S 1558 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL 1'EtTT NO. 4� /�
BUILDING DIVISION APPLICATION/PERMIT gNGPPLUNRPROJECT
IDENTIFIC \V V1 VX
IIUILDIM:PROJECT IDRNTIF'ICATION
BUILDING ADURI?SS'. SANITARY NO, APPLICATION SUBMITTAL DATE
AMP Z'4 I
Ow IiR'S NAME: 2 1'HO E: CONTRACT'OR'S NAME. LIC No
is PRIVI , NIC /[wl CONTROL p
A CfI1TECT/ENGINP iR: (J'T LIC NO: ADDRESS: ❑ y���
231.
C NTA(TU PHONE: ` I BUILDING PERMIT INFO
L �l� +u ❑ Consultant Fees Paid by Applicant(Initial) BLDG c PLUMB MECH
LICENSED CONTRACTOR'S UIiCLARAI(ON /^14 QTY ELECTRIC PERMIT FEE JOB DB$CRIPTION
1 hereby affirm die I not licensed under provisions of Chapter 9(commencing
.0.'Z with Sectiun]IMXy of Do cion 3 office Business and Professions Code.and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
NW2 in full force and effect. DSFDWL D KITCHEN REMODEL
�UV License Class C. APPLIANCES—RESIDENTIAL DADDITION ❑PLUM BING RE-PIPE
Z W Dae Contractor
t� - DMULTI-UNIT DSTRUCTURAL
F=y ARCHITECTS DECLARATION PANELS
Z O y„Z„ 1 understand my plans shall be used as public mcoNs MODIFICATION
O Z—� UPT02100AMPS DINTERIOR [ICHIMNEY REPAIR
[=.4Fm Licensed Professional 201-1010AMPS IMPROVEMENT ❑SWIMMING POOLS
<wx, OWNER-BUILDER DECLARATION OVER 10(XIAMI'S D BATH REMODEUREPAIR DDEMOLITION
Ir
C 1 berchy afliml Ilia,1 am exempt from the Contractor',,License Low far the
0:11.O
1`0 folkswing reason.(Sation]031.5,Business and fndersinns Code:Any city or rnomY SIGNS ELECTRICAL ❑OTHER
LLO y¢ which requires a permit t0 construct,o@r,imp mvq demolish,m repair any stmaum
m,J prior to its issuance,also requires the applicant for such permit to File a signed statement SPECIAL CIRCUIT/MISC. (�
that he is licensed paround to theprovoi.m.f the Contmamts Licenxc Law(Chapter`)
apo feommenoing with Section IllOnl Of Division J ofthe Business and Profcssinns Cole)or TEMP,MEIVR OR MILD INST. COMM
0. o that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
R^ Section 7031.5 by any applicant fora permi 'ahjeos the applicant to a civil penally of POWER DEVICES [ITENANT Ll FOOD SERVICE
not mom than Five hundred oaths(SSW). IMPROVEMENT
£yO Dl,as ox'ner of the pmpeny,ormyempinyees wish wages ustheirenle compenvtinn, SWIMMING POOL ELECTRIC
p. wind.ibework,and the shmctum u not intended or offered for sale(Sar.91414,Business DGTHLR
and Professions Code:The Conlri License law does not apply to an owner of OUTLETS-SW ITC]IES-FIXTURES
property who builds or improves themon,and who ones such work himself or through
his own employees,prvidnd Thal such improvements am not intended or offend for NEW RESIDENTIAL ELECT R SQ F1'.
sale.If.however.the building or improm
veent issold within one year ofcompletiun,the SQ.FT.FLOOR AREA LSU.4T.
cr.budder,will have the horde.of proving that he did nal build or improve for put, w
pow of sale). �'3 S•�: A1/0
D I,as owner of the property,am exclusively contracting with licensed cortrucloiv to T
en
ishuia the protest(Sec.](W,Business and Profcssinns Code)The Cnmmnnrs Li- //Vf11
cenulawdnesnalapplylOaswith a ofpropmy whobuilds Orlm in the
ContracanJ QTY. PLUMBING PERMIT FEE (i�/
' who wnaunvfor mchp jets withnnsmraaun(s)licwsul punuunun tha Conaamor's
License Law. PERMIT ISSUANCE
D I ten exempt under Sec. .B&P C fur IN,reason
(141 ROFECT DEVICE
(PA) VALUATION7— -�
Owner Dme_ A11I�i� � - ��
WORKIiR;SCOM PENSATION OI?CLARATIONR(YfELT.DI[VICC
'. I hereby anion under penally of penury one of the following de' � 3
D lhnveand will mainmin.Cenifieneof Comenl msclf-insure forvo, �R,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 37W Of the Labor Crile,for the n
work for which this permit is issued. FIXTII RES-PER TRAP
D I have and will out main Worker's Compensation Insurance,its required by Section
11an close labor Code,fist the performance of the work for which this permit N.,,tod. GAS-EA.SYSTEM-I INC.4 OUTLE OCC.GROUP APN
My Worker's Cmd,var ttioa Insurance carnation]Policy number are:
Cotner Policy No.: OAS-GA.SYSTEM-0VER4(LN)
CER)'IFICATE 01:EXEMPTION FROM WORKERS' GRFASOINDUSTRL WASTE INTERCEPT'
COMPENSKNON INSURANCE 13UILDING UI VISION FEES
(This union need not Wcomplead,tithe pemtii is forone hundred dollams($100) GREASETRAP or less.) §PLANCHECK FEEIcenify ohm in the performance Of the work for which this permit is issued lshall SEWER-SANITARY-STORM IiA.not employ any erms in any manner so as ni become mbject to the Workers'Camper- PEEP
cation Laws of Cali linam.Dam WATER IIEATER WNENTIEI.ECR0 ApplicantErn NOTICETOAPPL[CAW:If,after making this Certificate of Exemnption,you should WATERSYSTEM/PRINTING
bccnvde subject m the Workers Compmmrion provisions ofthe lobar Csd
tem madwitbcomply wi,h,.ch pm,i,i...or this pe.Oil shall he deemed ravnked. WATER S12RVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENT[, SU Receipt#
V 0 Ihembyafftion hot the. nmwrumion lending agency fonhe perfimmunco of
the work for whish this permit is iaeued(Sm.313)],Cie C) ` TO)'AL:
O U Lenders Name �1 "
W Lender's Address T L
/+ '—
Ly, 1 certify that 1 have read this application and abve information is
state that the oBUILDING FEE
f..p0.) correct l agrees comply with all city and Bounty ordinana,:mndstae lawsrdating of QTY. MECHANICAL PERMIT FEE O
U Z building Construction,and hereby nuthnprewms of this city to enter upon the SEISMIC PEE
riu maive
abovo-memloncd progeny for inspection pnrpowe. PERMIT ISSUANCEI?hEC'CRIC P
Z
(We)agree to save,indemnify and keep hamJess the City of Cu,sa lm against BI?
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER ORADDTOMECH. PLUMBING FEE
in consequence of the.grandng of this Permit. it
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NOWPOINT AIR HANDLING UNIT(TO to."CFM) MECHANICAL PER
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Iy000CFM) CONSTRUCTION TAX
Signature of Applicant/COmmaor Date EXHAUST I IOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thcapplicont a,future Wilding oecupammom or handle haemdns material HEATING UNIT(TO 101,000 B RU
as derided by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 25532(ap HEATING UNIT(OVER 110,000 B'I'Of
❑Yes Fl No VENTILATION PAN(SINGLE RF_SID) PAID
Dae ReaiplN
Will the applicant or future building recupam use equipmem or devices which BOILER—COMP DIT OR 1(X1,001 BTU)
emit havurdos air comuminunt,as defined by the Bay Area Air Quality Management TAL
District'! BOILER—COMP(OVER 1011.1X10 BTU)
❑Yes E]No
I have read the hazardous metedaE"arememx under CM1aptur 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma llizhh&Subtly Crile,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL.MFCIL SQ.FT.
building does not currently have a tenant,that it is my responsibility m anall the rccupam
of the requirements which most he roil p in,to issuance id.Cenillcale of Occupancy. _
Owner or authorized agent Date - T Vf/L' ISSUI?D BY: A a
OFFICE