31443 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPER'11NO - - BUIDING-ELECTRICAL PERMITNO,
RUILDINCDIVISION APPLICATION/FiERMFPPLUMBING-MECHANICAL 31443
BUILDING PROJECTE IDEMITFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
39 �,4,7,C� y�.
OW lNI>7F�TJ— PHONE: C A R II.1 Ll 0:
I�//�T'���� C �l N/C CONTROLp
•A CHITEC'1' EI?R: LIC NO: - A MS Ap ❑�' - t -
CONTACT: a PHONE: - BUH-jiljlibr ERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MITCH
LICENSED CONTRACTORS DECLARATION Q'rY ELECTRIC PERMIT FEE.
1 hereby maim that 1 am licensed under pmvisinns of Chapter 9(commencing JOB DESCRIPTION
Da'Z with Sm,ion 70W)of lhvision Ithe Business ernd yliccnse is
BOO l C�s� PERMD'ISSUANCE RESIDENTIAL:
F� Infull force and N _ �i In fin_
�U[F[,,]) License Clot, Lick �,G(' a✓ ❑SFDWL _ El KITCHEN REMODEL
�[..<L Uem ARCHOECCnnaae _ 3r," PPLIANCES-RI:SIDF.NTIAI. ❑ADDITION [I PLUMBING RE-PIPE.
ZO•�m T'SD N PANELS s ❑MULTLUNIT ❑STRUCTURAL
v�Z I understand my plans shall he used as public recnNx �p MODIFICATION
oz-- UP 1Y)200 AMPS ❑INTERIOR MNL'Y REPAIR
��[".,41 Licensed Prnfictomil 201-INXIAMPS IMPROVEMENT '
ppSx2' OWNER-BUILDER DECLARATION OVER11100AMP5 ❑BATH RF,MODELMP.PAIR 13 DEMOLITION
—N=, I hereby affirm that I am exempt from the Comracmrs License Law for the
U IN Coving rcaxnn.(Se.doo 903 L5,Bueiness.nd Pmfesslons Cade:Any city m Wmnly SIGNS ELECTRICAL ' ❑OTHER
al'3 W F which requires a permit m innsvuct,niter,improve,demulizh,or repair any anemre
prior to its issuance,also requires the applicantfor such permit to file a signed statement SPEC]AL CIRCUIT/M ISC
that he is licensed Panamint ro the provisimomf the Comr.cmf»License Law(Chapter 9
�p0 Icmnmencing with Section 70IX1)nl'Division 3ol the BuxineesunJ Professions Cwe)or TEM R ME TER OR POLE INS'E COMMERCIAL '
ayx e rG that he is exempt thefefrom and the basis for the ullegod exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W� Scction703 L5 by any upplicem torn permit suhjectsthe.pplinnuaacivil p<nehy of •' POWER DEVICES _ /
} OftEN
TANT ❑FOOD SERVICE
z
not more than Eve hundred dollars($500), -thIMPROVEMENT
O ❑I,us owner of thePmpeny,or myemployecswit0wngesastheirsole compensation, SWIMMING POOLELECTRIC
W will doe work,and the structure is not intended oroaered for sale(See.7044.Business [3 OTHER
W 2and Professions Code:The Cantrvctors License Law does not apply to on owner of OUTLET'S-SWITCHES-FIXTURES '�
property who hui]ds or impoon thereon,and who does such work himself or through
his own employees,provided that.such imem
provemns arc not intended or offered for .NEW RESIDENTIAL ELECIR SQ FT.
sale.IL howcventhehuildingorimprovcmeai is sold within one yenr of compinion,the - - SQ.ff.FLOOR AREA $/SQ.14.
er-builder will have the burden of proving that he did not build or improve for put- W -
Ptuofxalc.). - R 4
- ❑1,as owner of the property,nm exclusively contorting with licenstal contractors to TOTAL ry
construct the project(Sec.7(W,Business and Professions Code:)The Contractor's h9
cense Law does not apply to an owner of property who builds or improves lhcecon,and QTY. PLUMBING PERMIT FEE C�'/ FI
who contracts for such pmjecowith acontoctngn)licensed pursuant I tothe Contractors
Lima,law. PP.RMIT ISSUANCE' ('G 4
O lam exempt under Sec. .B&1'C for this reason
Owner Date ALTI?R-DRAIN&VENT-WATER(EA) VALUA l+
WOItKER:SCOMI'ENSA1'IONDECLARATION HACK F]OWPROTECT.DHVICE• 6 �`
I hereby mpr,under penalty of perjury one of the following decluretiav: Q J
❑ I have and will maintain.Cenificatenf Consent to self-insure for Workers Co.,.- DRAINS-FLOOR,ROOF.AREA,COND.
