S 4350 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 4350
BUILDING PROJECT IDENTIFICATION
BUILDINGADORF_SS; SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S# E: /illi LIC NO:
N/C CONTROL#
. RCHITECrIENGINEER: LIC NO. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Z ?Z El El E?� ❑
LIE C N T' k'S DLCLAkATION QTY ELECTRIC PERMIT FEE
1 hereby acorn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section]0uo)of Division 3ofine But, ana leaaiomeoae,andmy Beenseis RESIDENTIAL
F O full force and I. PERMIT ISSUANCE
CSF '" e�"c_-�G ❑SFDWL ❑KITCHEN REMODEL
GUU License Clans Line. API'LIAKCF.S-k[SIDIiNTIAL
y G fu Dale Cnnmannsljy .�,` ❑ADDITION ❑PLUMBING RE-PIPE
p.7y
ARCHFU CIPS DECLARRFION PANELS El MULTI-UNIT ❑STRUCTURAL.
Z p N.Z+ 1 undernmd my plum shall he used vs public records MODIFICATION
O Z-C UPTD 2M AMPS ❑INTERIOR
EPAIR
P,4tW Llcrol Professional 201-I00OAMPS IMPROVEMENT ❑SWIMMINGNEY POOL
WYE', OWNER-BUILDER DECLARATION L)SWIMMING P001.5
pC C Q 1 hereby affirm that 1 at.exempt from the Cnntmeam's License Law For the OVER 100 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
yKj'3 W F following reamer(Section 7031.5,Business and Profession Code Any dry or coumy SIGNS ELECTRICAL ❑OTHER
y which requires a permit to construct,alter,improve,demolish,or repair any structure �0 �N
F�05 priorm its issuance,also requires the applicant forsucM1 permit In file a signed statement SPECIAL CIRCUIT/MISC.
E�yJ
that he is licensed pursuant to the previsions ofthc Commetas License Law(Chapter 9
(commencing with Section 9000)of Divi%iun 3 oflhe BUsice—nal Professions Code)or TEMP.MEPOLL'TER OR INS'E COMMERCIAL
W a C that he is exempt therefrom add me basis far fie alleged xemp im.Any violation of
o P ❑NEWBLDG/ADDITION []DEMOLITION
Baron.9131.5 by any applic"n1 fm a Peaail suhjems the applicvm to a civil pu.,ally of POWER DEVICES
[I TENANT
~ mu more than rive hundred dollars($500). ED row SERVICE
^'SQ I,us owner of the n
IMPROVEMENT
❑ Prmle gur my ctnploycd wi0t wages vs theinnle mnnpensmina, SWIMMING POOL ELECTRIC
H will Bothe work.and the hominis oLicense Law do s not
apply to an coviver oz LI OTHER
O
13 m iia xmv%he b Code r The ContractorsmeeL and
w Law does sat apply s an rtthro of OUTLETS-SWITCHES-FIXTURES
progeny who builds or imP that
thereon,and who arts such wnrk himself or through
his own oweverex,provided that prov meet is sol within arc mol intended ur offered for NE\V RElIDENTIAL ELECTR SQ FT.
nailer M1awncelM1ebuildefaring nmpmvememithat heion build a,improve
5 .FLOOR
erbuilder will hove the burden al pnrving that be did not buil)or improve lar par-
Ease of sele
1I,as owner of the propenyl am.Business
contracting with licensed will i. TOTAL: ! I '
easLaw does
;oapplyto ant owner
and Prafnoi ba Cao":)The Gmtmdon.Lit Q i ( JUN 2 5 1 99 I
Lease oms J«rumOft Pr man with
Li ofpropery fi fenw ldsor improves Centra and TY. PLUMBING PERMIT FEE
ho nmlmcls fur such projects wile a cnnlrnnnr(x)Iiccn,ceA purxunm to the Conwemr's (
Lm°me law. PERMIT ISSUANCE
I-]Ism exempt under See. ,11&p C it,,this reason
w
ALTER-DRAIN&VENT-WATER EA)
IL
� Owner Date .__VALTlATiON ....._ ,^ ,
WOR miller P COMPENSATION DECLARATION BACK FLOW I'ROI'ECT.DEVICE
1 bn alba miller aander penally of perjury one odecimations:the following decimations:❑ (have and will maintain a Ce 3700 ofComent
Labor
Code.for
for
erfor aGmtpen- DRAINS-FLOOR.ROOI(AREA,COND' STORIES 'TYPE CONSTRUCTION
ration,as provide)lin mi Section 3]W of the labor Cotler,for the performance of the
wad for which this permit is issued. Is1X'I'URLS-PER TRAP
❑ I have and will maintain Worker's come ofthe L nkInsurance,for wh1 h required by Section
l](p of the laMn Code,,fonM1c performance oflhc wnrk for whichthis} 't's d. GAS-EA.SYSTEhf-I INC.a OUTLETS OCC.GROUP APN
My WnrkcUlConyguoyyn. e cermet and Polity/ ��.:7�f`
Cartier:�!!Y /lam POIIry No.;-r `� O GAS-EA.SYfi'f6M-OVER 4(BA)
CEB TFICATF,OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASESNDUSTRL WASI'F.INTERCEPTOR
(This section need not Ine completed if inepermit is(crone hundred dollan(5100) BUILDING DIVISION FEES
or less.) GREASE'I'RAI' pLANCHECK FEE
I certify that ran,performance afthe work far which this permit is issued,],but]
seuonlaws of Califon air mbcunnc wb' IFW17R-SANITARY-STORM EA.2W IT.
