S 0028 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPF.RTINO -BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION' ���® II
BUILDINGAJDRESS: SANITARY NO. APPLICATION SU13M1 rrAI.DATE
OW ER'$NAME:_b�raf PI10NE: CONTRACTOR'S NAM[: �ILICNO: ❑
y NIC _CIOONN7[RR�OOLL#
\RCHITECI'/fiNGINEF. LIC NO'. ADDRESS:
CONTACT: PHONE BUILDING PERMIT INFO
r /W[ t.��i bO ❑ Consultant Fees Paid by Applicanl(Initial) G ELECT PLUMB MECH
1 f a ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION th .QTY r ELECTRIC PERMIT ' FEE JOB DESCRIPTION
I hereby uRrm t I licensed and provisions of Chapter 9(commencing .
0%Z with Section 710g1)of D"' 3 ftheBus e.. dP Profession,Cade.and my lee . is
RESIDENTIAL:
100 wnVERS PISSUANCE
,H n lull force i ul cE.& .'�/)��� ❑SFDWI. ❑KITCHEN REMODEL
�UU License classVPLic.#, 7 APPLIANCES—RESIDENT IAL ❑ADDITION ❑PLUMBING RE-PIPE
h L Dun, Contractor
Foy ARCHITECT'S DECLARATION 1'ANIi1N El MULTI-UNIT ❑STRUCTURAL.
v4 Z 1 understand my plans shall be used as public record. ��_J/��� MODIFICATION
OZ—, UPTO200AMPS giy[F.RIOR ❑CHIMNEY RI?PAIR
f,4CFW Licensed Professional 201.1000AMPS IMPROVEMENT El SWIMMING POOLS
4 OWNER.BUILDER DECLARATION OVER IIXIO AMPS - BATII RFMODELTEPAIR 0DEMOLITION
R 5a 1 hereby ul'frm that I Inn exemprfrom the Cnnlruclors License Law for the
6 0 a U followinga (Section 7031.5,Business end Protex,r...Code:An d r count ❑OTHER
K 3 rice nn Y dY e Y SIGNS ELECTRICAL
W a which rcquircs o permit to coname,alter,improsu demolish,or repair any iamond
F Oe pnormits lissuance,alsore to the theapplicantfor Contrach rmiuofile a icense ned Law
SPECIAL CIRCUIT/MISC.
S;!I} that he is licensed pursuanrto the provisions of the Contractor's License Law(Chapmr9
W..GAO (commencing with Sermon 70001 of Division3 of the Business and Professions Code)nr THMP.METER OR PULEI COMMERCIAL'
that he is euntpt therefrom and the husis for the alleged co emption.Any vinlntinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y%1 Wy Section 7031.5 by any applicant liar it permit subjects the applicant to a civil pcmdly or POWER DEVICES ❑TENANT D POOD SERVICH
not more than live hundred dollars($500).
IMPRO�zG
El 1.as owner of the Plane",or my employees with wages as theirol
te compemiumn, SWIMMING POOL ELECTRIC, OTHER IiMENT
f�C will do the work,and thesmumr
ce is net intetMor
eddRened far cold(See 7044.Business []OTHERTHER
sail and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWI'ICHP.S—FIXTURES
63 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvemat
ents e not intended oT offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.howmcr,the building or impmvenmm is sold within ere year of compiler rilhe SQ.pL FLOORAREA S/SQ,IT.
