S 2253--APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
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CITY OF CUPF.RTINO 'WILDING. F]JICTRICM.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
.BUILDING PROJECT IDE.NTIF'ICA'I' ION -
PT BTNO
2253
BUILDINIADnRBSS: `
SANI'T'ARY NO,
APPLICADON SUBMI MAI. DATE
/2'Z OL
O 'NIiR'S N tl'' PHONE: -
rte'
CONTRACT'OR'S NAME: V I.IC NO:
'
NIC
C(INTHOLM
_
❑
ARC- iTEC'I ENGINEER: LICN ):
ADDRESS: A!N��S
'T/ %�'�
CONTACT: PHONE:
BUILDING PQRMIT NF )
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PL,U._M,BB MF.CH
❑ El L" ❑
LICENSED CONTRACIOR:S DECLARATION
I hvm1h, ld'Brm It,, Iran hramsm ummr liar of Cnaplcr 9 n, te,
Q'rY
ELECTRIC PERMIT' y'
t- _
',NET? '
JOB DESCRIPTION
PF.RMI'I'ISSUANCIi
with Sermon ]IXXp of Division 9 it he Businexs end Prom,,inam Calc, told my licence is
in fail ands 11'I
1Q
RESIDENTIAL,
DSPDWI, D
APPLIANCES- RESIDIiNIUd.
lrao
I.icen Us,.. ����k •9
Dam COyG/N a] G/�--
❑ADDD'ION ❑PLUMNING k1iPIPE
PLUMBING RE
DMUI,I'1 -(JNIT DSTRUCfURAL
MODIFICATION
DIN'1'li1GOk DCHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
ARCH1TELTSDIiCI.ARAd ION
1 undrrxlnnA my plun,.bull he used ds Public rcunds
PANELS
UP'I021)O AMPS
Liceawd Prolcsslonal
201- 10u)AMPS
OWNIiR- BUILDER DECLARATION
I berchy affirm that 1 am ewmpt from the Common,', Locme Law far the
following reason. (Section 7031.5, lousiness and 1'rnfesions Undo Any city or county
DNATII REMOUEI/REI'Allt LD�DEMQLIddQN
D nOO/THE^R'41A -A, FI Al Fie ,
FI�
OVER IINNa AA1PS
SIGNS ELECTRICAL
which mquims a pemul m eon,nm. cute iarprovs. demolish, or repair Imy ,Vacmm
SI'eCIALG ¢GGIT/MISC
III ill svmnca, also moriren lhcnpPh'am farxnchperndlm file a xRnedaemmom
dralhel,hrrnwiih Seuemmlhnpmvi snf Ne Ganlmiiess Ldlct,,e Lnw (Chnpmr9
[commenting avian Sectlon]IMXO o(Divi¢ion3nl the Businns enJ Pmf ions Cndel nr
that he is exempt nc�refmm enJ the basis for ire xlkgcd exemption. Any v;olm;un of
'TEMP. MISIIiH OR POLII INST.
COMMI,DGAL.
El NEW RLDG NG IADDITION ❑ DF:MOLI'I'(ON
Section]IU LS by any applicant fora pemait mbjeas lht applicanun rd,il proalyof
POWER DEVICES
El TENANT E] FOOD SERVICE
not more rain five hommul dalms (E50T.
D I, as miner ofthe pin cal,,ar my employees with wages as their sale compensation,
will do the war k, and Ihexlmmnm knot amended ar offend halide (See A44, Busincxx
OTHER IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECI'R
.red Professions Coda The Com are mr's License law does ml apply m an owner of
OUTLETS -SIND 'S 1'IXURP.S
NEW RESIDENTU il.li SQ PI'.
property who builds or improves Thereon, and wan d 'res w I. wok himself or Ihrnugh
his own cnrployecs, provided [flat such improvements are not intended or offered for
sale. IL hrxesernhe building nr inapnrvcmem issnld within'rise year of complotion.lhe
SQ. FL FLUOR AREA
SISQ. ET.
uer- huilder will have the harden of proving thou he did not build or improve for pury
pose of x,war
exclusively contracting with Ilcc conforriels m
D 1, as owner of the proped44,
l to Cammner,
on the pnrject (Sec. 7044, Business and I'ndbso
,
arimfhe
red
a La ply WOn y holds iml thereon ,and
seLri
QTY. PLUMBING PERMIT
PEIi
who comrars tar such pmjecu wish u nrmmoort ,)license) pursuxm Rr the Conrrecurrs
tar such with a complach icesenti Le the
PERMIT ISSUANCE
Liecnm Law.
E] 1.m emous Under See. . B & P C for This reason
ALTER -DRAIN & VHN'1'- WA'T'ER (EA)
Owner -Date
VALIIA'1'ION
WORnderPCIIM of EcOmy on DECLARATION
I hereby aRma under Penalty of perjury one of she following declarations:
BACK PLOW YROTECf. DIeVIC1?
and will o
Dlhave and provided for ection 3catc ofConwat to
Utfor ade.fum for rIontr's Combed.
