99090131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY el_
CITY OF CUPER'flNp Bun,Dmc-eLEc'ratcAh - B D �/ PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 7 'w, J
BUILDING PROJECT IDENPIFICATION,', g;, Ip St P
BUILDINGAUDRESS, - SANITARY NO. APPLICATION SUBMITTAL DATE
OWN 'SNAME: {ONE: CONTRACTOR'S NAME: LIC NO: r
NIC CONTROL#
RCHITECI'IENGINHER; LTC NO ADIIRESS:/ `{'/� 16 J1E4_ ❑
CONTACT: PHONE: ,i,+- , 'j ',BUJLDINCITERMIT INFO - n
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ KY ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRICPERMIT FEE , '
I hereby ulTirm that 1 licensed u d p f Chapter 9(commc ns 1. - '+ �. JOB DESCRIPTION
a��Qa IZ with Sal..700oafD '. i ftheHmi v Jtro@assnsCalc and my license is RFBIDENTIAL:
in full force onde c PERMIT ISSUANCE
Q V V Licens �'+ hie,p , ❑SFDWL ❑KITCHEN REMODEL
yQG Dme �Comr APPLIANCHS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
1„ ARCHI'T'ECTS DECLARATION PANELS ❑MOI.TI-UNIT ❑STRUCTURAL
Z I unJmtand my plans shall be used as public records MODIFICATION
c Z.., UP'I'020nAMPS ❑INTERIOR ❑CHIMNEY REPAIR
r,4 f'm Licensed Professional - 2014000AMPS IMPROVEMENT
❑SWIMMING POOLS
OWNER-BU arts I .a,DECLARATION OVER 1000 AMPS @
I hereby nfBmi Ilial 1 uta exempt Truth the Cantrnnadx License Lnw for me El REMODspFL/REPAIR (]-I�EMOhITIO
x4x 6 V following reamn.(Semon 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL OTHER A.IK � Ji A
u13 O F wbeeh inquires a Permit m construct,alcor,improve,demolish,or mpair any structure fw r
��y lemro,it,issmmce,alsnealmolsthe applicaul tai such pennit m flea'ined smmman SPFCIALCIRCUIT/MISC. 777
p. that he is licensed pursuant tothe previsions ofthe Commcmrs License Law(Chapter9
W (commencing with ScOnse9flIXBnf Division 3 ofthe Businessand Professiml CedOof TEMP.METER OR POLE INS'T. COMMERCIAL:
TY p,o C
that he is emm,n ihemRmn and ilio basis for the.11ce.d uxemptiml.Any violnion of ❑NEW BLD(:/ADDITION ❑DEMOLITION
W^LLN, Section'7tt
03 L5 by any applicant for a permit subjects the applicano a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Znot mom than five hundred dollars(S500).
Ea0 ❑has"no,,I eny,
the propnr Tny employees will,wages as their sale compemmimn, SWIMMING POOL ELECTRIC IMPROVEMENT
IS;F will do the work,and thearucture is not inmadedproffered for We(See7004,Pusinexs Of Ek
3 and Professions Cndc:*Hhe Contravenes Liceme law dlna not apply m an be,of OVILEB-SWITCHFS-FIXTUR&Sstil
propeny who builds or topmves demos,call who does such work himself ar Through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. t
wle If,however the bolding.,iniprocrovin is wild within me yeurof eomplmimthe ((� SQ. 4'Ir OR ARE S/SQ.FT.
owner-huddet have the burden f provingthtl did nothmlA or mpmve fo pu I
pose of sole) r
❑1,as owner of the pr perty am"elusively t i g vith 1 caned contract tinTOTAL: t SEP 21 19
construct The project(S 9044 B d P f ins:C de)The Cmem U - - - - '. -n s (�
lease lawdoes a apply to of property h b Id:ormprovesTender ad QTY. PLUMBINGPERMIT FEB 9J
who contracts for such projects with a commaons)licensed pursuanno the Comranmes -
Lice Ise Law PERMIT ISSUANCE 1/
❑ I am exempt under S . -,B&1'C for this reason 1
Owner
ALTER-DRAIN&VENT-WATER E 1) N3A1]D�'
Dine
WORKER'S COMPENSATION DECLARATION BACK HOW PROTECE DEVICE
1 hereby affirm under penalty of perjury one of the following declarmions:
I Trove cold will Tneimoin aCenlfirnm of Conswnn set(-insure for Worker's Cnmpen- DRAINS-FLOOR,ROOK AREA.GOND. STORIES TYPE CONSTRUCTION
station.re,Provided for by Section 37W of the Labor Cale,fm the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1T
have and a main or Worker's lame of
w hr,anrkfor hi h his ler by Sssued.
