99070061 A,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q Q�
CITY DI GDIVISION Rt111.BDING-ELECTRICAL ERMITN
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
CTNIECHANICAL
FIC
BUILDING PROJECT IDtNI'IPICATION MEW
BUILDING AUUItESS: n- ,n SANITARY NO. APPLICATION SUBMITTAL DATE
6 V L� J W� �Z `73
t "'NAME.n ,�ax.��/\r. HONE: _ ` CONTRAC'LOji Sg`lAt1@! LIC NO
IM-1i L.."U 1"' b,IT'\,p_cMy I l//1 VJ IN_(if N/C CONTROc�Lp
CHITECDENGINEER: LIC NO'. ADDRESS: ❑ 3�� J
CONTACT: PHONE - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED COMPACTORS S DI C ARAFION QTY. ELECTRIC PERMIT FEE
o z Z 1 nearby afar n,h t l 1 dad v .of chapter 9(wouncmem, JOB DESCRIPTION
Ih Section]B00)of Dwi:wn 3 rfthe B cin aPr l son,code,and m Janie,, RESIDENTIAL:
F1_ in full tome and effect PERMITISSUANCE
tit— ❑SFDWL L)KITCHEN REMODEL
UF` License Class Lic.M APPLIANCES-RESIDENTIAL ❑ADDITION 7)PLUMBING RE-PIPE
y 6 a Date Contractor
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL,
OZ=Z I understand mypluns,hall be used.,pmalicare d, PANELS MODIFICATION
UP TO 200 AMPS El INTERIOR LJ CHIMNEY REPAIR
Licensed P"ficeinnal 201-I000AMPS IMPROVEMENT L)SWIMMING POOLS
Z be W OWNER—BUILDER UEChARATION OVER 1000AMPS ❑BATH REX ODE: {2F 1 61 ,ITION
C C Q 1 hereby affimt the I am exempt from the Commetor's License Law for the C. A
cc -41
3 a fidhnving reason.(Section]1131.5.Business send Prolrzsimns Crate:An}city or army SIGNS ELECTRICAL OTHER
a y which requires a permit m comnwct,alter.improve.Jemoli.eM1,or rcpaia any,maser, W A V,
F�-OQ prior to its issuance,also ines the applicant for such proof to file a signed statement SPECIAL CIRCUIT/MISC-
y_ that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
WnC) (commencing with Section]g10)of Division 3 of the Business and professions Cale)or TEMP.METER OR POLE(NST. COMMERCIAL,
a a0 oe that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C1DEMOLITION
Section 7031.5byany.pplicmu for a permit subjects the applicant acivil penalty of POWER DEVICES [-]TENANT m [-]TENANT ❑FOOD SERVICE
m more than fore hundred dollars($5007.
F Z Y OTHER IMPROVEMENT
_Q
1,as work,
theproperly.
some emyemntended or offered
for theirsale solecompcnsmimn, SWIMMING POOL ELECTRIC
W, will doohearval Cade The
Comianms License Law
rotaply to(anwner of [I OTHER
I-
a 3 m amt artdesiob Cale:The nn,ficmre License I do docs not apply m an owner la OUTLETS-5001'1 CHES-FIXTURIiS
his own who builds or improves therm,ane who nut a such nwork deed or f through
his own employers,e pmvieW that such mentis old ware not intended offend for NEW RESIDENTIAL ELECTR SQ Ff.
sale.IL however.the building or improvement i,told within one yemof completion.the SQ.Ff.FLOOR AREA bISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for per-
p,a of tale').
1,as.,act of the prol%'ny,am udu,ivaly con:nefor,with Ikrnsed,en ran",to I-OIAL:
constrat the project(Sce70,1A.Business and Profccsions Code)The Comment,I Li- - -
wm Law does nor apply man owner of prnprny who nail.,or improves thereon,and QTY. PLUMBING PERMIT FEE'
ho controls for such projects with a conaatads)licensed pursuant to the Conlrecior's
License Law, PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WOH ;HS CO PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
lw'ner
1 6Y ff n p 'I fpeprylhfollowingdI' 1n: v
n.
