26545APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPESIO NO BUIL"APPLICATION/PERMIT
BUILDING DIVISION PLUMBING C'F ID IANIFIC
BUIIDING PRO.IELT IDN;NTIPICATION
PERMIT NO.
26545
BUILDING ADDRESS: ,
SANITARY NO,
APMUCATIONSUBMTITALDATE
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WA UNITS LOTH
PHONE
OWNERSN�i
CO ON'S NAME: LIC NO:
NIC
❑
G NIROLY
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// rro 57GIL'
LIC NO:
ADDRESSpynl OeR1V
CONTACT: R{ONE
QTY. ELECTRIC PERMIT EEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECE
PERMRISSUANCE
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihacby of Division3 ofthevcdurdm prwiaionofC Code. ndl my mains, wide
Sclivn ]0007 of DivisionJof the BuslrtevsvM Pmfeatiord CMe,md my liameisN
full force arch eff
APPLIANCES -RESIDENTIAL
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JOB DFS ON
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uProxoo AMPS
:Nax01 - 10110 AMPS /N
ARCIIf1ECTS DECLARATION
I utdcomid ro"I. shill b ioadl as' Nie retorts.
OVER IMAMPS
SQ.fT. FLOOR AREA
f/SQ. FT
SIGNS ELECTRICAL
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Liceo iRvfea'vu1
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OWNER -BUILDER DECLARATION
I M1emby affon that I am exempt from the Cauranala Lkrnte taw for the
following mmm(Scctim ]0313, Buwev and Profewian Code: Any cilymwunly
which rryuim a penrvt to contract, al inpmve, demolish, a repair any smsame
prior to its issuance. alar ou,so,r the eppliram for arch Permit to fik a sigrcd vuem,ot
tart IK is liancd punvtnnl b the pmvuiau dthe Gonuudor't uccmc law (Chapter
9(,omrm ins, withSecti�n]ll(n)of Divoino Sof the Boom,,,sand Profession, Code)
or thsr he it stemptthetefmrn and the seats for thealkYed exemption. My violation M
Sction7031.5 by any applicant for a permit subj" the applicant to a civil pmulry M
not mac stun five 111ndrml dol Ws ($5004
❑ I,vowmrofthoprnporry,ormyy ploys withwogm&rt drwlecompwauan,
SPECIALCIRCUIT/ME;F.
n I fY`ge
—. Lti1'1 Ys, V
I.
TEMP. MLTERORPOLEINST. 0 n A ^
1 1• r \ t -� I
POWER DEVICES '
rII
SWIMMING POOL ELECTRIC r n \ 1, v 1 u
..y V <'_ VALVAHON
1/(,
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL EIECIR
LORI
TYPECONSTRUC I N
will
ande3—
Prfesvoh, C,x1c hr,Cmeisrotin Li laffmydfa .,Iy 1. ron owner
Cak:'llrc Coamclor's License Isar Jmtl ros apply to an owns. of
pm extywvau
own crtywMb,Voyritnprovtld or,movrdwbadaenor mourk himcHorthnough his
roti rooMNaofferd fa We. If,
crop(the,bugnvid<dlbmwch ant
OCC. GROUP
RFS. UNITS
TO
is sed wood.
however. Nebuilding«impo suvir, is add wdidnoneyar ofavrnnve for theowner-
will have IM1e burJen of proving that he did not build m improve for purpme of
G
Qom' PLUMPING PERMIT FEE
aste.yr
❑ Le. owncroflM1e pmpeny,em exclusively cmuslingwith liceredcwvwwnlo
El
FLOOD ZONE
AEN'
c«uutat the Imsjct (Sec 7814, Busima arch Roftlaiau Cade:) The Convvebas
License Lew Jrxs not appty to an ownerofpmoertywMbuildsavnpovn daeceon,and
PERMIT ISSUANCE
who cwVacts for such oxets withacontranm(a)Iianacdpurauant loth[ Contractor's
License taw.
� -DRAIN&VENT-WATCR(E)
FEE SUMMARY
❑ I un exempt uNcr $a. , tl & P C fm W a reawnIDL
BACK F10W PROTECT. DEVICE
!
SANITARY Y N
Ovnar Dose
DRAINS- FLOOR, ROOF. ARIA, COND.
RFCEIPI'N
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
1 M1acby affbm tbu 1 Nvc • anifieate of Cmaenl lo,clf-inset, a • anifcuc of
ork.Conseruatioo her.aaarrifseEco%Ihercof(Sa. 3800, Lab C.) whireb
t—,
FlX'IURFS - PER TRAP
RECEIPTM
PARK FEE. Y —N—
all employee: archer W t proms.
