S 2452 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF LUPE RTINO BUILDING-F.LF,CTRICAL MIT NO.
B HLRING DIVISION APPLICATION/PERMIT PLUMBING-MIF.CHANICAI. S 24- 5- 2
NUIIAING PROJECT IDENTIFICATION
BUILDING ADDRESS: 100al '5.(3 �&/ ✓t. .—stn port( NJ. CA. SQ IU SANITARY NO. APPLICATION SUBMITTAL DATF
/ l J (1
OWNER'PAur) 0. 1 "0Mfwt PHONE CONTRACTORS COMfRACrOR'S NAME: LIC NO: 7
1�I[[lir NIC
CONTROL a
CHITI!Cf/ENCONFER: LIC NO: ADDRESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI.DC ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
MAIL avian Swann V0k0 of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
w O p PERMIT ISSUANCE
F in full force and vtlI D SFOWL D KITCHEN REMODEL
+ �U$U License Clue. Lick APPLI ANCGS—RES]DEN MAL CADDHION [I PLUMBING RE-PIPE
rn62 Dam Cooducas, DMUI.TI-UNIT L1 STRUCTURAL
�N ARCARCHITECTSARCHITECTSSDECLARATION PANELS
Z p m 7 I unde..umal my plans shall bo-uwvl ns pull,mcmd, MODIFICATION
Oy-Q UP 10200 AMPS [I INTERIOR DCHIMNEY REPAIR
-F�1qq Licensed 11 ,u at 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
yy,
OWNER-BUILDER DECLARATION OVER ffl0AMPS D BATA REMODEUREPAIR 0DEMOLITION
I herchy o irm that I am exempt foam the Comment,License Law for the
i4x d U following reason,ISecri,m]831 S,Business and Pudessions Code:Any city or county SIGNS ELECTRICAL ❑OTHER /����/�qq��
W LL LLO y which requires a permit its consumer,alter,improve,demolish,or repair any sanctum
proud,k,i...anaavlsn requires the applicam for such pe.iu0 flea signedsmtemenl SPECIAL CIRCUITIMISC.
.bat he is licensed p.,.anno Ne pm,kmds of lire Carnedemr's License Law(Chapter 9
Iy t(QC (commercial with Section]IKK)ofDismon Sof the loemessand Professions Code)or TIiMR METER OR POLE INST. CGMMERGIAL'
G G c K that he is awtopr therefrom and the basis for are alleged exemption.Any violation of D NHW BLDGYADDITION C DEMOLITION
Xray
Section 7031,5 by any applicant for a permit subjects the applicant to a civ] IK)WER DEVICES NANT El FOOD SERVICE
11LL r mom than live hundmd dollars 155(10). IMPROVEMENT
D Lmowaernfrhepmpeny.onryempinyx.cwiN wages vs Neirmle co motior. I 1 E ❑OTHE•R
p..
will emne work,and theswcatm isrotin 'ded nr otfemd for sale(SmJ
RW1 �m and Professions Codd:The Contractors License Law does nor apply m uanecf OVI' S— T FIX'
SS
�'3— propcny who builds or improves Thereon,and who does such work himsel r Ihmugh
his own employees,provided that such improvements are not intended is creel for li SIDENTI
sale.IL however.the building or improvement is sold widammae yearof coo SQ.1°T.FLOOR AREA SISQ.Ff.
ndrvhui dcr will have the burden of proving that he did act build or imp
se oLwle.). —
I,as owner of the property,am exclusively contracting with licensed conmcrnn toANJ t
omannat the project(Sec.]IIW,Business and Professions Cala)The Contractor's Lb
c se Law Aocs not apply to no,tuna of property who hoods or improves thereon,and QTY, PLUMBING PERMIT FEF.
