S 0564 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO ®R
UH.DIN I I.ECFRICAL PF�`1ITNo f^� y/�� /�11
BUILDING DIVISION APPLICATION/PERMIT PLUMRING•MRCIIANICAI. �/ O V V�i
BUILDING PR(IJ I:CT IDEMfIF'ICATION
SANITARY NO. APPLICATION SDBMI'ITAI.DATIi
BG1J6/ING ADDRESS &13t3 L�
OWNER' AME: PI30NL: CONTRACTOR'S NAMIi: LIC NO'.
SIC CONTROL is
IL/GO,V lilt
❑
•.
.AR CH TF:CT/ENGINEER: a C LICC/G ADDRESS:
CONTACT. PHONE - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSF,D CONTRACTOR'S DIiCLARATION ^ QTY - ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby aRrm that I am licensed under provisions of Chapter 9(commencing
0OZ with Sa ion]000)ofDivision 3 of the Business and Professions Code.und my license is PL'RMITISSUANCE RESIDENTIAL'
aCR in full force and effect. CSFDWL ❑KITCHEN REMODEL
GZf� Licenu Class Lic.p APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RF.-PIPE
�Q1� Gala Consmcmr ❑MULTI-UNIT ❑STRUCTURAL
F=y ARCHITECTS DECLARATION PANELS MODIFICATION
1 understand my plans shell od used as public records UP TO 21q AMPS
y ZnC El INTERIOR C3 CHIMNEY REPAIR
Fa, u1 IJanuvl Pimmasumad - 201.1000AMPS IMPROV17MENT 0SWIMMING POOLS
Ca � Comrec
OWNER-BUILDER DECLARATION OVER IIXIf1AMPS [I BATH REMODCVREPAIR [I DEMOLITION
1 hereby aBinn that 1 am exempt from the tot's License Law for the C OTHER
�0.�e O 0.0 following reasom.(Section 7031.5.Business and Rofessionx CNE:Any city or county SIGNS ELECTRICAL
RI'3 LL I' which requires a permit to construct.alma,improve,demolish,or repair any Immure
I-i�0� prior o its issuance.also requires the applicant for such permit,.file a signedstmement SPECIAL CIRCUITIMISC.
�;' that he is licensed pursual to the provisions of the Commaors Liana Law(Chapter 9 COMMERCIAL•
apo (commencing with Section 7000)of Division 3 of the Business and Professions Code)nn TEMP.METER OR POLE INST CNEWBLDG/ADDITION []DEMOLITION
0.yx �e
that he is exempt themfrom and she basis for the alleged exemption.Any violation of
Wim
Section 7031.5 by any applicant for aPermit subjects the applicant it)acivil penalty of POWER DEVICES ?NANT ❑FOOD SERVICE
= 1 more than five hundred dollars($5IX). IM PR
OVEMF.NT
F� ❑ I,as owner of the property.or my employees with wages m their sole compensaion. SWIMMING POOL ELECTRIC OTHER
will do the work,and the xtmcwm is not intended oroffcred mitotic(Sm.7844.Business
L3 and Professions CNE:The Contmcmrs LicenseLaw dues not apply man Owner of OUTLLTS—SWI'1'CIiFS—FIXTURES
property who builds or improves thereon,and who does such work himself a,through NEW R HAL EL R SQ PT.
his Own employees,provided that such improvements me not intended or Unarm for SQ.M.FLOOR AREA ASQ.FT.
