99110017 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY v (-J L
4CONTACT CITY OF CUPE RTINO HUD,DING.FECHA (CAT PE "'No —
BUILDING DIVISION APPLICATION/PF,RMIT DING P OJEC7 FIDZNTICAI -
BUILDING YROJF.OT IDENTIF'IC'ATION
ILUING AUUIt F.SS SAFHARV NO A//PLICAfI 1'1'IA OAI'F a / /2- # D fY,#tFIO � 2 Q 9 N13R:SNANIE' PHONE: CO IItAC'I OR'S NAME: LICNO I
�-�2 NIC CONIROLM
CIIITECT GINEER LIC NO ADDRESS-7B! tT*'SPE2 S;N
: PHONE: _ D ILDING PERMIT INFO
•��n ' r L+/-x^ may. +) y/J_ e ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT Pt.UMH MECH
fD,�— ❑ ❑ ❑
LIC17NSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am Licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
M=Z woh Sceaon]artmof Din hnthe OUaneas and Pmfessiann Cade.one my LCense its RESIDENTIAL'
WOO PERMIT IS,
g4 y)M Drems re mid effe,.t n ❑RPD WL 1P-N RIiMOUEI.
Q,UU Date Class l.icX i�/ APPLIANCES-RESIDENTIAL ' I ❑ADDITION ❑PLUMBINGRG-PIPE
LF,, W Date — Cnmmc w+ lcX--
r� L ❑A1UL1'1-UNIT' ❑MODIFICATIO
ARCHITEC I:9 DECLARATION
st„O y I UP TO S /1 MODIIICATION
y p�Z I undemmnd my plans vhdl be used u public records 7
OZ�� UP T0200AMPS IN'I PRIOR ❑CHIMNEY I21iPA1R
Lwensed PnNc....lol I 201-IB(N)AMP$ IMPROVEMENT SWIMMING POOL$
OWNER-BUILDER DECLARATION OVER IfM10AMP5 BATH REMODELREPAIR El DEMOLITION
IY Q 1 hereby allimt that I am exempt frnm the Con'etlor's License Law for th• I O _
0 y U lollowmg reason.(See( a 703 1.1,Business and Pooleaslnnx Code.Any any ar uamY I SIGNS ELECTRICAL ❑OI HF-R _
WO priormns�usanc�alsoreguireshecall rainfnsuchperonhofile signed statement ' SPECIAL CIRCUIT/MISC.
M that be is licensed pmoart to he provision,of the Conviclor's Lucose Law(Chapter'
R
a�q0 (commencing with Secom,7 00))of Def,u n3o f the Bauncs,end Protesmns Code)nr TEM P METER OR POLE INSE
i4 w°,y that he is exempt therefrom and the base for the alleged exemption.Any vmlanot,of DG/ADDITION ❑DEMOLITION
Ito Se..aon 90315 by at appincvm for a ,rnat soNuu the applicont m u civil Penalty of POW(? ' C ❑FOODSERVICE
not m no than fivc hundred dollmx($500) IN OVEMENT
Q El I......troftbe propert,or my employees with wages as their sole compensation, SWINI. :L.I' 14
3 Z0 wdldo the work,and the amemre i,marnonded oraffend larmle(See 9044,Emm�aw II!R
and 1'ro(exmnas Cade.The Contractor's License Law does not apply to an owner of /n OU'I'L RIVET 11=1 -FIXTI IREIIIIIIIIII0
property who hudds or improves thereon,and who does such work himself or through
his own employees,prtsnded dim such unprovenwola me not mranduf or oflomd tar NP,W RESIDI IAL I w.
sale if,however the bmldmg or improvement is sold within line year nfcomplelion,the FLOOR AREA 950.FT.
