S 3074 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO ]PLUMBING
ING-ELECTRICAL Pll 5(TT NO.
BUILDING DIVISION APPLICATIONIPERMIT ER",C B)"N'lcN. �J 3074
ROJECT IDEN'TIF'ICATION
HUILDING ADDRH_Sg' / SANG'ARY NO. APPLICATION SUBMITTALOWN' �f IsfF._ PH E: CO ACTORLIC[J(l:�,ll✓!7/ (^/ G/K�+�% NIC CONTROL0
92
RC1 TI'ECT/ENGINEER: LIC NO'. ADDRt- SQ/� ❑
CONTACT. cel4go PHONE: GG G BUILDING PERMIT INFO
'D/ p `77 �/ -�//- / /� ❑ Consultant F¢a Paid by Applicant(Initial) BLUG ELECT PLUMB MECH
Isle J10 10 f0(/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
OWZwith Section Division 3ofthe Bminessand Professianc Cale,undmy license is RESIDENTIAL:
OO PERMIT ISSUANCE
F in full farce an deFC._Z /_ �3� PA ❑SFDWL ❑KITCHEN REMODEL
tuV 4cense Class lU� lic.N & a J APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE:
l-Zul Da¢ Ctmmcmr E�
rnQa [I MULTI [I STRUCTURAL
FOy ARCHITECTS DF.0 RATION ZNG.+ PANELS MODIFICATION
Z 0✓�Z 1 understand my plans shall be used as public records UP TO 20p AMPS
OZ—Q ❑INTERIOR El CHIMNEY REPAIR
FQm tV Licensed on
11 Rtslol - 201-I(XX)AMPS IMPROVEMENT ❑SWIMMING POOLS
Kk .,.1 OWNI3R-BUILDIeR DECLARA'I'1(lN OVER 111(NIAMPS ❑BATH REMODEIIREPAIR El DEMOLITION
KQ 1 hereby affirm that I am exempt from the Centimeter's License law for the
ax O a V following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W aO In which requires a psmant to conawct,alter,improve,demolish,or repair any saucmre
so
prior m its issuance,also requimc Nea"heam for such permit to file a signed statement SPECIAL CIRCUIT/M ISC.
�y that he is licensed pucsonnrmtheprovisions oftheContractors License Low(Chaper9
I+I�Otc O (commencing with Section70YE)of Division 3 of Ne Business and ProfescionsCodepn TEMP ME'T'ER OR POLE INST COMMERCIAL; �, A /mC�
a ax GTL that he is exempt thetefmm and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION DEM�LI I ION
Wim Scenes III IS By any a,Ilb am for a permit sahjeaa the applicant 1,a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
net once than five hundred dollars(531X). IMPROVEMENT
eye ❑ 1,us owner of the property,or my employees with wugcsas their solo cmntpensaina, SWIMMING POOL I!LECfRIC
25A5, will do the work,and damnmmre is not Emended oroffered fursele(Sec.7044,Business ❑OTHI3R
Wm and Professions Code:The Contractors License law docs net apply to as owner of OUTLETS—SWITCHES—FIXTURES
a 3— property who build or improves thereon.and who does such wart hinudf or through
his an employees,provided that such improvements not not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale,IL however,the huilding.rimprotronat unsold within one yearofcompletion.the =FL�RUSQ.F1'.
