28420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRR77N0 BUILDING-NLIiC'1'RIt:AI• I'IiRMIT NO. O
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT I DEN'I'HICA'1']ON
BUILDING ADD PSS: ( ') SANITARY NO. APPLICATION SUBMITTAL DAM
/ V� UNITM LOTp
OWNERS N A�f!^.�t� Pliw E: �+ CONTRACTOR'S NAME: LIC NO: N/C CONTROL III
ICHI'T ECT/PNGMEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PEE BUILDING I'F.RMI'F INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE. ❑ ❑ O
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I In,ml fYrm lhatlam llunsed under fCha t r9 farmmendn LOBI11SCRIVI ION
CUCO Ya pal isimnsm pe eis in
�O %II lonemnal of Division3nl the Business end Porfessiom Cale,and my license is In PANELS
Ln f... and clfccl.
QQ up`�j Liccme Close Lic.N UP T02W AMPS
r 6 cacti Date Contractor 201-IM AMPS t
z 0.7ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FI',FLOOR AREA $/SQ.FT.
Z 1 understand my plans shall be used as public records.
y E SIGNS ELECTRICAL
Liccnxd Formation.)
�aOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO?F. I heresy affirm that I am exempt from the CmnwemPs c:Any law for the
L;!i:0rn which following lines. ($ution]OJLS,Busmess and Professions derions C.ormpd city or county TEMP.MEfER OR fbl.li INST. -
�LLOa whichrcyuimsepermiuouires t cLahee impovedemmitt or rtpained amcmrt
,R N e its issuance.alsostpro ions ofthe Co uoLicesi w(Ci men, POWER DEVICES
prior require pp permi gnc
RV� p that mis ncinxdpumuwnothe 000)of Division the Contractors License Lsion.Cpmr
�' 9(commenming with Section 7000)of Division Sof rhe Business and l'rnfcvinm Cade) SWIMMING POOL ELECTRIC VALUATION
y
or he is exempt herefrom and the basis for the alleged exemption.Any violmionmf OUTLETS-SWI'1 CHES-PIXTUHES r
GSectinn]031.51, vnyapplicam for a permit subjects the applicnm uracivil penalty of
C not more than five handed dollars($500). NEW RF.SIDF.NTIAL IiLELTR _SQ.FT.
m ❑ I,nsowncrnf lbepmperty,ormyemployeeswith wages ustheirsnlearmpcnulion, STORIES TYPE CONSTR CTION
43. willdmtholltmsande;Th CortsemsLnareasowdoes not
an
and 1'rlywholn.v Cade:The Cont envoi;, dwho latw does or apply ll cot owner of
os
owncpro,waywbohai Providedsai d
lot luves ll immuvnarennu mu work eredfill rnugh If.
huemplIlhabaoyms,dingo rd thntwrnand wid within ne onrocdmpletial l'ne own If, OCC.GROUP RES.UNITS
weveu tit have The
or i en of moving
i that be within of build or improve
elf r I purpose
f 'I'D
builder wlll have the huNen of proving that he did not buil)or improve for purpose of
aI )' QTY, PLUMBING PERMIT' FEE ROOD ZONE nPN
Las ownerjethe Sm.704Icorexclusively contractingwithde:)Th Contractor's
mrswe the does
not(Sec.owl Business and Professions Code:)The Commctors PERMIT ISSUANCE
Licensel.awdmmnmapplyloannwnermfpropery who builds rrrent oche Codur, ea
whoroutinesLaw.frnsuch projects with....meror(s)licensed pursuam m the Commnora
License Law. ALTL•R-DRAIN&VENT-WATER(HA) IrfiE SUMMARY
❑ I nm exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE SANITARY Y DL ES N
Owner Dare RECE Ta
ARG
ROOF, ,COND.
WORKMAN COMPENSATION DECLARATION DRAINS-BOOR, SCHOOLTAX YN '
❑ I hereby affimnhm l have acertiricam ofcmcsent noself-insutv.ora cmificam of RFCF.IPFp
Workers'Compensatiun Insurance or aemified copytherenf(Sce,3gd0,Lab C.)which FIXTURES-PER TRAP PARK FEE Y N
covera all employees under this permit. GAS-EA.SYSTEM.)INC.4 OUTLETS RECEIPT p
Policy p BUILDING DIVISION FEES
Company
C3 enrnnmJ erpr is berenr furnished. GAS GAS-EA.SYSTEM-OVER 4 CA) PLANCHECK LE
❑ Certified copy ix fled wish the city inspection division, GRF.ASE/INDUS'TRLWASTIiINTERCII iOR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCH
(This section need not he completed Hill,permit is normae hundred dollars l$100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance cribs work for which this pemtit is issued,l shall WATER HEATER W/VENT/ELECIR
not employ any person in any mariner so ss to become subject to the Workers' PAID
z Compemctin l lawsof Califomie. Data WATERSYSTEM/IREATING Dam Receiptp
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
(•' .�. become subjecrto the Workers Compensation Provisions oOm Lahr Code.you most
a forthwith comply with such provisions or this permit shall be dammed invoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 z
1 hereby affirm that then is a mo stmction lending agency for the Performance of
VP the work for which this pmlit is issued(Sec.ID9],Civ.C.) TOTAL: ELECTRIC WE
C1w Lender's Name T
U Lender's Atolls, QTW...,,s. MECHANICAL PERMIT FEE
PLUMBING FEIi
L) 1 certify that I have mad this application and state that the shove infoms
enrmet, lagreeercooplywithullcityundemumyordinancesandvain luwsrc tingm 1'IiRMi'1'ISSUANCG'`��0s'C'!r;.p. MECHANICAL PEE
abuilding conoruenon,and hereby authorize representatives of Nis city to cnterbon th
U F/7" above-axam ned prnpart for inspemimt putpems. [[r R D OMECIL CONSTRUCTION TAX
(We) g co ndenerify and keep mesa the City of Cupenlmr agalnq n -
liabilitics,w ns, eIa at expcnus which s in any weyxccru<sgninst olid City A A 1 'I' 11H1 CFM (�
in to uqr f gra linger is perm it. P
-17
Signa arc oT A adVCmnmarm m UST 11 /OUIt
I
PAID
I IAZARDOUSMATER ISDISCLOSURE HUAII 1 Data Receiptp
Will theepplicant or future building occupant amen,handle hamrdra,? 'al. UNIT(OVER IfM1,0006'I'U) TOTAL:
as defined by the Cuperp
ino Municipal Code,Chapel 9.12,and the Health and Safety
Code,Section 2.592OH VENTILATION &.!
❑Yea No (S NGW;�}PSID).--•. _ .vrl
HOLES-COMP CHP OR I W,fXXI BTU) ISSUANCE DATE
Will theapplicamarfutumbuildingmcupnt useequipmentordevicea whichemit p
�hazUistricfl anloue air concontaminants�����/////ss defined by the Bay Area Air Quality Management - BOILER-COMP(OVER If10,160,00s))BTU) P'4 1
❑Yea �Nn NEW RFSIDF.NTIAL MF.CI{, SQ.19'.
` {�
1 have mnA the hmaClou,ode.materials 5505.25533 under 34. I tar fl95 of the Cti-Y 1
iftile building add)
&Snfcty Cole.Seniors255115,t it
yr25534. 1ityto dmad that I I+
If tbriltingdwsnntcumcm lyhave all be thin it is my samearsiof. to the
O..'artupon.1'he requircnrenis which must he mel prior to issuance of u Cenilicum of �m4NL`L;
Occupancy,
Owner or amhorixd ngem
Data 'TOTAL: ISSUED BY:
OFFICE