99120023APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • UiE BALL POINT PEN ONLY • 4 C// 'LQ V 2, j
OFFICE
ITY OF CUPE RTINO BUILDING - ELECTRICAL
PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENFICATION
TI
UILDINGADDRESS:
Ii
SANITARY NO.
APPLICATION SUBMNTAL DATE
0591 C Avel
V'N 0, I LL✓O �PHONE 2_ O
CONIItAIi L NO:
N
N/C
❑
CONTROLM
,..:II / GINEER: LIC NO:
ADDRESS: 1 R Q . I' -a
`L
sia
CONTACD PHONE
BUILDING PERMIT INFO
I
❑ Co L pant Fetes Paid by Applicant (Initial)
BLDG [ICT PLUMB MECH
❑ ❑ ❑
LICENSED cONIRAcroRs DECLARATION
1 hereby a1Brm thu I em Icrnred underprnvinons Mhaped C 9 (commencing
wlm Sxahn ]1100)of Dlv Ion flhe Burins. anJl xio ud, ny lieensu
in fall forcerot
Liccrte Clw`�L 6.Lfiir
LYm Caatoc
QTY ELECTRIC PERMIT FEE -
- - -� -' - --
QOZ
SUE'
nz
Dh
D n Z
JOB DESCRIPTION
RESIDENTIAL
❑SEDWI, ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
STRUCRAL
OMULTbUNR CITI
MODIFICATION
PERMIT ISSUANCE
A IANCES-RESIDENTIAL
ARCHTIECPS DECLARATION
I undnwmtd my plan, shall heated ac pabliemeads
PANFJS
.Fly.
; U
J C, E"
UP'70"APS
M
❑INFERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING P(X1L5
❑ BATH RFMOD C PAIR ❑ 10Lmpy,„
e7itaiEl ER P �
Lwxtu,d Ptufcssiowl
OWNER -B exempt
RD the Contractor
ontratN
1 hedMy .(Sero that I om.vann ciao the Contrum oc L Any c ty o co Ithe
following mourn. (Semon ]11313. Hminm and Pmtcudnm Code: Any city tst county
which rtyunati u permit ri aae,thi ,,plie rn far sta deerm.t 1 Ere. sal m of structure
pimtoits rt
he he mRer,
3111-I(pO AMPS
Ir AMPS
SIGNSOVER
SIGNS IiI.I.Cl'RICAL
SI'ECIAI. CIRCUITIMISC.
qyqy}
Y�O
i n pp
LL•
^til
ESD
yF-
3
hemnecmalra
to cicad o one Comoumit
Law (Chapter
(coheircing dpunuvnuothe pnrvmuv of the enmocetc,an Pref Lsw,Coce) or
(commencing wish S«tiun]1Mp)M Uiviainn3nfthe Hutinssum Profmianx Code).
Beat he u exempt therefrom W the 6uir for the vllcgcd exemption. An, vird.tion of
Sectio.9031 S by any opplicum [nr u pcmtit mbjmle the vppllrsnt m e evil penally o!
not mart than live hundred dnllum y employees
❑Lax owar and tibe pvpdorado my mnploy,sorof gsuth (See. 1YO,Bomian,
will dollew., Cosi sltucmmoncer'nLie. aa, dint sale (See. 1. gwner of
Imo dos rot apply to o of
ad Pmfw1w,
Calc: T!c Contrmment Ixit
TEMP METER OR POLE INST.
COMMERCIAL
❑ NEW BLDGIADDITION C DFMOLFHON
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
E) OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SM'ITCHFS-Fl%TUR
ae
b
tterlyown who huiMli «improves t to doex.rueh work himself
l r thio
his
hi. awn mop ...IS i luno n arc tot i m offeml fo
1 eacd T-
pnniJN that such meat
NEW RESIDENTIAL IiLECI'R SQ
ear nfi
the is it within
"itidahoold Mmovetfonthe
SQ. FT FLOOR AREA
SSQ. FT
o,odef.huacanthhvethtymlmpmrmentit
ned will have the harden of proving that M did roll huild nr impnwe for par-
sak').
Mvk ).
TOTAL:
❑ I, in aorta of the
Ul y, excluonmes,ixxly connecting Ciro licensedieCmareca
(,Sir n . B ,Ito
anxlrWt the pmjal (,4x. ]IIIJ, Nu,rinw and Nnl'arxion,. Gde'J Iiw Conlrm'tor'r hi-
ce— Law does, wt apply to an owns of pop,cY who beildr or impoee, tlrrtan and
QTY. PLUMBING PERMIT FEE
who mntmcta for such pri with v conwc abil) lic,ns d portion uo tM Conrrecmh
PERh1IT ISSUANCE
IJccnw Law.
El L am exempt under Sec. ,B&PC fm rots ream.
- DRAIN & VENT- WATER (EAI
UniteALTER
VALUATION
WORKER'S COMITNSA'IION DECLARATION
BACK FLOW PROTECT'. DEVICE
of the
I hereby affirm under penalty of pmj mit ooc Iol liming d,clamtionx:
DRAINS- FLOOR, ROOF, AREA. COND.
