99090104 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 utT
CITY OF CUPF,RTINO BUILDING-ELECTRICAL
BUI DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
�' BUILDING PROJECT IDENTIFICATION
ft BUILDINGAODRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
IbI4 Aril 70WN -/ `-
WNER,'�SNrylE: PHONE: C N'I'R 'OR'SNA E.
BIC NU:
.L]aDAIG SC iIRAIgt 7u�46 1 l(�y/ �py� N/C CONTROL#
CIIITECI'INGfNI:I:k: LIC NO: AI)I :SA cs�� , , / n( ! � ❑
CON'IAC'1: �rAAll PHONE. f T- BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ or
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alarm that 1 alt licensed under provisions ofchapmr 9(commencing JOB DESCRIPTION
,0OZ with Semion]0000ofDivision JOfthe Bucinessond Prol'ession,Code.and my licensers p1iRmi r ISSUANCE RESIDENTIAL,
1-w in full force and effect.c '�{� OSFDWL 0 KITCHEN REMODEL
Q,UV Licemc '`s�t hinor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
f-ZW Dam Cnmmnnr
H66 ❑MULTI-UNIT ❑STRUCTURAL
F-=y ARCHITECTS DECLAR PION PANELS MODIFICATION
C)o', a s
Z Iund—modshy planhall he uwdm,uhhum,ords
2_4—aUP'1021N]AMYS INTERIOR ❑CHIMNIiY REPAIR
-hF'u: Licensed Professional 201-I000AMPS IMPROVEMENT [ISWIMMING POOLS
OWNER-BUILUER DECLA RATION OVER IINIOAMI'SS: OL BATH REMODEURF,PAIR ❑DEMOLITION
C C Q 1 herehy affirm that 1 am exempt from the Contractors License Law for the
ka U following reason(Section]U11.5,Business and Pmfessinns Gale:Any city or«henry SIGNS ELECTRICAL ❑OTHIiR
93 W h which requires It periodic m construct,alter,mhpmve,demolish,or repair any s'm«arc
�;
prior ah its issuance.also"des the applicant for such pennifto file a signed saltemem SPECIALCIRCUIT/MISG d / DN
} That he is licensed pursuanto the provisions of the Contractor's License Law(Chapter9
�apV- Lie cunearm,with Scn..at70Npol Division 3ol'the Business and Prote,ions Cod,)or 'I'EMR.MLTLR OR POLE INSISSI' R
d s c C that he is exempt thercfmm and the basis for the alleged exemption.Any Imichon of El NEW BLDG/ADDITION ❑DEMOLITION
X^,14 Section]011.5 by any applicant for a permit objects the applicant to a civil penalty of ❑TENANT ❑FOODSERVICE
me marc man five hundred dollars($5 W). IMPROVEMEDOTTER
NT'
S C LJI,ez meter of the Propcny,or mY employees wire wages es their sole rowmpcnmti W 1. 1 E RI
F will do the work,and the stmaure hs not intended or offered for mlc(SuJ03q,Bu sin
Oat m and Professions Cone:'De Commeno,License Law does not apply man nnm 'oM_rSX-sWlTItTRfR
d'3^ progeny who builds or improves thereon,and who does such work himself or through
his awn entooyem,provided Thar such improvements am not intended or offered for NE E EUA -
sale.It.1mWCveL the building or improvemenl I,sold within one year III completion,be01 SQ.FT.FLOOR AREA $/SQ.F4.