II d '11 'nt aC it temfC ii :If nen f N ke:Carioca- DRAINS FLOOR,ROOF.AREA.C'ONU. STORKS TY�ONtiIR CT10N
,,Ifni p 'd J f by S t' 3](10 of theLabor C d 1'a nt p rf a c of the 11
''////✓✓//11
work for which the perrni :issued, FIXTURES-PER'TRAP
❑ 1 have and will nu min.Workers Compensation Insurance,a,required by Section 11
3](X)of the LaborCWafor the per4smmance of the work far which this permit is icsuW.
GAS-EA.SYSTEM-1 INC.q OUTIFfS OCC.GROUT' All
My Worker,Compensation Insurance corder and Policy number me: q
Cartier: Policy Nm.: GAS-EA.SYSTEM OVER a(EA) J'" (n.3
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSI'RL WASTE IN'TF.RCtiYIOR ��
COMPENSATION INSURANCE - BUILDING DIVISION FEES
la"')(Thi„ecdon.acdoot Is,completed fthcpcnsil is Tartan hundred dollar,IS H(B GREASE RAI' qJ
ar PLANCHECK FEE
I unify that in the sr-fornance oftbe work far whichan,permit is Lamed,I shall SEWER-SANITARY-STORM EA.2W)FT.
not employ any permit in any mannano as m become subject o the Worker,'Cmnpcn. ENERGY FEE
Q Z no.laws of Califon"..Date WATER HEATER W'NENT/ELECTR GRADING FEE
72 Applicant
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSIEMn BEATING a SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Cede,you most
fonhwiM comply witM1 such provisions onhis pennn sM1all be deemed revoked WATER SERVICE
4
U z CONSTRUCTION LENDING AGENCY NEW HESIIl1iN'flAl.('LMB. SR f'l'. PAID Ao Receipt p
U p lherebyich histhat
arms,itv.cad(Sea onlcnding agency fnrthe pediannina of
D.) U he work Na whichthixpermil is issued(Sec.JfN],Civ.C.)
1<ndcrs Name TOTAL'
U Landers Addres, TOTAL:
r I rectify that 1 have read this application and slam that the above information is BUILDING s Q
Fy correct.l agree in comply with all city and county ordinances and sure laws relating to QTY islECHANICAL PERMIT FEF,
U Z building construction,and herehyautherin representatives ofthis city toemer upon the SEISMIC FE m/70
alaor-mentioned pro,my fur inspection purposesPERMIT ISSUANCE
(Wit)agree m save,iWemmfy and keep hurndcss the City of Cupcnino ngain,l ELECTRIC FF
Ilabllitie,.judgmeats.atxu and expenses which may in any way uwmmg.inat mid Chy ALTERORADDTOMECNPLUMBINGE2
asequence u(the gmming of Chia permit N 6
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM(
MECHANICAL FTi
SOURCE REGULATIONS.
19 AIR HANDLING UNIT(OVER IBM) CONSTRUCTION TAX
Siga A '.ntlContmor Dm EXHAUST HOOD(WNUCI) HOUSING MITIGATION FEE,
f1ALAH1�OUS MATERIALS DISCLOSURE
Will theupplicant nr ler
or
bmIdin,cxv,. .menae ser handle hazuNou,marnriol HEATING UNIT(TO[W.”BTU)
as defined by the Cap.nlnu Mun kipal Code,Chia,.9.Rand the Hc.R.can Safety
Code.Section 25532(a)l HEATING UNI'('(OVER IlXL,,,13'IU)
C]Ya, 7 N PAID
VENIII.XHON FAN(SINGLE RESIDE Data Rmmpta
will the applicant or future building occupant use equipment or device,which
mit bazvdous air contaminant,a,defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I W.WU BTU) TOTA
De,mrl^l CJ BOILER-COMP(OVER 100,1X0 B'TU)
0 Vat
AIR CONDITIONER
[haveIthe M1 d t tats Tey c d Chapter fi951thc Cal ISSUANCE DATE
fariaHealth
bulli He❑h&Safety
try Cl Sections 25505,2553y3 :M1 25534,
551)t I understood
h hattit
ttire
RI' IIII
NEW 7SN'UAL MECIL SQFT
7
of the men t abet reformat....necofa Ce Leas u may.
011e011tar par al6odzW agent TOTAL( ISSUED BY:
OFFICE J