00010123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY 000 ) ,012
RTINO
00 ) C012RTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING n1VISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
I' -- BUILDING PROJI?CT IDENTIFICATION
ItU11.1IING ADOR&SSt SAN1'I'ARY NO. APPLICATION SUBMI'TT'AL GATT
2223°0 �faMatoND WA-Y cJPki��Jo, c� �'J„ Uv�3 � _ � 2cm0
fIWNI?R'S NAMIi: PHONE: CONIRACI'OR'S NAME?: LIC NO:
NIC CON,
It lICI 11ITC'UENGIN'EER: LIC N. ADDRESS: ❑ 7 /
JuDE KI k G - °S<v
CONTACT: PHONE: HULLOING PERMIT INFO
YCA O TO N Y stun A- Asa/323—7100 ElConsultant Fees Paid by Applicant(Initial) BLDG El�ec{ PLUMB MEC
. 17-CO T YJ
LICENSED CON9'RACTOR'S DECLARATION 1 ,..� Et ECTRIC PERMIT FEE
1 hareny a1Rrm that I an,licensed under provisions of"opium 9 warmer amg Qpy JOB DESCRIPTION
QaZ with Section]W(nninivioma 3nflhe Basins.rad Professions Code,and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
y�U� in full fame effect. Lic.M %SFDWI. El KITCHEN RIiM0131JL
Q U APPLIANCES—RESIDENTIAL' ❑ADDITION ❑PLUMBING RE-PIPE
on W Date Cnmmem
w 4 ❑MULTI-UNIT ❑MODIFI SI MODIFICATION ARCHIT'CT'S DE ,AR TION
Z OPJZ undcrstmdm plvm 1 dos uh' records PANELS MODIFICATION
OZJJ _ UP T020(IAMPS
❑INTERIOR ❑CHIMNE REPAIR
al 201-1(MI(IAMPS IMPROVEMENT [I SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IUOTAMPS - ❑RATH REMODEUREPAIR ElDEMOLITION
rj OC uuII Q 1 hereby affirm that I am exempt from the Contractors License Law for the
ippi55,�O C,U following ancon.(Section 7031.5,Business and Professions Codes Any city or county SIGNS ELECTRICAL ❑OTHER
sec 3 O which requires a permit to construct.alter,improve,demolish,or repair any swcture
tat' primo its issuances also requires the nPPlicam mrsuch permit to file,ro,pedstatement SPECIALCIRCUTDMISC.
ythat he is licensed pursawn to the pmvisicnsof the Cmuncoses License Law(Chapter 9
GAO (rommm�cing with Seninn]0(gDof Division3 of the Business and l'mfessions Codgor TEMII METER OR POLE INST. COMMERCIAL:
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Iy Section 70313 byany applicant far.pecon,abjects the applicant too civil penalty of POWER DEVICES o ❑'1'F.NANT ❑FOODSERVICE.
F=Qat mm Nan five hundred do)[.Wall), IMPROVEMENT
�I,as owner ofthe profnim,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended oroffered far sale(Sec.]B44.Business [j OTHER
LL1and Professions Code:The Commnnrs Liceroc Law Jr,cs non apply to an owner of OUTLETS-SWITCH&S—FIXTURE
d a— property who milds or improves thereon,and who does such work himself or through
a his own employees,providN,hat such impmvensms are not intended or offered for NEW RESIDENTIAL ELECTR SQ E4.
sale.If however,the building or improvement is sold within one year at cnmpIt *the - SQ.FT FLOOR AREA $/SQ.FT.
owner will have the burden of proving that he did not build or improve for pial- ^ 3 ,—..•
Poe ol'dle.). /y' J
TOTAL:
T arc owner of Ne property,am exclusively cnnazning with licensed contractors m
,netrnet the Pmjuq(Sae.]f144.Business and Professiam CIxle)Too Crnnremr'e Li. -
cense Law docs not apply to an owner pmpeny who builds or impmves themm,and QTY, PLUM G P:RMI FEE / `
who commet.,forsneh projects with a nunctor(s7 licensed parmant to the Conaunoru 6 ✓ (--r
License law. PERMIT ISSUANCE
lame adima. ,B&PCfonhismasnn
ALTER—DRAIN&VENT— G ' ) VALUATION
er Date ��(j i-• - �—Z
f W bRI l OMPfN ri TgON DECLARATION BACK FLOW PROTECT.DEVICE
�rl Iherehy affirm er Certify of peCCmciaeofelf-asre for Worker Co
(have anA will mu R.