co,do,any prrson y manner ser us )cit m the Workers'Cmnpcn- ENERGY FEE
QZ ice.Dam WATER HEATER W/VEN DELECTR
Z C) Applicant GRADING FEE
N
NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTENUTRF.AI'ING
hennnu subject to the Workers Compensation provisions of the Labor Code,you mum SOILS FEE
W forthwith comply with such provisianx or this permit shall be dented revoked WATER SERVICE
4 Q
CONSTRUCTION LENDING AGENCY NEW RESIDF,NTIAL PhMB. S
a Z Q.FT. PAID
V I for
rnthmtthi is ed(Sectionll ling agency for the perfartnance of Data Receipt
� f-' the work for which this permit is inwal(Sec.J1n],Civ.C)
C) Lender's Name TAL:
V Leaded Address O'1' L:
1 emify that I have mad this application and nae that the oRave information is BUILDING FEE
h correct Iagree tocomply wM1b all city and county ordinattvs and state laws feluting to QTY. MECHANICAL.PERMIT FEE
(..1 Z Ift Mrgcaasbunion,and herebyaumoracrepmvenlativx cf miscitymemerurysn the SEISMIC FEE
abovcmmnlin led pmpcny far imlecdon Pu9ntses. PERMIT ISSUANCE
(We)agree m sate,indemnify and keep harmless me City of Cupeniaa against ELECTRIC FEE
Ii.,olaic,judgmems,coos unit axial which may in any way acemeagainstmal City AITERORADDTOMECH.
aneyucnce of the granting of this psrmiL PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IID 10,100 CFM)
SOURC EI GULATIONS. MECHANICAL FEE
6 25' AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TA
Signatual
re of aMCumral Date EXHAUST HOOD PNFUCq HOUSING MITIGATION HAZARDOUS MATLRIALS DISCLOSURE
Will the applicant or future building occupant sire or handle Intact material HEATING UNIT(TO IW,IXO BTU)
undefined by the Cupeninn Municipal Coll ,Chapter 9.12,and the Him ill and Safety
Cale.Section 25532ST? HLATI,NG UNIT(OVER 100,000 BTU)
❑Yea El No
VENTILATION PAN(SINGLE BESIDE PAID
a Will he ti t coula i f a fill I use c Dam Receipt p
II goccupun ympmcm or devices which BOILER-COh1P PHP DR IOO.gO BTU
mit hwaraous air comaminann as defined by the Bay Area Air Qmlity Managemcm )
DnmmR
E3 Yet F1 No BOILER-COMP(OVER 110,000 BTU) A e
I have mai the locuumaus mumdaN requirements under Chapter 6.95 of the Cali- AIR CONDI'r10NER ISSUANCE DATE
forma Halm&Safety Code,Senium it 255)1 and 255311 understand that if me NEW RESIDENTIAL MECH. SQ.F1'. -2-
'911
� n
building does not currently e,S a tion,mat it is 53 respm¢ibiltry 11n notify the hat if the /T
f tyrsrOuircm�cnuxhi�cLwusr mg pramissuance nfa Ceniffgt^, cu
Tier moor<Cxfit J agcm /� / Dmc TOTAL,: ISSUED BY:
OFFICE