ow er-builderwill have the burden of proving that he did net build or Improve for pur-
pose of aide). PAID
1,as owner of the property an exclusively contracting with licensed contractors to TOTAL:
ransmat the project(Sec.7044.Business and Professions C.c:)The Cmucare nHs Li- MAY 2�M
c se Law does not apply to an owner of property who builds or improves thereon,and QTY , PLUMBINGPERMIT FEF, M �rC
who summers mens for such projects with a contractor($)licensed pursuant the Common is /�
License Law. PERMIF ISSUANCE 'fir
1 am exempt under Sec. .R&P C for this reason C�• a V�'
Owner Dom AUTER—DRAIN&VENT—WATER( ) VALUIBION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE 2
1 hereby affirm under penalty of perjury one of the fallowing declarations: .YLJ
❑ I have and will maintain a Certificate of Consent toself-insure for Worker's Compen- DRAINS—FLOOR,RWP.AREA,CONT. S'1'OR]F:S TYPE CONSTRUCTION
sotion,as provided for by Section 9700 df the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES—PER TRA`
T have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Lobar Cole,forthe performance of the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wmke Cmftioylmurapcg,L and
erPolicy number are:
Carrier: a r�wk17 Policy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPI[ON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(Thiasatinnnud not bocnnnplmad ifthe permit is fnronc hundred dollars[$I(Np _ a ? BUILDING OIVISVU If
or less) - GREASE TRAP PLANCHECK FEE
I certify that in Performance Perfornce of the work for which this pemdt is issued,)shall SEWER—SANITARY—STORM EA. FI'. -
not employ any person in any manner so as to become subject to the Workers'Compen- . ENERGY FEE
,Z said.Lawsof California.Date WATER HEATER W/VHNT/ELECTR
OO Applicant 1 GRADING FEE
zy NOTICE TO APPLICANT.If,after making this CeniOcne of Exemption,you should WATER SYSTEM/TRI!A'IING
a become subject to the Workers Compensation provisions of the Labor Code,yon most SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
WJ
40
U O CONSTRUCTION
com LENDING AGENCY NIiW RLSIDENTIAI.I'LMB. SQ.FT. PAID Date Recei t4
I herbyichdathauhem iso ed
30lending agency for the performance of P
the work for whichda.permit is issued(Stt.3097,Civ.CJ
�' F" Lender's Name IOTA L:
ULender's Address - 'TOTAL:
1 cenlly that 1 have read this application and state that the above informwinn Is BUILDING THE72 7
correctl agree to comply with all city and county ordinances and state laws relining m QTY, - MECHANICAL PERMIT FEE - If
U Z building commotion,and hereby umborire on represenhaives of this city to eructation the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to sam
ve,indemnify and keep hadens the City of Coriagainst ELECTRIC PEC
liabilities.judgments,costs and expenses which may in any way acerae agminstsaid City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT' INO RSTAND' AND WILL COMPLY WITH ALLNON-POINT AIR HANDLING UNIF(1010.000 CFM)
;up ` MECHANICAL FEE
UR
Syy �►1 AIR HANDLING UNIT(OVER I10,000 CFM) CONSTRUCTION TAX
Sig t of pplicant/Conrc. Dam 1 EXHAUST HOOD(W/DUCf)
HAZA�ryJDO S MATERIALS DISCLOSURE HOUSING AiITIGATION FEE
WII l capplicamor HEATING UNIT(0 I(nano B'fU)
as def Sed by the ino Municlpnl Cndq Chapmr 9.12,and the HeulOh unJ Safely
Cotic,Section 25532(x32001)7 HHA'I'ING UNIT(OVER I(Nl,(N))B'TU)
❑Yes ❑No VENTILATION FAR(SINGLE RESID) PAID '—
Date Receipt a
Will the applicant or future building demand Bar,Dme ea Air Qu or devices which
emithazardous air contaminants as defined by Ne Bay Arca Air Quality Management BOILER—COMP(3HPOR 100.000 BTU) -
Di.aner? TOTAL:
❑Yes [:1 No 1301 LER—COST(OV ER I(LOCK)BTU)
I have real the haasrdoun rfamritds requirements under Chapter 6.95 of the Cull. AIR CONDITIONER ISSUANCE:DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL SUCH. SQ.EI.
Wilding this not currently have a main,that it is my responsibility to notify the occurred
of the rogrimments which must be nwt prior to issuance of a Cer Ream of occupancy.
Owner nr vuthnrixcJ agent 1 Date TOTAL: ISSUEDBY:
OFFICE