S 0431 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL - 0431
BUILDING PROJECT IDENTIFICATION Sl7
BUILDING o ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
e
NER'S SME: .e P NE: r CO R pRC'S 4'/{17A wf _!�ICNOLV ?N 19
: �/� NIC C
RCIIITECT/E GINEER: LIC NO: DRESS:
C N
CONTACT: PHONE: BUILDING PERMIT INFO
RLP r5 —212 0 Consultant Fees Paid by Applicant(Initial) BLLLDDDG. ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION G
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing QTY. ELECTRIC PERMIT FEE
v s JOB DESCRIPTION
HOZ with Semipn]BO(BnfDivision3aRhe Business and Professions Code,and my license is RESIDENTIAL'
ou� Infullfo¢eand eft W PERMIT ISSUANCE. ❑SFDWL ITCHEN REMODEL
�FUZ License Cl sF Let# APPLIANCES-RESIDENTIAL
N6 Date Cnnhnctor []ADDITION LUMBING RE-PIPE
I„7P>>j CHITECT'S DEC RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O n G I understand my plans shall he used as public records MODIFICATION
OZ�-1 UP TO 200 AMPS
❑
El INTERIOR ❑CHIMNEY REPAIR
pC Professional 201-1000AMPS. IMPROVEMENT
Oat I am
m Ce Conti ON ❑DEMOLITIONPOOLS
1 hereby affirm that 1 am exempt from the Contmcmr's License Law for the OVER 1000AMPS ❑BATH REMODF.UREPAIR (]DEMOLITION
O y U following reason.(Section 7031.5,Business and Rofes,ions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
ty 3 H which"units a permit to assistant,alt,improve,demolish,or repair any xWcture
prior to its issuance,also requires the applicant for such permit In file o signed statement SPECIAL CIRCUIT/MISC.
=M 6a that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
Q (commencing with Section 701 of Division 3ofthe Businessand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
y� that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�"m
Section 7031.5 by any applicant for a perrnitsubjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
> not more than five hundred dollars(8500).
O6 Dl,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 'IMPROVEMENT
❑ will do the work,and the suucture is not intended oroRered for sale(Sec.7044,Business ❑OTHER
W and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,pmvided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR S
sale.If,however,the building or improvement is sold within one yearofcompletion.the. SO.F,FLOOR AR EA $/SQ.ET
owner-builder will have the burden of proving that he did not build or improve for pur-
lrose of s.b.)
❑ I,as owner of the properly,am exclusively contracting with licensed amtmetors to TOTAL:
construct the project(Sec.7044,Business and Profeselon,Code:)The Connector's Li-
cense Law Hoes not apply to an owner ofproperty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who cemmas fill such projects with a carnations)licensed pursuont m the Contrucmr',
License Law. PERMIT ISSUANCE' - D
04
❑I am exempt under Sec. B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) C•9
ON
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /f
I Ihereby affirm under penaltyofficiony one of the following doelamtince �y
❑ I have and will maintain a Certificate of Consent to self insum for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORI /' `� TYPE CONSTRUCTION
soma,as provided for.by Section 3]00 of the Labor Code,for the performance of the
ark for evidential,permit is issued. FIXTURES-PER TRAP CJ
❑I has
end will mvimvin Workers Cumpws,tion Insomnce,as mquireJ by Section
3Agl of theL Cnde.for the performance of the work for which Nis permit is issued. GAS-EA.SYSTEM- INC.4 OUTLETS
My Worker's oro ns tion In,u c J Polic bar ore: _ OCG GROUP APN
m
/ Grtien a ePolicy No.: GAS-GA.SYSTEM-OVEk4(EA) '
CERTIFT ATEOF ONFRWORKERS'
COMPENSATION INSURANCE GREASFANDHSTRL WASTE INTERCEPTOR BUILDINDIVISION FEES
(This section Deed and be completed if the permitis barren hundred dollars($100) GREASF.TRAP
A,mionof
PLANCHECKF
n the perfonnanceof the work for which this the W rkes'Com en- SEWER-SANITARY-STORM EA.200 FT.
o oily manner so as to become,abject to the Wnrkec�Compen- ENERGY FEE
amia Date ae
WATER HEATER WNENT/ELF.CTR
GRADINGF
NU If,after making this Certificate of Exemption,you.should WATER SYSTEMUREATING
e es Compensation provisions of the Labor Code,you must SOILS F
forthwith comply with such provisions or this permit shall be deemed revoked: WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.' SQ.Er. PAID
U O Ihereby affirm that there is a construction lending agency for the performance of ate Receipt#
1.4 H the work for which this permit is issued(Sec.3097,Civ.CJ
0 U Lenders Name sillTOTAL.
Lender's Address TOTAL:
yI cavity that 1 have reed this application and state that the above information is B
In correct.1 agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT 4tMECIANICAALFEE
,E
U building emaswdion,vnd hereby authorize represenmtimaridhis citymenmrupon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupevino against 'FEE
liabilities,judgments,costs and expense,which may in anyway aceme against said City ALTER ORAIIDTO MECH. NO FEE
in aonsequence e% ting of tM1is permit.
APPLICANT ND ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE R GU. ON I AL FEEAIR HANDLING UNIT(OVER 10,000CFM) r10NTAXSigna ofA canUCommmm Date EXHAUST HOOD(WMUC) ITIGATION FEL
AZARDOUS MATERIALS DISCLOSURE
Willthevpplico rfutnre building sccupunc wore or handle hozardpus manrial HEATING UNIT(TO 100,000 BTU)
's defined by the Cuper in Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(n)? HEATING UNIT(OVER 100.0011 BTU)
E]Y., C]No VENTILATION FAN(SINGLE RESID) PAID --'
Date Receipt#
WIII the applicant or Pomm building occupant use equipipem or devices which BOILER-COMP OHP OR I00.OIX1 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District?
❑Yea ❑Nu BOILER-COMP(OVER lIX1,fNq BTU)
I have read the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomie Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.EL
building does noceotrently have tenant,that it my responsibility m pacify the occupant
of the requirements which must he mm prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE