S 2231 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PEg fl`NG. n f�31
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. lJ LG
ItU11.U1NG PROJECT IDRISTIF'ICATION
BUILDING ADDRESS: SANITARY NO, AI'I'hICA'IlON S11BMI'ITAI.DATE
1 ,1_ I L n 7 ZZ 4g
OW IIR'SNAME: - Pfl(1NE: CONR OR', AME: 6N 0,
Gw ��� (y �` 5C O P NIC CONTRM.p mpNo
• ARCHI I'ECTANGINIIER; LIC NO: O ADURIiSS:- J J C ❑
300 I N
CONTACT: PHONE BUILDING PERMIT INFO
� 2 �2J ❑ Consultant Fees Paid by Applicant(initial) tl1.IX: ELECT PLUMB MIiCH
/�C_ VA L �/ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby arum that I ate licensed under provisions of chapter 9(commencing JOB DESCRIPTION
CIYz ntfull fntreeumIfen rvisinnloftheBusinessunA Podczsinns Cole aadmylicenals RESIDENTIAL:
OO_ �'t PERMIT ISSUANCE
RUF License �3 Let.p � � <� ]SFDWL ❑KITCHEN REMODEL
Q U — APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
yZUI Datu TS DEmr
F 6 mFy ANCHITECT'S DEChARAI'ION PANELS ❑MUhfl-0NIT ❑MOIMFI STRUCTURAL
ON
Z O n? I understand my plans shall be uad as public reasrds CHIMNEY
REPA
py..� UP T02fX1AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-I( 'S IMPROVEMENT 0SWIMMINGPOOIS
OWNER-BUILDER DFiC1ARA'1'1ON OVERT X1 PS ❑BATH REMODEVREPAIR El DEMOLITION
Q I hereby affimt that I am exempt from the Contra tor%License Law for the
xCx.O IoW,U following reams.(Section 7031.5,Business and Professions Code:Any cityor county SIGNS CAL ❑OTHER
00'3 W Nwhich re hires a Permit In cenatruc6 alum improve,demolish,m repair any abuchare
f=oil prior to its issuance,also maracas the applicant for such permittofile asigned statement SPECIAL CIRC C.
f�y Ihmlmixlirenvedpursunmmthclou,sionaafla,Cnmmctorb License Law(Chap¢r9
CC) (commencingwiNSenion70 1nf Division3nfthe Businessand Profasinns Cade)nr TEMP.METER OR POL: S COMMERCIAL•
t1 q m y that he is exempt IhereGom ane Ne basis for me alleged....ii ine.Any vinhaid of ❑NEW BLDG/ADDITION ❑DEMOLITION
i tr. Section Rllll by any applicant for a permitsubjects the applicant m a civil penallyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
>y nut mum Nan five hundred dollms($500). IMPROVEMENT
M [] I,ux owner of the property onny emNoyee,wish wages ns their sole cmtpcnsaion, SWIMMING POOL ELECTRIC []OTHER
willdothe siok,wal Neswcmreeimal imandedorcifered mrsale(Sec.7th ,Business
0, and P..bastions Code The Cen omm',Liccn.c Law does am apply m an owner of OUTLFLS-SWITCHES-FIXTURES
property who builds or improves domain.and who does such work hlmnelf or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC:R SQ P.
sale. Lhowevaq the Wildingor intpmernme,issold within nncyur of cnntpletiun.Ihe $Q.Ff.FLUOR AREA LSQ.Ff.
owner-builder will have the burden of pressing that he did nm build or improve for pur-
pose of sale.).
