25957 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION - � PEaMITNo. 25957 5^5 7
APPLICATION/PERMIT PING PROJECTID MECHANICAL L `�
BUILDING DIVISION BUILDING PROJECT 1!)EN3'IF'ICA2'I(IN
BUI//LDING ADDRESS: r-^I// �� SANITARY NO. APPUCATIONNSSUBMMITAL DATE
K9 57-1 ��J✓ •^'Y UNIT# LOTH L�C.1
OW .NA E: PHONE: CONTRACT'OR'S NAME: LIC NO:(, l••
V /� _�. 5 yz1C�, NIC CONTROL p
ARC(ITE /ENGINEER: LIC NO: ADDRESS: '
I IS c4-e4neg4r Awrr eg4am^)e CA
CONTACT: PHONE: ELCBUILDING PERMIT INFO
QTY. r: E, TRIC.PP.RMIT FEE
L ELE PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
pKZ Ihereby affirm that l sm licensed under provismosofChapur9(commencing with
00 Section 9000)of Division 3 of the Business and Professions Code,and my license is in PANELS
FZ{{''' full force and effect. /
'y) Licwm Class - Lic.# y71OY'� UPT0200AMPS
io<sx, Date Card. r 201-I"AMPS SQ.FT. R AREA $/SQ.IT.
ZOo,z ARCHITECTS DECLARATION OVER 1000 AMPS
b Z^G 1 understand my plans shall the used as public records.
F ce t w SIGNS ELECTRICAL
QY ,'4j Licensed Professional
QQV OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contractor's License Law far the
My following reason.(Section 7031.5,Busum and Profeesirm Cade:Any city memory TEMP.METER OR POLE INST.
0y� which requircrnm
eapnit cmnshuct,alter,improve,demolish,or repair wY structure POWER DEVICES
f Y� prima its issuance,also requires the applicant(orsuch permit to fileesignedswement
that he is license pursuant m flue provisions ofthe Comractors License law(Chapter SWIMMEJQ POOL ELECTRIC
S e 9(commencing with Scoom 7")of Division 3 ofthe Business and Professions Code) VALUAI'I
pay
aided heisexempt Nerefromand the basis for ilia alleged exemption.Any violationof / O O Q
1.. a Section 9031.5 by any applicant for a Permit subjects the applicant to a civil parWty of OUTLETS-SWITCHES-FTXTURFS l
w not mom low five hundred doll.($500). NEW RESIDENTIAL ELECTR _SQ.FT.
C [JI,osowncwDhepropcny,ormycmployceswiNwegesm Neirrolecompensedan, STORIES TYPE CONSTRUCTION
yanilide Nework,andthe structure is not intendedoroffered forsale(Sec.]o44,Business
and Pmtessiams Cade:The Communes License Law does not only tow owner of
propenywhobuildsorimproves therewand whodoessuch work himselforthroughhis
rwnemployees,Favidethat such improvements mcnotinmndeoroffertdf..she.If. OCC GROUT' RES.UNITS
however,the buildingor improvemem is sold withooneyearoftmmpletion.he owner-
builder will have the burden of proving that he did not build or improve for purpose of
B°I`')' Y. PLUMBING PERMIT FEE
❑ I,asowner ofthe property,umexelusively, amrwting with licensed conrs QT
vectoto FLOODZONE APN
construct the project(Sec.7044,Business and Professimu Code:1 The Conwctora
Ucemrc Lawdoesnm apply to an ownerofpropeny whobuildsorimproves thereon,and PEfMIT CE
whmcmnracts forsuch projects withaccntnmm(sHicenud pursumUn Ne Conrectols
License Law. ALTER RA ' �_JI'
V -. A R( FEE SUMMARY
❑ IamexcerounderSec. ,B&PCfarthisrtason
BACK O olY _I V SANITARY YN
Owner Data D INS-FLOOR,ROOF,A .CO 11 RECEIPT'#
c WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby uffiwthatlhaveacenificam ofcanxm mself-insurt,orettnificam of S REChIPI'#
Wotkers'Compemmiot lnsurwce or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
f oversell employee's under this permit GAS-EA.SYSTEMd INC.40UTLEfS BUILDING DIVRECIISION FEES
Policy#
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Caddied copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need not becomificad ifthe permit is forwe buereddollus($100) SEWER-SANITARY-STORM EA.200IFT. ENERGYFEE
or less.)
I cenify Nat in the performance of the work for which this permit isissued.)shall16�Y�J,
WATER HEATER W/VENTIELECfR
not employ any person in any manner so or to become subject to the Worker' PAID
ns
Compeation Lawsof Califomia Data WATER SYSTEMITRE TING Dam Receipt#
7" Applicant
O0 NOTICE TO APPLICANT:If,afar maldng this Cenificam of Exemption.you shouldNEW RESIDENTIAL PLMB. SQ,FT. TOTAL: 61
V] become subject to Ne Workee.Compensation provisions of Ne labor Code,you..,
ai forthwith comply witheach Provisions,his Rwitshall bedecmalmvoked. BUILDING FEE 6700
LQ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 6
tZ I hereby affirm that there is a conswction lending agency for be performance of TOTAL: ELECTRIC FEE
U O the work for which his pewit is issued(Sec.3097.Civ.C.)
Lender's Name
O IsnJcrs Addmss MECHANICAL PERMIT FEE PLUMBING FEE
„
LU 1 cenify Nat 1 have read this application andtat
se that the above information is
0. correct. l agreeto comply with W city and county ordinancem s and state laws relating PERMIT ISSUANCE MECHANICAL FEF.
N builiimgconswetioa,sed hereby euNmiurtprtsenmtives ofthis city to enlerupon the CONSTRUCTION TAX
L) above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupenlno against
liahilities,judgmeats,costs wdexpanses which may'narty wayaceme againstsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in cnm xF` (the granting of this wit.
- AIR HANDLING UNIT(OVER 10,000 CFM)
2!
Si rcu ApFic VContractia p m EXHAUST FOOD(W/DUCq PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data Receipt#
Willthcopplicamar furore building occupant score m handle hasadoas mmanid HEATING UNIT(OVER 100.0011 BTU) TOTAL: Lp a
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Second 25532(a)? VENTILATION FAN(SINGLE REMO)
❑Yes ❑No
ISSUANCE DATE
Will Neappliemtorfumubuildingmcupantuseequipmentordeviceswhichemit BOILER-COW CIHP OR 100,000 BTU)
humrdous air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER IM."BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. yIS a
1 have read the husoeous materials requirements under Chapter 6.95 of the e_ #'1 ' O
California Health&Safety Code,Sections 25505,25533 and 25534.I understand Net
if Inc Building does not turmoily have a tenant,that it is my responsibility to notify the MK
occupant of the equircments which must be met prim to issuance of a Certificate of
Occupancy.
Owner or amhotixed agent Dau TOTAL: ISSUED BY:
11
OFFICE