24802 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
BDH.DI .-ELECTRICAL. PERMITNO. ^ zee ^O/N
CITY OF CUPESIO NO APPLICATION/PERMIT PLUMBING-MECHANICAL L 4 }V( L
BUILDING G ADDRESS:
DIVISION BUILDING PROJECT IDENT'IFICAT'ION
BUILDING ADORI?SS: SANITARY NO. A�PP1L/IC—ATaI�O/N S^U�BM(IwTT�A2DATE
' O "220 C.C.P. UNIT LOT# ✓ `J _VV
NER AME: PHONE: COMRACfOR'S NAME: LIC NO: NAC CONTROL#
RCHI NGINEF.R: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FF.E
BLD P� MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL lOB CR
000 Ih7")ofmvision amlicensed names itProfesioChapter and(commencing with
�00 Seetion 7")of Divisimnlof the Business and Professions Code.and my license is in PANELS 1
toll force and effect. UP TO 2M AMPS P
<ZtU Lomas Class Lit.# -- -
t[o—<Ly Date Contractor 281-IM AMPSUe— , LOO - SSQ.FT.
zOya ARCHITECTS DECLARATION OVER I"AMPS � �
o z p Ind
uerstand my plana shall od used as public records.
rN. SIGNS ELECTRICAL . A 11 y P �I F7 R
.,.1 Licemal Professional Ipl••(l
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
w, www
a�dd O y F 1 hereby affirm that 1 am exemps from the Committees License Low for the _ V
u13au,a following=son.(Section]031.5,Business and Professions Coda Any city or county TEMP.METER OR POLE INST. ATE
�O l which requiros a permit to construct,alter,improve,demolish,or repair any structure
,rzf}� prior in its issumm,also imams the applicant for such permit o file a signed statement POWER DEVICES
p that he is licensed Ammar no the provisions of the Cmmmcror's License Law(Ch-Pum
pSWIMMING POOL ELECTRIC VALUATION
m
R' a 9(comeoeimgwith Section 7000)of Division 3ofthe Business and Professions Code)
W_w or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTl1RE5
tz,Q Section 7031.5 by any applicant for a lemur subjects the applicant to a civil penalty of
S< im,mote tlwn rise hundred dollars(5500). NEWRESIDENTIALF.LECTR _SQ.FT. STORIES l'YPECONSTRUCDON
❑ 1,nsownerofNopmperty,ormyemployeeswim wages as thelrsolecompensatimn,
enl amthework,andthe he Conianminmdederoffendforsale(sec.t a4,owniMss
W Professions Code:TTe Convenors License Law rices or apply tom owner of
property who builds or improvestherron,undwhodcessuchwmrkhimxlforthrough his OCC.GROUP RES.UNITS
own employees,provided Net such i mpmvemmts are nm intended or offered for see.If,
however,the bulldingsnimprnvemenl is sold withinon,year of completion,them mer- TOTAL:
builder will have the burden of proving that he did not build or Improve for propose of
le.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as owner ofthe property, nt
y.aexclusively contracting with licensed coractonsm
cnnsuuct the project(Sec.7034,Business and Profession.Cdc:)The Contractors PERMIT ISSUANCE
1]cenx Law docs nm apply t o on er ownof pmpeny who bui IJ
s or i m proves thereon,and
who contracts for such projects with acomarions)licensed pursuanuothe Cannot ALTER-DRAIN&VENT-WATER(EA) MESUMMARY
'i.Low.
❑ I em exempt under Sec. R&P C for this reason BACK FLOW PROTECT.DEVICE UT.ID:FEES
SANITARY YN
r Date RECEIPT#
WORKMAN COMPENSATION DECLARATIONvviouDRAINS-PLOOR,ROOP.ARFA,COND. SCHOOLTA% Y__N_
[31hembyaftino that l have a cenifcate ofemsem to self-insmFIXTURPS-P
s,or a O,aifcate of RECF.IPfM
Woken Compensation Insurance or u certified copy themof(Sm.3800,Lab C.)which ER TRAP PARK ME Y N
RECEIPT#
coven all employee's under this permit. GAS-PA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FEES
Policy#
Company GAS-PA.SYSTEM-OVER 4(BA) PLANCHECK ME
❑ Certified copy is hereby fumishd.
❑ Cenilietl copy is filed with the city inspection division. ORFASMNDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' ORIASETRAP soils FEE
COMPENSATION INSURANCE
Cutis sarmnned tat becompleted ifrhe permit is forms,hundred dollars(SI00) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
m 1e ca)
I certify that in the performance ofthe work far which this permit is issued,Ishall WATER HEATER WIVENIORLECTR
cad emyploany person in any manner so as to became subject to the Workers' PAID
Compensmioulswsof Califnmia. Dote WATER SYSTEM?REATING Date Receipt#
0 z Applicant-- NEW RESIDENTIAL PLMB. SQ.PT. T'OTAL:
�j 0- NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should
s7 �• nomare subject to the Worker's Cumpenxtion provisions of the Labor Code,you must BUILDING FEE tree
Forthwith comply with such provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ,Q
Lender`s Name PLUMBING
Fl:E
T. . Leather Address QTY. MECHANICAL PERMIT FEE
O U 1 cenify that 1 have mad Nis application and sma that the above infmmmlon la MECHANICAL FEE
>" W cored.legrec mcomplY with call city anJ<aumy ordinances and state lnwsrelutingm PERMITISSUANCE
91.y buildingconstruction.and hereby authorize repmsematives of Nis city reenter upon the CONSTRUCTION TAX
U 7 above-mentiond property,for inspection pwpoxs. ALTER OR ADD TO MECH.
n•-7- ' (We)agree to save,indemnify and keep harmless the City of Cupenino against
hubilities,judgmeats,cnstsunitnseswch may in my way accrue against said City AIR HANDLING UNIT(TO RXOCFM)
in asnx u mem the gree' rmhi
AIR HANDLING UNIT(OVER 10,00)CFM)
S r plicmUComrector m EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,800 BTU) Date Receipt#
Will the applicant or future building occupant some or handle hvxmdmis material HEATING ON IT(OVER 100,800 BTU)
as dented by the LLpenine Municipal Cole,Chapter 9.12,and the Health and Safety
Cade.Sation 25532nd? VENTILATION FAN(SINGLE RESID)
11 Yea EI No ISSUANCE DATE
Will theapplicanmr fu[umbuildingaccupant useequipmemordeviccswM1ichemit
BOILER-COMP QHP OR 100,000 BTU)
aardous air contaminants as defined by the Bay Arta Air Quality MmagecuZ BOILER-COMP(OVER 100,000 BTU)
Droner? -11PAID
❑Yes No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hauudous materials requirements under Chapter 6.95 of the
CulifomisI1ealth&SafetyCd,,Sections25505,25533and2SM. luratmmdthm FV r 8 ,E5190)
if the building does not currently have a rent,that it is my responsibility m notify the
occu the requirements wmust
of ihich Fe met prior to issuance of a Certificate
g
ificaof C
Occupancy.
fry
Owner ormalmaiud agent Dam TOTAL: ISSUED BY: U
OFFICE