ter-Builder writ have the Burden of proving that he did not build or improve for per-
p oc u1'nalc.l. 1
CI I,as owner of the pmpeny,um exelaroelY cloamc ng with licen.vd"ITI.clrR In
consumer he cancer(Sec.90uut.Business and Professions Gnle:l The Contractor's Li
rens,law sows reu r,ply m on owmer Of propcny no Builds or improves thereon and FEE
who conuacts for such projects with a nmtraclons)licensed pursuanno the Contractor's
License Law. PERMIT ISSUANCE
In Ion exempt under Sec. .B&PChmthisreaam
ALTER-DRAIN&V IiNT-WATER(EA) VALUATION
,goDale
ter WORKIiHti COM PIiNSATION DECLARA'TION SACK Iq,ON'PROTECT.DEVICE
1 herehy affirm under penalty of perjury one of the following reductions:
❑I have and will maintain a Cenificatc of Conscnnnttll-Insure for Worker's Compen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
saint,a,provided ler by Sceion 1700 of the Labor code.for the red mance oI be
work for Is Bich alis permit is soared. FIX TO RES-PER TRAP
❑1 have and will maintain Worker's Compcmation insatmncc,as equibed by Section
17I0 of the Labor Coote.for IPullonnurecOhewark l'ou which thispennitls issued. GAS-ISA.SYSTP,M-1 INC.q OUTLETS OCC.GROUP / �.PN / O
My Wm c k C n Ir u mer and Policy nuh91 r s �sO�-��M�
Carseat h nsa K`Polis,Ner: N W/79/�� GAS-EA.SYSTEM-OVER
O
❑:RTI IC IE OIe I"' MPHON FROM WORKERS' GHFASpIINDUSTHh WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
GjL,,Oam ncNnor Becamp,unOt he per is fmm ehundreldolims($100) GREASETRAP
PLANCIIF.CK FTE
To less)
I cenifythat cache pcRumonee of me work for which this pemut is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
sur employ any fa'^ an,m now as u,Loccomrmbjecnothe Worker,,'Compere ENERGY FEE
Z zdian Laws of California.Date en WATER HEATER WIVE AELECI'R GRADING FEE
z C) Applicant
z i NOHCE'10 APPLICANT.If,eller making sols Cenilicute of Exemption,you should WATER SYSTENU TREATING SO LS
(✓ ' become subject to the Worker's Compensation provisions of cror u labCode,you must
forthwith comply with web provisions er this permit shall be deemed evukeJ. WATER SERVICE
I e z
7Z CONS'TRUCTIONLIiN DINGAGENCY NEW BIiSIDIiN'fIAL I'LME. SQ.I'f P��r Date ^Receipt#
1 Beebyaffirm that here isa,owmaetion lending agency for the performance of t
lUL P the work far which this.....it N Issued(Sue.)119],Cie.C) I V L-r d � Al.a 1
OU Lender's Name s
W Lender's AJdres TOTAL:
I ceddy tan I have rend this uppliuron and stale that the shove infurnmtion Is DING FEE
F' N comet.l agree tocomply with all city and county ordinances and stale laws belting to QTY. MECHANICAL PERMIT FEE SEiSMICPE.
U building enodmction,and hereby amhonze represcmatives ofmis city reenter upon the
urm,,ra lured pmpeny lin inspection Purposes, PERMIT'ISSUANCE ELECTRIC VIT
(We)agree m save.indemnify and keep harmless the City of Cupenion cigaunt
liabilities,judgment%.codsand expenses which may in aaywayaceme agonstsuid Iny ALTER OR ADD TO MECH, PLUMBING PEE
In a loci Lure,ml the Inc rag m'his permit.
APPLICANT UNDER STA US ANU 'ILL COMPLY WITH ALL NONROINT AIR HANDLING UNIT(TO IU.000 CPM) MECHANICAL.FE-11
SOURCE GULATIONS
j//pjJ���Y 9 rF/]Q AIH HANDLING UNI'I'(OVIiIt IO,INN)CFM) CONS'TRUCTION'I'A%
Sigmiury dAvl ppl'ieml/Cmntm«or ['DDoc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building amupant store or handle Bumblers material HEATING ON IT(TO 100.000 BTU)
o da5ncd by the Cupcnlmr Municipal Code,Ch lne,9.12,and rhe Health and Safety
Cele.Section 255121a)a DEAL INC,UNIT(OVER 100,000 RTU)
L]Yes CI No VENTILATION FAN Ed NGL,RESID) PAID
Ra pc x
Will the applicant or future building recupam use equipment oOnce r devices which BOILER-COMP(NHP OR IIXI,fNlll ETU)
jr-
emit hazardous a.......inants as defined by me Buy Arca Air QlahLy Mwagement TOT L
D'ant4IIDILI?R-COMP(OVE IAd,ndBB'TC
❑Yes DN.
I have .it Itch t,ardom rsunials ac,mle'nenw red,Ch,lir 6.95 of the Cal l- AIR CONDITIONER ISSUANCE DATE
folio Health&Safety Code,Sections 295115,25517 and 25514.1 umlastand that if the NEW RESIDENTIAL MECIL SQ.FT
building doers not curon base a mw L that it is my msMu ibility m notify the occupant
ntrincgaruimmen,whit mot r i Prior to loon':-fa CeniE � y
/�JJ1LlIAA.-. TOTAL:
Owner Or umhari/ed agent Dines ISSUED BY:
OFFICE