S 0279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PITRMII NO.
BUILDING DIVISION APPLICATION,PERMIT IHNG PRSC.aa:CENTIFIC Q 0279 2 7 9
BUILDING PROIECI'IDENTIFICATION O .7
BUILDING ADDRESS: SANITARY NO. APPLICATION SUdMI'TCAL DRIB
�2i 1J pe� � � Oq
OWNHIASNAME: 1'110NE: CONI'HACOIH'S NAME!' LIC NO'.
NIC CO
gpNfItOLN
�AHCIII'TP.L'I'IIiNGINI!I!H: LIC NO: ADOBES S
� : ❑ �/I� 1�
!ES W ns. o' utzar
CON'1'ACU PHONIC BUILDING PERMIT INFO
❑ Conmitant I'm Paid by Applicant(initial) BLDE; ELECT PLUMB MdcH
cid ,¢,yrF zs`g-7973 ta '�g ;ff Gd
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I nerchy foto item fun li,rn,cd under",.,of Casts,9(co. nim, JOB DESCRIPTION
�d'Z with Sacimn]OXHofUi,kim 3of1he Hu,inessrund"ofcsion,Code."or,license i. RFSIDENTIAI,
�E, in full fora and cffal. I'ENMI'I'ISSUANCE a
¢l- llWl. C1 KITCHEN HEh10UliL
aVZV
License Chis Iic.N APPLIANCES-RESIDENTIAL DDITION ❑%,UMBING RE-PIVE
I-.10. Gore
C�ntrvctur
ARCIIHECrS DECLARATION ❑A LTE-UNIT ❑STRUCTUHAI,
'luderstaml my Mens shill hetxda,Public rxcall PANEIS
ZONZ MODIFICATION
OZ�-'per UPT02MAMIN ❑USERIIIR ❑CHAINF,Y REPAIR
G��u] Licensed Pmfouinrul 101-1000ASIRS IMPROVILMElsV E]SWIMMING POOIS
OWNER-BUILDER DECLARATION OVER 1000AMPS El BATH REMODEIIItF.PA1H ❑DFJs1QLITIQN
C W Q 1 harsh,eRnn tbm I.m esemq fru.the Cmm.emrs license Law forthe
L O L U following vamon.(Salion 7031 s,Belin esx and Pmu,sions Coale Any city or coumy SIGNS HLECLUCAL ❑OTHER
u1 IL whim r�YirtA Y PC.YI m c0¢�1N[I,Mer iI111NTC d[IM1;li,n.M RPNr any YN[IYM1' �A A
prtbeisssenwil e,alcarcqui11.deapgicam for Coo Permit Lien 1C1ucmmt SPECIAI,CIRCUITMISC. —
�y the Nu.....scJ pursuant tri Phu ofDi,iun,ofof Cnmrucessroscenn:law(Chega9
�CO (romnercixanith5cnior.andI alDls'Islm3 of Reaped ax,attd Pmfedma,CMe)or TEMP.MMR OR POLY.INST. /�
a%o eC nil le is exempt Ihvcfmm end the basis for tlr ellr6cd urntryion.Any s*,wnon of ❑NEW I'AIQJI 1R{ry�}'�p)'D SLITION
ERVI
y Section 703 5 by any applicant for a permn sunceis the applicant ton civil Penalty of POWER DEVICES ❑'fGNANT LJl'[]f)U SIiNVICL
F Z Y not more Arm five hudred dollurx Gifts)). IS F 1
I;uwmer of Ate pcpcny.ormy cmplvyswid wagesas Heir Wecmtpemmim. SWIMMING POOL ELERIC ��' uurtHl7N()
a=Q � CT
F,O will dvhe work."the grvchimisra;mended rrrlicnd 4nvle(Sec]ON,Bu.mos ❑OTHER
W�. ford Prufecsi^n,Cotle:The,Central I.Xcnw Use Joe,not apply to an owner M OUTLETS-SWITCHES-FIXTURES
el. propecy who nuild,all impova Aerem,and!will Jsea such work himself or Ihmugh
his own employs,Provided that such imgovemcris are not inco l or offered for NFIV RESIDENTIAL ELECTIR SQ FT.
w1aIt'.hclwever.Ihe building or improvement is add widinoric yewofcanpinirm,the SQ.FF..FLOORA IiA LSQ.FT.
o„
noxi-hider will hove the burden Of Ivwing that he did nN ba lld or Imgove fed qu-
fwle.).