nesCmificvte of Conserv msdf-insure for Worker's Compen- pRAINS—PLOOR,ROOF,ARFA,COND, STORIES TYPE?CONSTHUCI'ION
sminn,as pmvideJ f�r by Section)]011 of the Lahr Cnde,for the perfonnence of he
work for which this permit is issued. FIXTURES—PER I RAI'
❑1 have and will maintain Walkers Compensation Insurvme,as matured by'moon V
3700ol the LobesCode,far the performance mate work for which this permit il,osed. GAS—ITA.SYSTEM-1 INC.4 DO I'LETS (ICC.GROUT' APN
My Workers Compensation ltssumnce carrier and Policy number are:
Comer. Policy No.: GAS—EA.SYSTEM-OVER 4(EA) -7-•
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASE INTERCEPTOR
COMPENSATION SURANCE BUILDING DIVISION FEES _
(Thissedion need not be completed if 'doordis for anehantlreJdollan($100) GREASE TRAP
nr less.) PLANCHECK PI?E•
lc y titin Ne nrmmccof r hich this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FI'. -
not eon , person i sty non s town .wnjem m the Wudciv'Cooper. ENERGY FEE
O tie .Date WATER HEATER WNENWELEM R GRADING ITE
Z P rm s e
N :TO APP NT:IL r raking this Cenihcme of Esemptiun,you shout) WATER$Y'TEM(IREA'E'ING SOILS FEE
a ? be come evnjecnothe worker oopcnca0rn pnwisinns e[the Lnhor Cole,Ynu muxt -
{1.I forthwith comply with such rserthis permit shall be deemed revoked. WATER SERVICE
Q
C STRIICTION LENDING AGENCY NEW RESIDCNf1AL PLMB. SQ.FT. PAID
7 Z Date Rcaelpt k
U Ifor whamrmt Inhere issued(Secti30 len ding vg ency for the perfonnunce of
r the work for which this permit is issue)(Sec.309],Civ.CJ
1•]"' (' lenders Name - 'I'OTA 1.:
U Loader's Adams TOTAL:
,y W� _ BUILDING I'EE
[r I evenly that 1 have read this application and state that the above information is
M corect.I agree h,comply with all city and county ordinances and state laws relating m QTY `MECHANICAL PERMIT IEE
V Z building constmction,and hereby acarus,representatives of this city to enter upon the SEISMIC FEE
abovo-memirned property for impeninn pure s. PE'RMI'T ISSUANCE
(We)agreed,save.indemnify and k armless the City of Cupeeino against ELECTRIC ITE
Iinnilitics.juJgmems,costs expensesw may in nny way accnae against said City ANTER OR ADD TO METH.
A�ERS
the gran gnf Nis pe t. PLUMBING FEF.
ON[) \NUS A .L C PLY WITH ALL NON-POIN9' AIR HANDLING UNIT(TO I0.000 CPM)
MECHANICAL 1'17E
TI S.
AIR HANDLING UNIT(OVER 10,1700CFM) CONSTRUCTION TAX
of Applicnnt/Cn P nr Doe EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEIi
HA2A US MATERIALS DISCLOSURE
Win Nonpplicsml Enure brildingoceupa Imre or handle hvzardonsmatenal HEATING UNIT(In laa,orq ETC)as defies, mo Municipy CWe,Chapter 9.E2.and the Health and Safety
Ctde,Section PSSJ2 )'1 L-�.tls/ HEATING UNIT(OVER 100,WO B'IT)
❑Yes VENTILATION FAN(SINGLE RESID) PAID.
Will the applicant or ue building cecunt pause occupation or devices which Dam Receipt N
ln
BOILER—COMP(JHP OR IIXI
t hazardous air contaminants as defined by the Bay Area Air Quality Management ,11008'N)
r1 D 'IOTAL�
nsloetlBOILER—COMP(OVER 100,0001CU) •V U/
Yes 5e No
r1th&
hazardous math'", men lc un der,Chapter 6.95ofthe Cali- AIR CONDITIONER ISSUANCE DATE?
fomiaCode,'eairns 5,255 d 25534.I understand Nat if the NEW RESIDENTIAL MECT SQ.Fr.
Is ditly h; .thalitEraym. nsibilitytonofifytheoceupontof the hm a e Poor n,issuwse d'n Ccnificam of Waryis
wrest prized agent ILte TOTAL: ISSUED BY:
OFFICE