25841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE1.1TINO III PERMITNO.
APPLICATION/PERMIT
PLUMBING 25841
BUILDING DIVISION BUILDING PROdRC1'IURNI'IFIGTION
BUILDING ADDRESS: l I� /��/��//����� - SANITARY NO. APMCATIONSUBMITTALDATE
Of
O' 3 k P� T I �—Z-a P� UNIT# LOT#
OWNERS NAME: PHONE: NTRACTOR'S NAME: LICNO:
klfs N/C �•� CONTROL#
I ARCIUTEQfENGINEER: LIC NO: DDRESS: ❑ /I�•Y'#�/ #
CONTACT: FP172 (i.� Qom,4'i,,� *fi x aEL RIOPERMIT FEE BUILDI(N/G�P"E�R�M/IT INFO
F BLDG PLUMB MEC
2 �a � PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz Iherebyaffl=thatlamlimnsdunderprovisionsofChapar9(colmnmcingwith JOBDESCRIMION
+4100 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS
K
F.. full force and effect
P�Zy`!1 License Class P, Lu.# 68"1U S UP TO 200 AMPS
y ftD Camara, r 201-1000 AMPS
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR $/SQ.FT.
OZ^G I understand my plans shall he used as public records.
K y�lSIGNS ELECTRICAL
Licensed Professional
�Cw'u
OWNER-BUILDER from
m doo ORATION SPECIAL CB1CUIl'/MISC.
OaU I hereby affirm that 1 am exempt from Ne Conwetore License Lew for des
1+13 a y
following reason.(Section 1031.5,Business and Profrsamns Code:Any city or county TEMP.METER OR POLE INST.
F-�v� which rcyaires a permit to construct,slue,improve,demolish,or repair any awemre
tic Tai prior to its issuance,also rectubes the applicant for such pemdtto file aaignedsummem POWER DEVICES DI\
1u`5 0C that he is licensed pursuant to me provisions of the Contractors license law(Chapter SWIMMING POOL ELECTRIC VV
9(commencing with Section 7")of Division 3 of the Business and Prifesaio,u Cade) VALUATION
WM, err that he is exempt therefrom and the basis far the alleged exemption.Anyvioldonof SWITCHES FIXILRES
GSection
nthan veanYapplicantfm apermit subjauthe epplicenno acivil peneltY of
m o
mre than Eve hundred dollars($500). NEW RESIDENTIAL ELECTR _ S .FT.
p ❑ I,uownerofinepmperry.ormyemployas withwagesastheirmlecompcmadon, _SQ.FT.' TYPE CONSTRUCTION
a will dolhe work.aod the swnum isnmintended oroffered forsale(Sm.1044,1dnsinhas
and Profusions Code:The Contmcam s License Law does not apply to an owner of
property wholowldsarimproveslhereogand who does such work himselfor throught is
OCC.CROUP RES.UNITS
Awnemployers,pmvidd that such improv led wit arc not oundexmoffendfor sale.IL
however,the building Orden of emem is sold within ar,e yam of improve for thepose of
' builder will have the burden of poising that he did not build or improve for purpose of
sho). QTy, PLUMBING PERMIT FEE
❑ I,uowncroflhepropenyamexclusivelYconvaclingwiNlicensdcolnratmm FLOODZONE
APN
construct the project(Sm.1014.Business and Professions Code:)The Commmols PERMIT ISSUANCE
License Law does not apply to nn owner of psoperry who bui lds or improves thereow and
whommruclsforsuch projects with aconaamor(s)licensed pursuant to me Convectors ALTER-DRAIN&VENT-WATER(EA) FF17SUMMARY
License law.
❑ 1 am exempt under Sec. ,B&P C for this reason OUTSIDEFEES
BACK FLOW PROTECT.DEVICE
SANITARY YNR
Owner Date
, , RECEIPT#
DRAINS-FLOOR
WORKMAN COMPENSATION DECLARATION ROOF.AREA.COND. SCHOOL TAX Y N
❑ Ihertby aRnn thetlhaveaartificam of cmnsenuo self-:Assert,oraanificaa of Fl%111RES-PER TRAP
Worken'Componation Insurance or a certified copy thereof(Sec.3800,Lab C)which PARK FEE Y N
covers all employee's under this permit, GAS-EA.SYSTEM-1 INC.4,!� / RECEIPT#
Policy# BUILDING DIVIS ON FEES
Company GAS-EA.SYSTEM-'�, PLANCHECK
❑fmird copy la hereby furnisbd. a, �y,y
Codified copy is fill with the city inspection clivus: GREASEnNDI�.' r.ZcMINTERCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WO RS' GREASETRAP\ SOILS FEE
COMPENSATION INSURAN
(This section nerd wine completed ifthe Permit' ehund d11 ($100) SEWER-SANITARY-STORM FA.200F1'. ENERGY FEE
or less.)
I certify that in the perfomunce of thew f ich Nis pourn.W, sed,ishill WATER HEATER W/VENT/ELECIR
not employ any person in any mower so as oma s w Ne WmkerA PAID
Compensation lawn o(Glifomia. Date WATER SYSTEMJTREATING Dom R
O z Applicant
NOTICE TO APPLICANT:IL aper making this Coni ate of Exemption,you should NEW RESIDENTIAL FUME. SQ.FIL TOTAL:
V) become subject to the Workers Compensation provisions of the Labor Code,you mus BUILD G
1
forthwith comply wish such provisions or this permit shall be clamed revoked.
Its A
6Wi G(] CONSTRUCTION LENDING AGENCY S C FEE Z
2 I hereby affira that there is a construction lending agency for me performance of /1 IC FEE
U Q the work far which mis permit is issued(Sm.3091,Civ.C.)
Lenders Name
Lenders Address QTY.- MHCHANICALPERMIT FEE PI aME
r kU11 I minify that I have mad Nis aPPlication and sure mal the above informati §` '' " "`"` "e
•1' correct I agree m comply with all city and county ordiruncu ad slaalawartlsli gt PERMIT ISSUANCE rL , AL FEE
building conswction,salloorby authorise expersentativesofthia city to scom.prs the
L-i VJ CONSTRUCDON TAX
U 7 above-nomliond property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m ave,indemnify and keep harmless the City of Npenino against
liabilidw,jud cormandUpsenes which me yin any way accmcagalnatssid City AIR HANDLING UNIT CFO IQ000 CFM)
inc sequc e diet this peamit.
,arom'(J_ AIR HANDLING UNIT(OVER 10,000 CFM)
gigna ¢o Applic omucmr I owe EXHAUST HOOD IW/DUC11
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('1'01W.W0 BTU) Date Receipt#
Will lheapplican,a,fuumbuil&ng mcupmt t.or handle hvardws material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by me Continuum Municipal Code,Chapter 9,12,and the Health and Safety
Coda,genlmn 2353$x)'1 VENTILATION PAN ISINGI.E RISID)
❑Yee ❑No
ISSUANCE DATE
Willmoispplicantnrfuture building mcupantuse wimpenemar devices which emit BOILER-COMP(3NPOR Hg),"BTU)
wsordom air contaminants re defined by the Bay Ares Air Quality Management BOILER-COMP(OVER 100,0110 BTU)
DislrictT P! � ' D
❑Ycs ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hsasnlws materials rclairements under Chains,6.95 of the �sl���
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that p
oiu
f me building does not currently have a naa6 that it is my responsibility to notify the
Ocepanic f me impiarmens which as,he mel prior to issuance of a Certificate of Y
p y 11
Ouvemmmahodudageat Dale L ISSUEDBY:
OFFICE