30490` APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPLi RTINO BUILDING - ELECTRICAL,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. 3 0 //Aag1� T 9 0
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BUILDING ADI FSS:
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SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNER'S NAM O PHONE:
CO R'$NAME LI O-�
NIC
❑
COMROLI
ARCHITECTIPNGINEER: LIC NO:
ADDRESS
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CONTACT: PHONE:
❑ Consulfanl Foes Paid by Applkent (Initlel)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LIC IM- SED CON'fRACOR'S DIiC1.ARAncIN
I hereby affirm that l w Been nd under Provisions of Chapin 9 (amrnetaing
with Sano.](IOo)of Division J ofthe Huai. and Profeasiort. Code. a td fir, U me is
in full fair and cRan.
llcue Clea. Lk.I s
QTY ELECTRIC PERMIT FEE
JOBMSCRIPTION
RF$IDENTIALc
❑SFDWL - [_1 KITCHEN REMODEL
❑ppDITION C] PLUMBING RE -PIPE
❑MULTIUNIT C1 STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT '
C1 BATH REhfODEf/REPAIR ❑DEMOLITION
ID OTHER
PERMIT ISSUANCE
APPLIANCES -RFSIDPAL
DuemComrntu
ARCHITECTS DECIARATION
understood!ZO`r�Z Iunderunderstood! m
a understood! Trials sholl ha usaPrublie rccmds lu
I PANELS' '��
UPT0200 AMPS
Craniad Nofo.iaul
bat I m esemptER DECn Corub ON
I hereby aRrm Jut 1 un <ump form thin Camrutals Licence Lew for Nc
fallowing recon. Menem ]OJT S. IfusionIc. and Prvfesswau Code: Any city or county,
which rcyuires a Pcrod In cvnvtvan, alter, unpruve, demolish, or repair any swcmrc
fourov in iasonoce, akvfiNides deepplicvu faauch perrounfkasiprcd<rml
swt
Nat ha m lileoal Pasuam to the povisionsofthe Conrenot. Liceme Law (Chelfcr9
(canntencingwi,M1Smion]Il .f Dipliainnt'If the Bunines,.1 Prufeuion, Cn.lcla
nbar he is exempt therefrom and he huu for the agegd exemption. Any violation of
Seeuon]OJIS by any yli ieentfor a pmnit.ubjecta Neapplicanttoa civil pointy of
out more Ilan five hund,d dollar. (5500)..
Q I,asowncrof Nepropcny,mmyemployc6wiNwag utlrirsolcro ipma on,
WIT m the wic and tic strtanure is. intetdNoroRvad for sale(sae.]IW, Dust.
Professions Code: The Comrxto/.a s LkanLaw die. on, apply to an outer of
pmpeny who build, or Improve. Thereon, end who dtea xoch work himself m Wough
his own employees, Provided that such impmvementa uvldei a
e not iluoffanl for
sale. If, Iwavevn, tic building.improvement is sold within one year ofsrmpletion.the
sun n-0ui Wer will have tlx: burden of proving that be did not build or imptove for pur-
Fuse ofcaleJ.
❑ I. as owner of are, Property, am eachors ly nwrxfin, with licensed mntuaon o
c mstrun th<ptolcet (Ser. ]111, Bashes, ltd Pmf<aione CM,,,) Tic Conuuch., Li-
wnse Taw does no.pply,. an owtrr of pfi m who builds or Impose. the. amt
bncunn<ufasuchlro;e<tswi armttr [Ms)lic r pumani to Ne Cont,Ma
Li. law.
1P IemexempnenderSa. ,B&PCfar Ni.rtntou
201.1100AMM
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITMISC.
TEM('. MEIER OR POLE MST,
COMMERCIAL
❑NEW BLDG/ADDITION ❑ DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
THER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHRU
S-FTURES
NEW RESIDII C ELECTR SQ FT.
SQ.' OCR AREA
6 _
L
SEP 5 1996
$nQ. PT.
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN &VENC'. -WATER OIM
Ow'rlcr Dale
-'' VALUATION
WORKERS C tyapjuT ofC fiRAIION
I ItvelY affirm etvhm peealry N perjury uc of Jr fdbwing hclvutau:
Ili.veard will maintain eCcuuBscmts ofCunsanttn relf-Insure for Warkrr's Ganpen-
Minty as Provided fa by Section J]IIO of for lalwr Cuk, Gtr one lvfonwrce o[ Ne
work for which this porno u issued.
I] I have ard will maidain Worker. Carnpmaaion In.atana, of, rencio d by Sniicm
3III0u1,lobo Cnk.Bn,h<pcArnumcofthc work fa which Nin Penni, is isswxl.