,sale.If,however,the building or improvement is sold within one year of completion,the
ownembuilder will have the burden of proving that he did not(wild Or improve for par- P A '
you of sale.). TOTAL: a`V D
1,as owner of the pmpeny,um exclusively contracting with licensed contractors to
construct the project(Sec.70,14,Business and Professions Codia The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUM PF. IT FEE (� agfJl�CV
who comms for such projec'ks with a contmnur(s)licensed pursuant to the Contractors /�
Lima.Law. - PERMIT I IAN s CITY Uf
Two exempt under Sec. ,B&P C for this reason V
ALTER—D ENT—W TBR(EA) WAtalfri
Owner Date
WORKER'S COMPENSATION DECLARATION BACK .OW PROLE . V .E
1 hereby effam under penalty of perjury one of the fNLw.ing dcdamti�ns:
VVhaveaudbadRmaionin a Cenificate m Consensmsel Finsure for Workers Camper-
;n,
ompete DRAINS—FLOOR,R .A STORIES TYPF.CONSTRUCT'IOF
smton,us provided for by Section 37M of the Lotwr Cude,far the p,ro mn me of the FIXTURES—PER TRAP
(or which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section OCC.GROUP
] aOhe Labor Code.for the performance of the work fur which this Permit is issued. GAS—EA.SYSTEM'I INC.4 OUTLETS APN
Mykr/ CC oil boom carrier and Pobeyn am: GAS—EA.SYSTF.M-OVEROIEA)
Cartier `rA`l� 4fBtl.�_Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERSGREASrANDUSTRL WASTE INTERCIIPTOR
COMPENSATION INSURANCE DI DIVISION TEES
(ThissectionnecdnnthecomplaNifthepennit isforonchundmddollmOSINN, GREASETRAP PLANCHEC
or less.)
Loy any
he any manner
t work for which Nis theparruntWislesuCompenl SEWER—SANITARY—STORM EA.2110!4. ENERGY
not employ any person in any manner w u to become subject to the Wmrkern'Cnmpen-
Z sasion laws of California.Data WATER HEATER WNENT/ELF.CTR GRADE G
0 0 Applicant t
Z y NOTICE TO APPLICANT.If,after making this Certificate Of Exemption,you should WATER SYSTEMIFRF.ATING
[+ ^' become subject,.the Workers Compensation provisions of the Lada Code,you
must SOILS FEE
Lail fmnhwish comply with such provisions or this permit shall be deemed revoked. WATER SERVICC
Q PAID
7.z CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL.PCMB. SQ.FT. ate Receipt to
U 0 l hereby affimuha there iso cnnstmetion lending agency fnnheperfmmance Of
It'
the wont'ser which this permit is issued(Sec.3097.Cie CJ T 'fAL:
0 H Lenders Name TOTAL.
U Lenders Address BUILD! FEE
I unify that 1 have read this application and state that the above infumotion is
t7o!) correct.l agree m comply with all city and county ordinances and slow laws reining to QTY. MECHANICAL PERMIT FEE SEISMI FEE
U G building consairmuon,and hereby anatomic repreumdives m dos city,.enterupon the
above-mentioned propany for inspection purposes. PERMIT ISSUANCE ELECT ICFFE
(We)agree m some,int nify and keep harmless the City of Cula,"a m against
liobilitiaital .1 o'cusisa xpensc,which may in any way see=against said City ALTERORADDTOMECH. PLUM ENG FEF.
in conseyve Of sb rant of this permit.
APPLICAN 1 ND ST )S AND WILL COMPLY WITH ILL NON POINT pIR HANDLING UNIT 0010.000 CFM! MECH FEE
SOURCE 'G L 10 '.
'jj, '? AIR HANDLING UNIT(OVER IO,g10 CFM7 CONSTRUCTION %
Sig or APPRe IContmcm TI Data E%HAUST I IOOD IW/DUCT) HOUSING MITIGATI NFEE
AZARDOUS MATERIALS DISCLOSURE
Willman icon,.,tater,building wcapanl stone Or handle htwookos material HEATING UNIT(TO 100,(X10 BTU)
as defiand by the pertino Municipal Code.Chapter 9.12,and the Health and Safety HEA'T'ING UNIT(OVER UR%000 BTU)
CNE,Section 25532(a)7
❑YesVENTILATION FAN(SINGLE RISID) PAID
Date ecciplM
I Will the applicant or future building occupant use equipment on devices which BOILER—COMP 0HP OR 100,000 IOU)
emit hazardous air contaminants y defined by the Bay Arca Air Quality Management IMP TOTAL:
District? \ A BOILER—COMP(OVER 100.0110 BTU) -
❑Yes 1{Z�V/to
AIR CONDITIONER ISSUANCE li
I have ad Ne hat awards rem anter Chupmr 6.95 of the Culi-
fomia Health afesy C .Satoi,25505 533 d 25534.1 undersmnd that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoeion
nn tmthm n ewo , m t abiliryto osifythea:cupant
Ofthergo' m h uahemespdO 0 to rte f
Owner 9uthnrlI gent )a TOTAL: ISSUED BY:
OFFICE