ownerbuilder will have the burden or proving that Ire did not build to Improve for put-
pose of sults.). TA
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cada;)The Comments,Li-
censelawdoesnotapplymanowneref property ishe builds or improves thereon,and QTY. PLUMHINGPERMTT F
who amorals for such projects with a contractursu
n(s)IlcenaeJ pant India Coni net,n,
Licence law. PERMIT'ISSUANCE
❑Tam exempt under,Sec. ,B&P C far this reason
ALTI;R—DRAIN&VENT—WATER(IiA) VALUATION
Owner Dae
Wo RK17R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / O
I lies by anion muter penalty of pe Jury one of the following deth rations:
❑Ihuve and will maintainnCmilicate of C...cneoeelTimuref..Worker's Compete DRAINS—FLOOR,ROOF,AREA.COND, ql, ES TYPECONSTRUCI'KI;
catavion,as provided for by Section 3700 of the Leiser Calc,for the performance of the
or which Nis Perron is issued. FIXTURES—PER TRAP
e and will maintain Warkers m
Copensation Ins,more.ac required by Section
GAS—EA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
w W nfthe LabarCodu,for the perbnneirce ofthe work lar which this permit is issued
y Worker's en.Rion I .urance net and Policy n t v set
Cartier; Policy No.: 7 GAS—CA.SYSTEM-OVER 4(EA)
ERTIFICATE OF CMIMPT10N FROM WORKERS' GREASI%IN RL WAS EkCE
COMPENSATION INSURANCE, BUILDING DIVISION ISIS
MisuctionnednotbecompietediftheNmsit is for one hundred dollars($IIX)1 GRI, SEIR
or leasPLANCHI!CK PP.E
I
I cenify thatimhe pe,formancorthe work for whichlhispermit is issued.[shall SEW,R_V I1'1' NY M XI
not employ any poor.in any manner sous m become subjects.the Worker:Compton- ENERGY PEC
Z satinn laws.(C.1ifomia.Data WATTRIAV I RWNF MLECTR
0 Applicant GRADING FEB
NOTICE TO APPLICAMr:If,after making Nis Certificate of Exemption,you should WATER Sys matirlRI!ATING
a ; become uvh{em to[be Workers Compensation pnopions el the labor Code,you must SOILS FEE
forthwith comply with such provisions aphis permit shall Be deemN revoked. WATER SE 1 '
Q ��
Lkt CONSTRUCTION LENDING AGENCY NEW RISIDENTIAI.PLMR. SQ.FI'. PAID Dakt Rtteiptp
.
I hereby affirmthat then Is a construction lending agency for performmnce of )ak
U
the which this lwmut is issued(Sec.3097,Civ.CJ
TOTAL:
0 Lender's Name _
ITyfAI.
U .
Lender's Address
1 earthy that 1 have read this application and stem w
that the aIe bottommost is BUILDING FEE
eF-s� cured.l agree to comply withal[city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT EEE SEISMIC FEE
V K building construction,and hereby amharire representatives of this city to enter months,
idxor-naeurkocd,o,;A b rinspection purposes. PERMIT ISSUANCE ELBCTRIC PEE
(We)ago suv,indemnify and nattiness the City m'Caperton against
iabilitics.ju eat"e Ia a,., ich may in any way accrue against said City ALTER OR ADDIT)MECH. PLUMBING FEE
n muse cc of lh or oft ' mm.
APPLE NTU D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNEEO70 10,00i I MECHANICALFEE
SOLI '1: .G A �5
//� AIRIIANDLINOUNI'I'IOVER 0A I CFM) CONSTRUCTION TAX
Si mreof Ap no contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will eapplicenmr furore building occupant more or handle buvallous material HEATING UNIT(TO 100,006)BTU)
as definel by the Cupenitio Munlcipul Codr,Chapter 9.12,and the I Icahn and Safely
Code,Section 255320)'t HEATING UNIT(OV HR IN)W)B'HJ)
❑Yes [I No VENTIIATION FAN(SINGLE RGSID) PAID '-
Dam Rcttipt M
Will the spplicunt in furore building occupant use egWpment or devices which BOILER—COMP(3HP OR[00,000 NTIH
emit Enormous air ammoimants as defined by the Bay Area At,Quality Management TOTAL:
District! BOILER—COMP(OVER I f1i It I'ED
❑Yes 7N
I have muddies haurdouc reactors requirements We,Chapter 6.95 of the Cadi- ATR CONDITIONER ISSUANCE DATE
famia Health&Safety Code,Sections 25505.25533 and 25534.T understand that if the NEW RESIDENTIAL.MECM SQ.FT.
building does am Omen ly base a tonam,that it is my ce,onvilipay to notify'he tccupam
a]the ox,mrements which must be met prior to issuance of a Cenilleme of Occupancy.
Owner er auaborixed agent Dam TOTAL: ISSUED BY:
OFFICE