-�0 !the LaburCNe.lnr the pert rmuncc of the work for which this permit is issued. GAS-fiA.SYSTFM-I INC.40UTL[il'S OCC.GROUP p��N
My WI4"s Cg t -fa earn manner and PolicyyyPPatl+er � .,,'iY
Came Pnlic Nnu ZA.60DIOI GAS-PA.SYSTEM-OVER 4(EA) V [
CERTIFICATE 01'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CREASFJINDUSTRL WASTE INTERCEI'1'OR arm a& BUILD INGDI
' VISIONFEITS'js S d
Thissealm,need naheamlplHediflhelwrnitiafnrnnchandreddel... SIBd)
or lmsJ GREASETRAP
PLANCH[CKFEE
I ccnify that in the peAormance of The warkfnr which this permit is issocJ.l sM1all
naempin SEWHR-SANITARY-STORM EA.200 FT.
y Tmy parson in any manner an ar In become subJen to the Workers'Cnmpnl- ENERGY FEE
,� soon li D -
O O A 1[ WATER HEATER WNI?NT/BLHLTR
pP
-aC L ` GRADING FEE
pj N(YI'ICI? APPI.ICAN'I: ,afle making this Ccroficme mf Exemption,you dared l WATER SYSTEMRREATING
a ; become subject to Ne Worker's Compensation previsions of the Labor Code,you must SOILS HE
W foMwith comply with such provisions or this pemtit ebull be Deemed revoked, WATER SERVICE
Q
DCONSTRUCTION hENDINGAGENCY NEW R[SIDENf1ALPLMB. SQ IT. PAID
Lj 0 k for
hill,nn that then ise ed(Suni30 lending agency for the perfnfmance of Date Receiplp
W [-I the work for which this paTmil is isaual(Sec 31N].Cil CJ
V Lender's Name
W 1<nJ AJd TOTAL:
(A Ic nify thin a,toco p mad des pandc nand din that able laws roti '.v - ) x. BUILDING FEE
y correct.I g t ply 'Nall city J ry ordinances and stain laws relate g t QTY. MECHANICAL PERMIT FEF
U Z build' ,c...omelets,and lambyumhnnze repremmemi,es of this city to enmfupon the SEISMIC FEE
move-mcmioacd proper 'm impation PTTrpose, .
(We)agrec lr. ,indemnify and keep hmmless the City of Cupenino against PERM I ISSUANCE ELECTRIC FEE
Iiabililies,c"gmento Iso an apenus which yin any way accrue ngvn Isaid City
in coms"do of In go This - AL'T'ER OR ADD TO MECH. PLUMBING FEE
APPLIC NT F AN AN W .L CO I W H ALL NON-POINT AIR HANDLING UNIT(TO 10,OW CFM)
SOU 1 S. MECHANICALFEE
/ AIRIIANDLTNGUNIT(OVF.RI(Ip000FM) CONSTRUCTION TAX
S alone nfAPP-an Commcmr Date EXHAUST 1400D(WMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicerma,uture buildingmccupamsmt,ver handle hazardous material HEATING UNIT(TO 100,10)BTU)
as defined by the Cupenlne Municipal CWc,Chapter 9.12,and the Health end Safely
Cede,Sarion25532(a)9 HEA]ING UNI'I'(OVER 100,000 BTU)
Dyes a VENTILATION I-AN(SINGLE RESID) PAID --
Date Receipt4
Will the air nam it furore building by the B use equipment or device.v which BOILER-COMP OHP OR IMOM BTU)
mit haznNous air comaminnms as JefnW by the Bay Area Air Quality Management
'TOTAL:
DinrietYes
BOILER-COMP(OVER IOLUM BTU)
I have
chazardon Iatenms re< ' meals under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE /Y
Torula HmItM1& afety ,,e .I5,' 533 nT 5594.I undenland that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdt s to. Yhuv vel intled T No,, ilily tonotify thi,cempant
of the men ich :I Cenifi ofOaupancy
C
O ons ngem t Date TOTAL: ISSUED BY:
OFFICE