S 2623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUIE•Dlu:.E.EcPRICAL PEiRMrr NO,
BUILDING DIVISION APPLICATION/1"ERMI'YPLUMBING-hIECDANICAL S 2623
BUILDING PROJECT IIIEN'VIFICNTION
BUILDINGADURESS: SANITARY NO. APPLICATION SUBMITTAL DA'
a Qct c do 3-- 1?
OW ME; IE: CONTRACTOR'S NAME: LIC NO:
`Z bDNlc cQNTkfn,a
ARCHIrECUENGINEF.R; LIC NO: ADDRESS. ❑
CONTACT: PHONE: r BUILDING PERMIT INFO
3 ^ ❑ Consultant Flees Paid by Applicant(Initial) BLDG ELECT PLUMB M17 IT
(l( ZV ❑ ❑ ❑
I.ICIiNSE!UCONTRACTOR:SDF,CLARATION QTY ELECTRIC PERMIT FEE
I hereby elan Inn I am licensed under provisions of chapter 9(commenrnag JOB DESCRIPTION
aaZ with Section 7lX)IB of Division3of the Business and Vrnfcssions Code,and mylicenu it RESIDENTIAL:
WOO PERM I'I'ISSUANCIi
F,2 in full fort Offer,. ❑SFUWI. ❑KITCHEN REMODEL
aULicense Clash Lo.4
V~izU D:nc Cnnlmnor APPLIANCES—RESIDENTIAL ❑AUDIT]ON O PLUh1BING RE PIPE
I„pq ARCHITECTS DECLARATION I'ANEI•S ❑MULTI-UNIT ❑STRUCTURAL
Z O y L 1 understand my plias,bull M rind us pubfr m
nee , MODIFICATION
OZ^0 Of'10 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FNF-'fel Licensed l'n meacnal 201-IIXXIAMPS IMPROVEMENT
Q F'� OWNIik-I{UIhUIIH DEChAHAII(1N
SWIMMING POOLS
W Q 1 hereby mEm Thal 1 am exempt from,he Contractor's Licnsw Law forme OVER IU1X)ANI'S El BATH RIiMODE1lRF,l'AIR DEh10LIT10N
�3 c.0 following ea ,,. Suction 7015.Basncs and It fc........Coe Any 61yo ugly SIGNS ELECTRICAL. El OTHER
y which ruyuirex a pLYmtil m conswm,ul,cr,fimpnn-n,Dem t'sb,or mpair tiny.Iluclure
6 prat I ales y ,l pl he ,I 1 R' FI 'g d tasmcat SPECIAL CIRCUITI.MISC.
'halh licensed pru I the m. fth 111 L (Chnptcr9
W¢'QD (utt n 6 'thSe ]IXOB IU"is 3II B s I. ' coale)nr TEMP MFIER OR IroLE INST. COMMERCIAL'
Q.d c C that h p,m• I h is[ d se p A Y ' hn on of E3 NEW BLDG/ADDITION ❑DEMOLITION
k rn W
Section]031.5 by y applicant lora i1 w let. he apphcam m a civil penalty of POWER DEVICES
W^m ❑"TEKANI' ❑FOODSERVICE
nu Ih f A act;:l ($5 ).
F 7 Q n❑ I them n) ) l y th g s Ih 1 peon 1 on, SW IMh1NG 1'001,ELhCrkIC IMPROVEMENT
rill II J , t' I J d ft' dl sal (S .7W4 Bus' less ❑OTIiFR �-
4wm and Probe,.- C .Th C L I d not apply to Own of OI1ThITIS-SWI'TCIICS fl%PURLS
property wh ar p 'c' creno,a J h,does such k M1 If r,b gb
his own employees provided than such improvemcm,arc not intended or offend for NEW RESIDENI'IAt,LLECTR S
sale If,howocu 0t buildingorimprovca lis Mdd within Oney at afcmeplction.me SQ.ET FLOOR AREA $/sQ.FI�
ern
ler-builder will I ice(lie burden of proving that he did not build or improve lin put-
pose of sale.). -
2� cof the pro wily,ma exclusively contracting with licensed contractors to AI
uuuct meprojm(Sec.]WA.Ifuxincxs and Pro@nsionx Crude)The Conoacmr's Li-
wLaw does resupply to an owner of property who builds or Improves thereon.and QTY" PLUMBING PERMIT F.F
who contracts for such prefers with a mntracions)humored pursusu oIM1c Cnmravle"s
Lic<nse Law. _
CI I ern e.nmplu ,S I Bdc PChorookrcanan PERMIT ISSUANCE
sc. ,
AI:I'ISN-DRAIN.F VESH-WA'T'ER(EAJ
O n 1 Da,u VALUATION
WORKERS COMPENSATION DE CLARATION BACK(LOW PROTECT.DEVICE
I hereby uli ismut
mer Certify of perjury one of the follow ng declautlion.. V
El um,as wand will main mi Section Certificate ofCe scan Labor Cede.for the WoormaCompury DHAIN5-PI"OOH.RUOEARBA.CONU. STORIES I YPE CONSTRIICTIO