,mono, as for by Section 1]IM of the labor Cade, for the perG,nnunce of the
DRAINS - IB (R)k. R(RIIr,AREA ,COND.
STORIES
TYPECONS'THUGMON
kf n'�n lh's p. oril Nr,,umd.
which
11' ill W F :C p 'i i I day Section
FIX9 DRI:S PLR fRAI'
_
GAS I:A.SYSUFMI lNC,40U'I'I.ETS
3981 f1 I'hnr Cod 1 rl I for ,e ft work for n 1dspunan is saved.
IICC. GROUP
AI'N
My W I I I cy(j,qy^ y
Carrier art Policy Nm.u/a�Cn I -R
GAS - EA SYSTEM OVER 4(BIG
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASI]INDUSTRL WASI'11 INTERCEPIOk
BUILDING DIVISION PEES
('Phis xcnion need nil M completed i( the permit le formal hnndred dallms ($II(p
r 1 vx)
GRHASE'I'I1AP
- --
PLANGI II ?CK MID
-
I cliff ythm lathe perk onnanceof the work for wniehunk pcnnil isiaowd. l shall
not employ any Person inony manner �po�J to b rings Wnrkro'Compere-
SEW[R- SANITARY- 5'IORM BA. 200 PI'.
L�
v
ENERGY PEE
WATER HEATER WNEIEVU ECfR
GRADING FEE
all
saiun laws nrral;n,mi:r. n:eo / � �7 O
ApplicamT iIF 41 l�k 1'
NOTICE TG APPLICANT': L after making this CcniOrde of Exemption, you should
her xohiro or he Work,.', C.... wnsarmn pnrvisims of are Lnhmr Code, n o n nnut
WAT17R SYSTEMM RHA'I'ING
SOILS FEE
mnhwim eomply with xhpm,,,,am,or( Ills permll.vfall bedeaned revoked.
WATER SERVICE
CONS, RUC'HOR LENDING AGENCY
I hereby a @ran that them is a canammimn leading agency for the Performance of
NEW RESIDENTIALI'1.MB. SU. F1'
PAID
Dore
'eiPap
the work for which This pcmrir is issued (See 3097, Civ. C.)
IcndrA Nmna
TOTAL:
Leader's Addmxx
'IY
f
.rV
BUILDING I121i
I our, the, 1 have read fans application and ante that she above information is
comer. l agreed comply wimall city and county ordinances and .state laws relating,,
builAing nmsrmninn, and hereby authorize rcpmxnlvrieee of this city m enmr urym the
Q'IY.. I' MECHANICN.PERMIT.
FEE
SEISMIC PEP
PERMI "r ISSUANCE
ELECTRIC
above - mentioned properly for inspection purposes,
live) agree la, Iva, indemnify andkeep harmless the City of Copartner against
PLUMIIIN 19!
)
Iiabilioecjndgmenl'c ndcxpcnseswhichnmyirl ywaynccoma,dns,caIC,q
' ssepumrcen , m�llir . of lh;a I air.
APPLICANT .1) 1'AI US�Y! IMPLY WITH ALL NON -POINT
SOURCP 'ill. DNS
ALT ER Olt ADD TO MECI I.
AIR HANDLING UNI'fp'010.u00CPM)
MECIIANICALIIiE
AIR IJA GUNI'1' )(M CFM)
CONSTRUCT ION TAX
,i
Sigamrc of Applicant/Co ctor Date
HAIgARD 1115 MATERIALS DISCLOSURE
EXHA fi/ ffiOD ( I
HOUSING MITIGATION FEE
Ifl;Ad ' 1NWITO I ol,don IITII)
Will fhem,pade,ml or lnluru hadding ocmrpanl vale or hnndla h'ardins malminl
as de0ncd by the Capenina Municipal Coda Cha9ucr 9.12, and the Health and Safety
Cole, Section M532pd?
HG G UNI1'It OAR1o'(410 BTU) ^
C3 Yes No
PAID
VE ry' ./G ION FAN (S I NGLE RE;- 0
Date kecciplp
H IP`E (3HP OIt Illl,lll`A) BTU)
'
Will the applicum ear fumic building occupad use CQaipnmm or devices which
coil bazurdon,mfmnmmineel,a, defined by We Bey Arc. Air Qnula, Managcmmn
B011JJi -COMP (OV
Dislricl'1
❑Yes C] No
AIR CONDITIONER
I nave read the M1anlnlou, nmmrials requircmm�ts sander Chapmr (� 95 of me cell.
forma health & Safety Cole, Sort inns 25505, 25513 and 25534. 1 mrders and that if I I
b.idingd,RSnotermallyt vculcnunerM1Uril is rn,no. pnnsi bilify lonolilylhcoaupanl
ISSUANCE DATE
J % -
NEW RESIDESH Al, MUCH. SQ. Ica'.
of the rcgnimncnlx which mull be met prior to i,watme of Ctnilinac ofOecupere,
/
ISSUED BY:
TOTAL:
Owner or awborized agent Dare
OFFICE.