,of the Labor Gyle,you must SOILS IEE
Wfonhwich comply with such pmvisionsnr chis permit shall he deemed revoked. WATER SERVICE
P
CONSTRUCTION LENDING AGENCY NEW R151DPNTIAL PLMB. SQ.Ff. PAID
UZ Date- Reecipl#
U C) Ihereby affirm mat mem is a construction lending agency for the performance of
me work for which this permit is issued(See.3097,Civ.C.)
u' (~ Lenders Name OTA L:
U Lenders Address 'ID)T'AL:
I certify that I have read this application and state that me above information is BUILDING PEE
F u!) wrest.I.,me to comply wich d[city and counryoNinances and stem law,madirgm QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby contorts,representatives of this city to enter upon the SEISMICFEE
above-mentioned property for inspection par ow, PERMIT IStiUANCE
(We)agree to save,indemnify and keep harmless the City of Catania.nyaimt ELECTRIC FEE
liabilities.judgmen¢,costs and expenses shish may in any way some against said City ALTER OR ADD TO MECII.
in consequence of ilm gm thug of this permit. PLUMBING FEE.
APPLICANT UNDERSTANDS AND WILL COMPLY WIT .I NO - ITAIR HANDLING UNIT(TO I Ik000 CPM) MECHANICAL:PCIS -
SOUPQU Raill LION'.
AIR HANDLING UNIT(OVIiR 10,000 CPM) CONS'I'RUC'1'ION TAX
Sig wren Appli ntnuounmor Date EXHAUST HOOD(W/DUCT) ..HORSING MITIGATION FBI:
HAZARDOUS MATERIALS DISCLOSURE +
L me upplicem ar(muse building acup#nl nmr,nT handle hataNaus annelid GRATING UNIT(TO Email)BTU)
as defined by the Cu,,cftims,MurfApal Code,Chapter 9.12,and the licahh and Safety -
Code Section 25542(a) HEATING UNIT(OVER 100,000 BTU) )
E]Yes F-1No
VEST[LAI'[ON PAN(STNGLIi RLSID) AID Id
,Ilam 'V R,ro,a#
poll th it c r John,M1 l nee ry theupon,use Area
p t devices.wh2h - ""' nIIN _
IFznrdau'a cuss t defined by the llry Are.A' Qally Munvgcmmn, BOILhR-COMP(JI{POR I0I,I0113TUJ rI T(I'PAL:
District - - �. BOILER-COMP(OVER 100,IIBOBTU) -
C]Yen ONo - _ ..
I base commit hamrdoas earned.1 t ts under Cha ter 6.95 of m,Cali. AIR CONDITIONER
yairemm� p ISSUANCE DATE
Extra Health X Safety Code Surfaces 255115 25533 and 25534 1 radcossal hold rhe NEW RESIDENT JAI,MECH. SQ.ET..1 me
building I voliel)h mount, hat r y 0 .1 ib l ty t i lOccr occupant
o[mrequirementsrwhich yea Ipda r faCcn'1 I f0 eoccup.
Owner or authorised agent Dal, 'Ry TAL: ISSUED BY: �1
OFFICE i