owner-budder will have the burden of proving that he did not build or improve for pur-
pose nfnaleJ
1,as owner of he property.am exclusively comranmg with licensed contractors tit Olin'
oosaaa the project(Sec 7044,Humneas and Professions Code)The Cartel Li-
rose Low does nr toppl,amownerol properly who hu0ds rnmproves h....r,a,it QTY. E
white allicu for such projects wnh a conlremr(d licensed puramor to the Contractors -
License Law. /w PERMIT ISSUANCE
❑ lain excropona er Sec .B NS P C for this reason — -
- I �ALTIiR-ORAINffi VENT-WATER II'A) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK PLOW 1'ROTSiLT.DEVICE J w,
er l'Iierebyaffimiunde rpenahyofpc0comem Ocif fol.refor ookca'inna: I I I �// no
'Qur,asatidwdOmaime SOcromificmeof the Labor Codefin for Workers Compete- I DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTkI1CT10N
otlnn,its provided Tot by 9 lwa 3"100 of ilia Luhnr Cnda,innhc pcnfovriwta of d —
;�1,r and'vihrs pennd rsi Winkle I / PIX'NRES-PER TRAP
have and will maintain Woders Compensation Irtxurno. m required by Section ( 1 Q
3900ofthe Lahor Code,for he pednrm,mce of he work fryer whmh,hk,comt iwarosd. GAS-IA SYSTEM-I INO4OUTLE'IS 1 OCQGROUP S 7AP�/
My Wurkc�,�C At� v)F� aniPaleyth/ b � ��� GAS-EA SYSTEM OVER 4(EA) I CV/
Carrier. ZS'
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRL'ASF/INDUSTRI,WASTE,INTERCEPTOR
(Tans section need not he completni tithe perms is forone hundred dollars($100) BUILDING DIVISION FEES
or less.( GREASE TRAP I PIANCHECK FEV
I certify that in he performance of he work lorwhich his penon is owsi,I shall ( SEWER-SANITARY-STORM EA 200 FT
not ereploy any person in any manner sit m to became suhjeO ROhe Worked Camper. IiNERGY IiE
Oz s.Iwn I.ww1cf Cd1fwro,Dmx WA)BR DEATRR WNENT/ELECTR (GRADING IRE
z O NOTICE TO APPLICANT If,after making this Ccmficam of Exensption,you should
y WATER SYSTEM?RF;ATING I SOILS FI'+t C} I
abeeomc subject y the Worker4 Caiou,nsmmn Perot s of m he tashrt C«le,you iron• ,,,•�•". ^ lul
'p{S7 ImnM1wih comply wrth such provisions ar this pennii shall be deemeJ revoked WATER SERVICE
d CONSTRUCTION cH ng t NEW RESIDENTIAL I'iMB. SQ. T, IPAR
7Iherehyrirm that th.. s. leading fonlm pcifnt oure of Data Rcccipt0 Ann
Whe work for whch his peman is Issued(Sce.3097.Civ C.) A' +
lenders Nan•• /�
LUF7 Lenders Adinx _ TOTAL:
1 comfy that I have read hrs apphcalun and site ilia'the atwve information,, I I HULL C,FEE
i..+.,[�j!1 corzeeLlagrtt so comply wish all city wastewater,moment mWssase laws relating tnl QTY, MECHANICALPERMIT FEE ISlilti� ''
V r7 building conawepnn,end hereby vuhons rcpm+enmuves nl this eny menter upon the _� =>�--J
abovomemmmed property formspenmn purposes /
(We)vl to nave,vmcmwc ly and keep barmless the Cny of Cipriani o+sgm PERMIT ISSUANCE no, ( ( 1E.c., me
Inahlhacs,mdgn¢nts.cost,and expenses which may many way accrue against said City ALTER OR ADDTO MUCH.
PLUMBING FEE
c of the ofINN permt.
APPkICA NT UNDERSTANDS
AND WILL COMPLY WITH ALL NON-POINT I AIR HANDLING UNIT('(01(1,010 CPMI MECHANICAL PEE
S01 :E REGULATION.S�.
AIR HANDLING UNIT(OVER I(l,fl(NI CPM7 CONSTRUCTION OAK
\Nsig dMire oJ'Applmant/Connector Die ` EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
// VV HAZARDOUS MATERIALS DISCLOSURE t
Wdlon,i'heamorma..huddmgecc'emaow,ter handle Initiation,mmennl HEATING UNIT ITT)f IN),n(1B BO U)
as dclincd by he Cmperuno Municipal Code.Chaper 9 12,end he ftralth and Safety
Code,Section 2353200' HEATING ON]'F(OVER 100.000 BTU)
CYca No OO}
VENTILATION PAN(SINGLE RESTD) (PAID a LIV
Dais Receipt
Will he rippl¢am or furore budding occupant ass equipment or devices whch i
•- BOREK-Camp aHP OR IWJHID BTU) I
♦xnn hamrdovs air cnmvimnants vs tlefned By he Nay Area Art Qu:dliy Management .I
Uisulm'I
Ydx NO HOLLER-COMP(OVER IM.00013TG1
❑ ❑ � l
T I lure;read the ha.dausmWerials oNtorements under Chapter 695 of the Cali. I AIR CON PIT ION BR I I
ISSUANCE DA
formagdoes,fr Safety Cale,entenat,that.2553]and 25534 Ito nolifytheontitheI NEW RFSIU[NTIAI.MECH. SQ IT.
bmldmg deeseem, hick aveotenem,ibmnrsmy cards Crinyrsinotifytheoccupom
rf the mw which muv nisi pnmmissaunce ofe Cenifieule of Occupancy
wit imbm1 ;1' Date I - TOTAL ISSUED BY. r—
OFFICE