L owner of tie Fro eny,am exclusively contracting with Iwemad mnlor acrs err T T
t the pmjmt(Sm.'lOsa,Business and Pm[a,irm Codc:)The Contras G
en,claws.x iMlyto nownerofpfo ywh^bnild,nimpmvesmen(m.and Qn% PLUMBING PERMIT FEE 1 "'
wed contacts fir such pnrJcreu with a contractures) iccn+W pursuant to EaCrnlraetors
License Law. PERMIT ISSUE
❑ I am exempt under Ser. /O`/-u ,B&I'C for this rruvn
ALTS R & '. '1'-WAVER GFA) VAL
Owner;
Date
ORKIR'S COMPENSA ON DECLARATION BACK FLOW (TIELT. ' 1 b a ��
I here Y affirm(near pemllY n(pp jury nc cal INC foltrwing dcluminn,:
❑Ihave afd will exaintvn a Cattle.N CmxxrI to self-insure for Wickert'•Coospem DRAINS-FLOG GAR
cation,a,Provided fur by Section 3"!00 of the IaMCod,her Cofar the E ceforrmnxc n(the SCORE NPE CONSTRUCTION
work for which this peril is a sued. FIXTURES-PER TRAP
❑1 have and will maintain Worker',CU.pvssado,Imamate,-ryuired by Section
3700oflhc E&I rCade,for de pefforurecofne,work forwhich do per.it i,ieual. GAS-EA.SYSTEM-TNC.40 S OCC,GROUP APN
My Wnder',Cour emnlion Insurance Cartier and Policy,nuenlaer mr::
Cartier Pall,Nu.: GAS-FA.SYSTEM-OVER)(A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INIT:RCEPIDR
TD,welian nml not be ermphtd i l the penult i.trune humdml collary IS 1011 HUI )I VISION PEES
m la,.)
GREASE TRAP �
PLANCFH:CK tE
I ttnily irks in the ter(nmwnce ufthe work fir which his permit is iumJ,lshell SEWER-SAKETARY-STORM EA.20X1 FI'.
not century any petmn In any nwnncr so as to haeme xubjeat toted Wirtrri Cooper, ENERGY IIT
ZZ Nation Lias of C.Iifineie.D.uc WATER HEATER WNESEPHLECIR
O Applicant GRADING 19 '
Iq
ADVICE TO APPLICANT':If,after making this Centeno,of Excntgion,you dmud WATER SYSTE-M/ EAHNG SOILS
becorA
ne,obje.ten e Wrekermrn
s Ctpsmimt provision,of ole Labor Cade,you mail 's
foMwith m comply with such tmvl sxor this pertit shall he Jcul revoked. WATER SERVICE!
a �
Cia,hal UCfION1,ENDINGA i,ne, NEW'RESIDFNIIAL%Jr18. SQ.FT. PAID
7 Z tI-w fh do dvthere isaali(See ran leMin Date RttcigN
y e g agency far the perfomurce rf
U O Ire work r whim die�nnh is iamd(See xH],Ci,.e.)
F, hoer"NanoaaTOTAL
U Lenders cerify,
W BUILDING /N
1 cenify IM1ut 1 M1uvc read this.ppticminn mW ntwc that de uMrvc infomalim i,
Val currecr I agree n.asmplY with all shy cad axmry orJinancu vfd nuox laws mistime m rQTY. MECHANICAL PERMIT FEE O
t
U Z inklingormruc
ctint.afdereby a
tail r ,pm anter upon of this cityantupon the SEISMIC FE.
chose mannered!lwfc,fmqisc,,in ¢cliort purl PERMf1'ISSUANCE
TU
(We)egrec to save,indemnify sold keep lufmll de City of Cupeniess against ELECTRIC 'EI!
linbililla.judymcnta
areas;all ssprn,e,which mayd any way rcme against aid City ALTER OR ADD TO M ITCH.
in m,aiuenceof Ate posing of die permit PLUMBIN FEEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0I)CFM)
SOURCE REGULisT1ONS. KIECHANI LITE
AIR HANDLING UNIT(OVER 10.010 CIM) CONSfRUCIIONTA
Signort ofApplican✓Cmmaxer Daae EXHAUST HOOD fWA)UCn HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will Ilia applicant or future heiklingoecupsurd Nneor handle haauMw+rears l HEATING UNIT(10 100.00)d'IV)
as defiled by the Cupcnitn Municipal Cede,Chapter 9.12 and!the Health afd Safety HATING UNIT(OVER IfN1,Og1 BTU)
CMC,Seddon Z5932ta)1
E]Yes 7 N VENTILATION FAN(SINGLE RF_SID) PAID
Use RadgY
Will Arc applicant or fmurc building occupant use<Ruitnent or Mica which
mA hu'ranfms air cnnlaminant,w Jetind by the Bay Arab Air Clarity ManagementBOILER-COME'(3HP OR I W,(0)BTU)
�stnctl BOILER-COMP(OVER 100,001)BN)
❑Yrs FIN.I have read AblehveNoons ntwtcrials recuitmd
ccnns Oder Chapter fi 95 M the Cali- AIR CONDITIONER ISSUANCE:DATE:
forma Health&Safny Corte.Sectiones;n."..3533 and 2553x.I unln.+efd Area if Are NEW RESIDENTIAL MECH. SQ.
Jon FT
holding ro csoontfy Inv,a mwm.MA it k my msiornihtorridly rntily de occvpnl
a
of the rryaueu whish mimed he naw gior N i.ss.a.Cadds to M Oohed,
Owocr ramMriad agent Datu ) ISSUED BY:
OFFICE