sation,as provided for by Section 37M of the Labor Cole,for the performance of the STORIES TYPL GDN$tRBLTIDN
workforwhichthisperniriei...ed. ; - FIXTURES-PER TRAP
I have aril will rmatAo Workers Compensation Ins/mame,as required by Sm imi370d _
My Wart �rtvensatinn crfnrmanc nil Pnlio9 w c tca� nf77
GAS (EA)
�S - OCC.GROUP, APN
Currie [.�' - Policy No.. (� r
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASRIINDUSTRL WASTE INTERCEIvi OR
BUILDING DIVISION FEES
'(Thou section need not le completed ifthe permit is for one hundred dollars($IW) GREASE TRAP
or lass.) PLANCHECK FEE
I cenifythat in the penformancc ufthe work for whichthispcmtit isissucJ,(shall SEWER-SANITARY-STORM LA.2(N)FT.
not employ any pit in any manner so as to become subject to the Wmkcm'Compon- ENERGY ITE
Oz sation Laws of California,Date WATCk,HEATER WIVENTA3LELTR
Q Applicant GRADING FEF. -
V) NOTICE TO APPLICANT:If,after making this Certifieute of Exemption,you should WATERSYSTEMfTBEATING
a; become subjeat to the Workers Compensation Provisions of the Labor Cade,you must SOILS FEE
W forthwith comply with,.Ch provisiotrom this Permit shall to deemed revokN. WATER SERVICIi
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID ,.
U O Ihoshyaffirm that the.is.consuuctin.time.,agency fortheperfamanc,of Aoi5l
c''e'PtX
H the work for which this Permit isissued(Sec.3097,Civ.C.) '
Q U lender's Noma _ TOTAL:
W ]enders Address h TOTAL:
.�" 06 ]certify that I have read this.pplication.nd stat but Nc above information is - - BUILDING Ft:E
CZ) correct.I egret,to comply with all city and county ordinances and ante laws re]ming m QTY. MECHANICAL PERMIT FEE
U itbovengconametir.pC hereby wnhlnlzereprexaoto0ves of this city In enter upon rho SEISMIC FEE
nbove-(We)ami since
1.Cave findmnify an keep es' PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamticss the City of CuPcnino against ELECTRIC IT/
]iuhii]ties,judgments,costs and expenses which may in any way acerae against said City ALT17R OR ADD TO MECH.
i it consequence of the grunting of this permit. PLUMBING PE.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ifl.000 CPM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCfIONTAX
Signature of AppliesnVContracor Date EXHAUST HOOD(WIUUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willdit.pplicer,or future haddimg occupant soe.rhundle hazmlmix mmedal HEATING UNIT(TO 100,oN)BTU)
as defined by the Cupamon,Munit l Cole,Chapter 9.12,and the Health and Safety _
Code Section 25532/.), HEATING UNIT(OVER 100,000 BTU)
❑Yes Nn - PAID
VENfI1.ATION FAN(SINGLE RESID) pate �RecelptN
WIII the appliaml imams a hail g occupant use Area
Air a or devices which
�emllllalBndOYs air atmamirtams as seed by the Bay Arta Air Quality Management BOIL1?R-COMI'fJHP OR I(NI,IIW BTU) ..
Disvict? ' TOTAL:
❑Yes No BOILER-COMV(OVBR I00,000BTU)
Ihavetcaulfth metedals tyuirtmcros under Chapter 6.95 of the Cali- AIRCONDITIONHR ISSUANCE DATE
facia H Safe, ous tin 5505,M533 and 25534.1 understand Nat if the NEW RESIDENT JAL MECH. � SQ.PT.
in an
aur h�t it is it, ow,ma to notify the occupant
'nf th m n m n puncy. ,. m '
nm or t athorized vgem Dat TOTAL: ISSUED BY:
0FFICE