- v,ion,as pnsviJeJ for by Section 3]1X1 of the LaborCede.for the performance of the
work for vTuhmia permit i.,issued. FIX I'USES—PERTRAP -'2__ ��
1 have and will maintain Worker's Compensation Insurance,as required by Section
37(mof the Labor C,dc.for los pediannunm of the work for which this pmtit is issued GAS—EA.SYSTEM-I INC.4 OUTLETS UCC.GROUP AI'
My WorkersCsmpsmakin humuneecumer and Policynuntberart, ,� .�
Carrier. Policy No.: GAS—EA"SYS TEST 4(EA)
CERTIFICATE;OF EXEMPTION FROM WORKERS' O Z
COMPENSATION INSURANCEGRE; SI%ENDUSI'RLw'AS'rF,INTERCEPOR
('(Tis we ion need not be coniamed if Lha pcnnn is foramc hun teal dollars I$10(o BUILDING DIVISION FEES
or loco lacnify l hatin I'LANCHECK FEE --
mufwr0inn:mewffthe work dirt whicluhis ryrmit ix;rued.)shall "W R—S STOR64� , A.21X1
not employ any pcnnn in'uny manner xo:ts rat become subject to the Workers'Contpen- I N1 IiNEHCY PEE
O Z ,action L.—of California.Dim HEATER WNEN 11: F
Zr 0 Applicant GRADING FEE
NOT ICF.'IU AlIPLICAN'fl IL after making,his Certificate of Exemption,you should R 4 'I[I' 1 G
ahewn c mhjer,m the Worker's Cnntprnsnmoo p o,Narns Oda,Labor Code.you ams, •t SOILS FYai
forthwith comply wish such Coro,inns or his pe..,,,but]W kemcd revoked.\\ PR SERVICE;
Q
:D CONSTRUCTION LENDING AGENCY )
� Z N PSIDI!NI'IAL 111,MB. .h ', 011A
U O 1hcrcbyalf! outthere is a construction lending agency for the performance of F' the wank for which,his permit is i smad(Sec.3097,Civ,C)
Lender's Name TAI.Lender.Address TOTAL:
1 certify that 1 have read this applicuumn and rate that the above information is 1 agreemmnply rimall city ant county ordinances and sum laws relating in QT'Y. MECIIANICAL PERMITFEE
Zbuilding construction.and hereby amboriie repre,enlativen ofthis city m enter ulnen the ul e....coal vis nymny fm i sura a pumu.cc
(We)agree Io save,indunmify and keep hvnnlca IM1c City of Caper ianngninst PERMIT ISSUANCE hami,ies,judgmenls,costs and expeows which may in any way accrue against said CityALTGk OR ADD'TO M[CH.in cnnacyucncc ofthe greeting ofthis pcnnn
AVI LICANIUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO III.INXI CPM(
SOURCE REGULATIONS. MECHANICAL E t
�• 1��� AIRIIANDLINGIINH OVER 10,000CIM) CONS'TRUCTIONTAX
Signmureofdppficanl/Comracmr �R Door H%HAUS'I'HOODIW/DCC1)
HAZARDOUS MINI ERIALS DISCLOSURE ](DOSING MITIGATION FEE
Will the applicant or future building occupant store or handle Im.ardoux material HEAT ING FINE T(10 f IX),I(m RT U)
a,defined by the Cupeninn Municipal Code.Chapter 9. 2,and the Health and Safety
Code,Section 25132(a)'1 HEATING UNIT'(OVER 100,A)KI 111 H)
C]Y., ❑No
VF;N'1'ILA][ON FAN(SINGLES RFSID) PAID
Ni11 the applicant nr future building occupant use or ilex ices Das Hereip,b
nnllhamrJOuair cmnaminanl,as defined b,,hc IBay Are.Air Quality S..gmuch,
BOILER—COMP1311P OH IW,OIMI BTU)
Uiatrin'! )TA
❑Yes ❑Yo BOILLR—COMP(OVF,k I00,I011 WITH
I have read ds hamNous mertriad,tegmen ms Order Chapter 6.95 tithe Cali- AIR CONDITIONER ISSUANCE DATE
foie Heald,.&Safety Cada Smtion,25505,25533 and 25534.1 undec,and mat if the NEW RESIDENTIAL h1F.CH. SQ.FT.
building Jas not currently have a Irnen,,ma it is my responsibility to unify the occupant
I�yry`tcm<wM1icb muslMmct prior rt issaanu•ol'a Cenifi,I1tle oy\LLelcu y. ^/ 4
v.dagenl Dale TOTAL: ISSUED BY:
OFFICE