❑1,as owner of the property,sun exclusively contracting with licensed amarecmrx m TOTAL:
construct the project(Sec.7044,Business and Professions Ce—)The Cnntmaor's Li-
censeLawdeasnmapplytoanownerofpropertywhobuildsorimpowtvthereon,and QTY, PLUMBING PERMIT FEE
who commas for such projects with a enmurcomp l licensed persaanua the Contractive,
License Law. ^O
I um exempt ander Sec. .B&P C far lhisreason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA) ATV N
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW FROM=DEVICEnn
1 hereby afro under pcavlty el purl ury one of the fnilowing d.liat a,
❑I have and will maincona Cenifirmecuf Conard oself-insurefor Workers Compcn- DRAINS-FLOOR,ROOF,AREA.COND, STORIES TY NS'TRUCTION
satins,as provided for by Section 37M of the Labor Code,for the performance of the Q n
Swork fire which this pe.,it is issued FI('I'DIES-PER'IRAI' EP'2
Y70haveand will maintain Woekers Com....find improper,as required by Section
nfthe Labor Code,I I pert mance nIff wnrkfor whichlhispennilisiemed. GAS-EA.SYS1'1IM-1 INC4OIITLETS OCC.GROUP APN
My Wo�sl�om Iia aero cammanJPolicy ng)pl� C� g GAS (T
Car der -�(((yy�policy ROMWO By
CENTIFIC OMPE XITIONINN FROM WORKERS'
COMPENSATION INSURANCE: GRGSF/INDUSTRL WASTE INTERCEPTOR B
(Thkiwchoneradnmbacum0lcoa iium,cool Lcfnrnne hundred Jolle,31W) GREASE TRAP
or less.) PLANCHECK FEE
I certify lhmln the perfnnnnncenflhe workfor whichthis permit is issued,[,hall SEWER-SANITARY-S'FORM EA.200 IT.
not employ any person in any manner so as m become subject to the Workers'Compen- IINERGY REI:
7. cation Lawsof Celifomia.Dam WATER HEATER W/VENT/ELECfR
Q O Applicant GRADING FEE
zy NOT ICE TO APPLICANT:If,after making this Cenificatc of Exemption,youshould WATER SYST'EMIGREATING
a ; become subject m the Worker's Cara,m atinn Provisions of the Lahnr Gale,you mull 14 SOILS FEE
W ti forthwith comply with such pmvislnnsorthis pemrilshall be deemed revoked. WATER SERVICE
Q
r
.7z CONSTRUCTION LENDING AGENCY NEW RF.SIUENTIALI'LMB. SQ.FT, IAN Date Reeipt#
U � Ihereby affirm than Nem is aconswnimn terming agency for the Performance of
Lks the work for which this permit is iemed(Sri.31197,Civ.C.) TOTAL:
F•' Lenders Nome
U lenders shares,
,7s III BUILDING FEEI certify that I have reed this application end state that the above information is
correct, agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorise representatives of this city to enter upon be SEISMIC FEE.
r ,aleme-mentioned progeny fur inspection ,,,a,. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmles,the Cil,of Cmwmno again I ELECTRIC FEE
Iiabilitics.juJgments,coe s and capes ,which may in any wiry accme against said City gLTER ON ADD TO MECH.
in cnnsequenc a gr ling rf to permit. PLUMPING FEE
APPLICANT )EI TAND' ND WILL. .OMPLY WIl'H ALL >N-POINT AIR IAN DUNG UNIT('I'O 1(1.001 CFM)
SOLING .A ONS. MECHANICALIME
AIR BANDUNG UNIT(OVER q0(p CFM) CONSTRUCHON'FAX
Sig urn pp nt/Com sour Dmc EXHAUSTHOOD(WMUC) 1 IOISlNG MITIGATION FEE
HAZARDOUS IAL S DISCLOSURE
Willthcappiicant nr furore huildin ccup:mumm or handle hazardous material HEATING UNIT(TO 11X,000 BTU)
nn JcfincJ by the Cupenlna Municipal Co .Chapmr 9.12,unci the Heahh anA Sefcty
Cal.,Section 25532(a)p HEATING UNIT(OVER 1(10.000 BI U)
]Yes G4Nc PAID
VEN'fILA'FION PAN(SINGLENESID) Date Bacteria it
Will the applicant or future building occupant use equipment or devices which
emit hvrd
nouv air conm unams as define)by the Bay Arad Air Quality Management BOILER-CONI'(JHI'OR 100.0[s)BTU) TOTAL: O
❑Yes No
DlatricC BOILER-COMP(OVER 100,01)BTU)
�
Il�ave read the amninus mabord,usimmmanls under Chapter 5.95 of the Cali ALR CONDITIONER ISSUANCE DATE
fnmia Hsallh afet Code,Serb. 25505,25533 and 23534.I understand that if the NEW RBSIDEN'r1AL MECH. SQ.FT.
building do Ica nlyhvve.a .,,thatli ryrespnreihilirymno fy the cupam G�
of the 1- tichm sec olT Cenilicvt rl(� olm
9 —TP
Ow mired ugcm am TOTAL: ISSUED BY:
OFFICE