who conamrs for such pr.+jecrx with a C,nnador(s)licensed pursaanuo the Continuou's
License Low. PERMH'ISSUANCE
E1 Imoom mlmu]cr Sce. ,B&PCfnuhinrcu.nn
AI T R—DRAIN&VENT—WATER(EA) VALUATION
tune Date
W.at nfe, COMPP.NSATION UF.CLARAT]ON BACK FLOW PROTECT.DEVICE
Ihadd ulBnp radar panffiem of Conertyond of far self-i meiar dedroWorkerdnm:
�]have and will f..by eCmificomof Concerttosure for Worker's Compen- UNAINS—FLOOR,ROOF,AREA GOND. STORIES TYPE CONSTRUCTIOF
sation,to provided for by Section 3700of TM1e Labor Code,for the perfonnunce ollhc
work for which This penial is issued. FIXTURES—PER TRAP
D I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of The work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wurkcrs Compensation Insurance cagier and Policy number are:
Cartier Policy No.: GAS—EA.SYSTEM OVER 4(EA)
Chat HICATE OF EXEMPTION FROM WORKERS' GRP.ASEANIIUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Unix Seddon need not be completed if are permit is for me hundred dollars(SIWI GR1111i TRA('
nr lessJ PLA CIIHCK ITP.
I certify thin in the perfunnence of the work for which this permit is issued.I shall SC:WER—SANH'ARY—STORM EA.200 FT.
not employ any Iwmm in any manner so as to become odfira to the Workers'Crimper- ITE
ZZ man Laws of Califomia.Date WATER HEATER W/VENT/ELECfR
Q Applicant IING E
lin NOTICE TO APPLICANT.If,atter making this Cenificam of Exemption,you should WATER SYSTEM/TREATING
F-' become subject res the Workers CmuNnsation previsions of the Labor Cade,you must SOH S FF.
Wr�i forthwith comply with such provisions ur this proud shall be deemed revoked. WAI'ERSERVICE
Q
a
CONSTRUCTION LENDING AGENCY NIiW RIiSIDF:Ni'IAL PLMB. SQ.Ff. 11 IlReceiptk
• V ti lforw watfirmhich
Nal Nerd ivamnatee.ionlending agency for perfnrmamx of
the work lin which rhls Mrmil is issued(Sec.31y3],Civ.C.)
W. UIxndcr's N:nnc TOTAL:
ULender's Address TOTAL:
1t I woody that I have cad this application and stare that the above information is ❑Illl.11l '131?
y correct.I agree to comply with all city and county ordinances and stain laws m1mial to QTY. MEqMICAL7P'I FEE SEISMIC It q-
U 7 huildingcnn.tnaniogond headayaathorim mpmscntutivea of Nm is raym enter upThe e
ah,ve-mentioned property for inspection purposes. PERMIT'ISSU
(We)agree ,,saw,indemnify and keep h.nnlessthe City of Cupcnino against' HLECTRI TH
liabilidesjudgnemn,costs and expemes which may in any way accord against said City AI.TERORAI M
U —FEE
in amrcrornaAPPLICANT
Nthe runfiRSTA g S ThisD WIT.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IfANDLI UNIT G'O 10,001 F MIiCHA CALFRE
SOURCE REGULATIONS.
�- U AIR HANDL NIT(OVER IB,"CFM) CONS'IRL ION TAX
S feta ApplicanUContnwmr Date EXHAUST HOUSING MI CATION FEE
HAZARDOUS MATERIA ISCLOSURE
Will the applaud or future building occupantstore or handle hazardous material HEATING UNIT(TO 101.0011 BTU)
m ddned M1y The Cupcnino MunidIs Code,CTapter 9.12,and rhe ii.ilh and Safety
Code,Section 2553Na)'! HE TING UNIT IOVF.R 100,1100 RTU)
D
Yd, 'ENED.AI'ION FAN(SINGLE RESID) PAID Da¢ Receipt If
Will the applicant nr future building occupant use equipment or devices which BOILER—COMP(3HP OR 1(10.000 BTU)
air havrdnuc
,or
conmmiwnt,os defined byline Be,Area Air Quality Management :%AZ
isnictf �,// HOILER—COMP(OVER 100,000 BTU)
❑Yes Jam°
I have mud The havudoux materials requirements under Chapter 6,95 of the Cali- A]R CONDI'HONER ISSUANCE DATF.
mania Health&Safety Code,Scillox 25505,25533 and 25534.1 a demand that If tire NEW RESIDENTIAL MECH. SQ.ET. /
building das tun e...dody Iovc in tcnunt,that it is my responsibility to notify Nc occupant
of The rryu ul which n n't hd mu.riortn'. of a Cen ll.le of Creation, (1
O m+orded.,cut Dale TOTAL: ISSUED BY: 4�
OFFICE