My cr's Compensation lnsti. carrier and! Policynundber ere:
, Policy No.:
CERDFlCATE OF BXIih1PIION MOM WORKERS'
' COMPENSATION INSURANCE
OTU section need m be, coopNd if JS Pamsm
in is fnee hutmed dolWs(51W)
or las.)
workfa which Nispoenisiaud.lOW
Coy any Natinthe my at
Tax cmpby any person ioan to h<tmrsub' nmtkx'orkni Cam _
.anion laws of Cath Nunn, Dam��su�
Applicant -
BACK FLOW PROTECT. DEVICE
DRAINS- PLODR. ROOF, AREA. COND.
STORIES
TYPE CONSTRUCTION
FIXTURES- PER TRAP
GAS - EA. SYSTEM -I INC. Y OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM-0VER i (EM
GRGSFIMDUSTRL WASTE INTERCEPTOR
BUILDING DIV ION FEES
PLANCHECK FEE
GREASE TRAP
SEWPA- SANITARY -SIT)RM EA, 200 FT. .
'ENERGY FEE
WATER HF.ATIJI WN liflILECTR
GRADING FEF.
NOTICE TO APPIJCANT: If, aftn making Elia Coif to of E+emptic , your sltwrW
beenvx rxbject,.de, Worker. Canpenatinn prnvisiotu of fle laM Cask. you must
hrtbwuh comply with.Nach provision, or this petmir shell he deelned revoked.
CONSTRUCTION LENDING AGENCY
ILnrhy offimnhan Nem i. n conamcnitm lending agency Gr Nc perLxmenm I,
S, work for which 06 Permit u isanl (Sec. 309], Civ, C.)
Lanni Name
WATER SYSTPM/TRGIING
SOILS FEE
WATERSERVICe
I
PAID
1 iptM -
NEW RESIDENTIAL PLMB. SQ. F(.
TOTAL:
Leder's Address. -
TOTAL:
1 cenify Net 1 nave recd Nia applicut'xn std were Nu Ne above inlmouum u
caraaa.l agreemmmply wiNall city and aumY wdioanm am sone law, relndpg to
bcd,ingcnnatrucnitn, and hereby amhnmemprtsentani,es of Nisciny In cmnvpmthc
olaove-.1i.mvl prupeny fm innpacu . P.r . I
(We).gran to save. iMartaify ad keep hanmina the City of Cupenim age'va
Ii.dli.jolli.s, ttms std expenses whirl nay in any way.. against said City
in con acuc. of Ne ,nut of Ni. Pcood.
APPLICANT UNDERSTANDS AND WILL COMPLY FALL NON -POINT
SOURCE R ULALOSS.
BUILDING AV
QTY, MECHANICAL PERMIT FEE
SEISMIC FEC?
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADUTO MECH.
PLUMBING 1}E
PIR HANDLING UNIT (TO 10.000 Milt
MECHANICAL PEE
ATR HANDLING UNIT (OVER 111,000 CPM)
CONSTRUCTION TAX
viJann Dare
HATARI)IUS MATERIALS DISCLOSURE
Will the nPplicant or future building occuP:mt store m hamlle hatcani mnerod
as, defined by do CuPcNrn Municipal Cod, Chapter 9J2, and the HeaIN and Safety
Cork, Section 255116)]
❑Ye. ❑No
Wil Ne air wane i fuzee l ,Piing ocal4mumea Air uo-JMunaices which
mzctmN(ms air amnvnlwnu a. JcOned by the BayAra An Quality Munagertunt
Ustrict?
F1 yes ON.
1 have read the h",a^M1a,s ntvarids redid au nndai ChapLLr 6.95 of Ile Call.
fomia Hea, &IN & Safely Code, e.timu . he, , 2-1.133 yad 25500. I utdctsy th thou if flan
c,fleo din'nIb awhichnbd a,inet pooh oulcurreN.m ibllitytadeaify N,clsoi nt
of Ne mryiremrnu which must he, rrct Prior no iuuvxs M o Cvdfrue of Ottvgrcy.
EXHAUST HOOD(W/DUCq
HOUSING MITIGATION E
HEATING UNIT(TO 100.000 BTU)
'
HEATING UNIT (OVER 100,M) BILL
PAID
Dane Be, I
VENTILATION FAN( SINGLE RESTD)
BOILER - GOMP(BHP OR IW,IM00 BTU)
AIL
BOILER - COMP (OVER I00,000 BTU) '
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RISIDPAL MECH. SQ. PT.
"
OwnermucIlienudii,nt, Ilam
TOTAL:
OFFICE