Policy Y
RECEIPT 0
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Corn, y
GAS-EA.SYSTIM-OVER4(E)
PIANCIIECK FL'B
❑ Cenilied co%ia M1ertby fumidsed
GRESMNDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ CertifiM copy is filed wish thm city inspection divium.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS IFF.
SEW fiR-SANITARY - STORM FA. 3(10FT.
ENERGY RT
(Thio cation nad ma bernmplued iftic permit c, faorc hlodrM dollan(SI00)
a les..)
WATER I [FATES W/VEM'/ELF,CI'R
I ratify that in the perfmr .fNeworkfor which this pc nom is issued, I shall
M "kay any Persoo many mmuar w as to bet c subject to the Wakai
PAID
WATER SYSfEAV1RPATING
O,z
z0
Cartpcnlretion laws of CJBmnia Due
AMR.
Dae R«iptat
NOTICE TO APPLICANT: IL after meting this Certificate of Escmption, you should
NEW RESIDENTIAL PI -MB. SQ, IT.
TOTAL-
OTAL(n
(Z)
W5:
become mrbicl b die,Wal Canpe"co am provoiae of the Labor Code, you mum
Rmhwim comply with such pmsi,ir—or shit pcmlitshall he dcvtad revoked.
BUILDING FEE
SEISMIC FEE
LW 0. Q
CONSTRUCTION LENDING AGENCY
U Z
O
O
e pmurtce
I hereby affirm Nat Jaen is a construction ding ageray fa the of
the work for which Pit 'mm is issued (Sec 30s0, Civ. C.)
1<Mr'a Nmrc
NameAddress
I TOTAL:
ELECTRIC FEE
IsraNa p 71
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
F"'rnn'
L) Z
I ccnify that Heave read Ws and state that da abate to.. la
cumecl. legtm mcomPly witM1 nil city arch wumy admanctl arch state laws mlewglo
bwldingeorixntctior, and herebyaudwniee reprstwtivtl of Wscity w mum upon the
shove-tnrnrrnrseJ FmRny foriruyycticn purpamv
PERMIT ISSUANCE
MECIIANICALFEE
ALTERORADDTOIrtECH.
CONSTRUCTION TAX
(We) egmc to save, ,_. _ ..y and tap liemlca dt< City of Cuperdro agaimt
li udgmene, ma.mal ea ,which yinany wvy cerise agaiwsaid Ciry
AIRHANDLWGUNITCO010,OOCFM)
of this
O�-3/— f
�J
AIR HANDLNG UNIT(OVER I0,XXCFM)
.ipalurem'Appticant/Camruaa a2
EXHAUST GOOD(WIDUCT)
PAID
NOTING UNIT( ID IropOp BT'U)
MATIRIAIS DISCLOSURI
HAZ.ARture
Dmc Racipt#
building
WiD Ne the Cu,ormnaam or uCase. Cwtdtrrtar hanand the
Aefiad by de Cupcniro Municipal Code. Chapter 9.12, arch Ne Health aM Safety
HFATING UNIT (OVER il))." BTU)
TOTAL
TITION FAN (SINGLE RESID)
VFNE
Cal
Code. Sctian xSSJx(a)'f
El Yea ❑ No
Will dseapplicmllafumrebuilding pantuaecquipntem oro mdevim which vett
BOILER- COME (311P OR 100.1100 BTU)
ISSUANCE DATE
ffdffiftwrslwu
air trmrdt..r. m define) by rise Bay Ao,a Air Quality Management
atria]
BOILER-COMP(OVER 100,000 BTU)
❑ Yes ❑ No
I have read thte hvardws materials is under ser 6.95 of the
rtg5,155 Chea
f!
C4 Gz
NEW RESIDENTIAL MF.CII. SQ. PI',
aIlcadhts Safety Secliorri 5531 that
1ity
-
ox
if the .fortyr25514.
to omit
ifla,Pcom off dotlnor rnorm, dy has.<ruxa be lh price.
rie.iss,PaLSibf.Cer awRon the
Npanl of Ne rtGuireRlnna whkh rma be rraf prig w iasuarce of a Cmtificue M
Ikcupom:y.
.QSEP .a
t.-� 1
ISSUED BY: —
Owneraamhnri'md agrnt Etc
TOTAL:
OFFICE