❑Ituxx and willrminlain eCertif Ic of Conumx to xelf-ivluc fa M'Ithcr's C«open-
u provi,od for by Sic. ion 3]00 of thin Labour Code, for CoR. the perforrence of the
STORIES
TYPE CONSTRUCTION
work or which this pi ie iaw:d.
FIXTURES -PER TRAP
❑ I have ud will trdtluin Worker's Coruremarion Irlwra ce, as reclaimed by Section
3700ofile fide, (a lte dmtana n[me wlmk for which mix pemtit is isxud.
My Wta t 1caliann mud Policy
Came Policy No..lowtotj
niff
GAS - G. SY STEM -I INC. O OUTLETS
OCC.GROUP
APN
/ r..'Y
2
GAS - G. SYSTEM-0VER J (G)
CERTIFICATE OF P.XEMPTION FROM WORKERS'
� CAL-'
COMPENSATION INSURANCE
(this rection teed nn he cortmind if the permit it forces, hurdrd dollars (SI W )
or lest I
GREI F%INDUSfRLWASTE INTERCEPTOR
BULLDINO DIVISION FEES
GRIiASH TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM PA. 3W IT
OZ
Z O
I certify that in the pcHnmurcc of the woh for sail Box Parent u ivveJ, lsholl
not employ any person in any mantled sed as to bei object m dtc V'orkerd Compcir
otic. Law, of California Duro
Applicant I
ENERGY FEE
WATER HEATER WIVENI]ELECTR
GRADINGFEE ,
NOTIO?TUAPPLICANT I[aftermuhng lhir Cenifcme of lhentpinn, yew should
bnome rubjcct to dlc Woks't CotNctwtim povi.tiom of the Inbar Code, you rtxrN
forthwith romply withwch pnvisiwts.e thio fermit.thall he tk,med rtvakd.
WAI'ERSYSTEMTRGTING
(n
F -I '�I
SOILS EEE
WATER SERVICE
NEW RESIDE\ -PIAL PLAIB. SQ, FL
a�
U.
U.
CONSTRUCTION is
(IN IFNDINGAG ,lacy
Ihereby hich i, Ai. i, amm�ru.ti30 lending ageecY for the perfcml:uce of
me .A for which mix permit lr loud lS«. 91H]. Co, CJ
1<Mer'a Nacre
PAID
Dxte Rcaipp
TOTAL:
r'
O
IcMer's AMlres,
TOTAL'.
U
yI
ser iry mot I lax. tried this epplimaction and xtme that the wove iuftmmati.n is
BUILDING FEE
QTY. MECHANICAL PERMIT - FEE
pr'
co rest. I .gate to emalftly with all city and county announces and rota laws relating to
Muldingeoromelicn, end hereby aullamic mpr,a,nmtivs et thiseity In enter upon the
SEISMIC FEB
o
abov.-tndnnd propmy for impxti in p rpovs.
(We) .gree to active, antimony and!nlsa th
keep harre City of Culemod ageimt
PERMIT ISSUANCE
ELECTRIC FEE -
Iabilc'judgmanl nand csprnoni abich may in any way amore against xis iCity
inconsequence pof gran' u perrtti
ALTER OR ADU'IT)MECH.
PLUMBING FEE
ALR HANDLING UNIT (TO 10.000 LEND
MECHANICAL FEE
APPLICANT ,DER Nf LLC ITH ALL NOWPOINT
SOU ULA 5.
ALR HANDLING UNIT(OVER 10,11(1(1 (TEM)
CONSTRUCT ION TAX
Slgwttua of App
HA9Alt RrRDDU5 MATERIALS DISCLOSURE Dote
W
EXHAUST HOOD(WIDUC)
HOUSING MITIGATION FEE
HEATING UNIT TO IO0,II00 RTU)
Wil or future mart or l
Coe,
y the Clicml
Chapter
v def tied by the Copeniru Mwicipd Code, Chapter 9.13, and tK Heddl end Safety
Municipal and th Heiilta and Safer
Cndc, Section 35532(v)?
E] yes .'o
ar doriManat which
Will the epplicam or Tatum building by me, B um Area Air Quality
coir baiuNwa air cmnlarnhWlf u olelited by the Buy Atex Air Qudity Mvnagrnrnt
District^y
�Yer �Nn
HPA'IINC UNIT (OVER IIMl,fgfl NTU)
PAID --
Dua Receiln M
VENTILATION FAN SINGLE REMO)
BOILER -COMP EHP OR 100.000 BTU )
TOTAL.
&llLliR-COMP RIVER IIMI,I1fM1 BTU)
AIR CONDITIONER
I have rem c M matcdws taryirttte is unJn CTups h.95 of Ile Celi-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
R—im Ileahh . we : We, 'ra4�,05..2 itJ 73530. 1 tv.Lenud that if be
Wimin9J of nJY rmp.uiItryoft
ilicil m xCmrfi,amot Oc,o r,,
n
i
ISS WJQ;�k
weutAm agcm Ihm
TOTAL:
OFFICE