99100105 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -�-- 0011 L)V �US
CITY OF CUPF.RTINO BUILDING-ELECTRICAL. 'RMI'p O.
CAL
BUILDIM:DIVISION APPWCATIONIPERMIT PING PROJBINCECT IDHANIFIC SOOO1
IfU11.DINC PROJECT IDF:N'I'TF'ICAI'ION
SANITARY NU. AI'I'hICAI'ON SUIiMI .DAT
B;Y.LDING ADURISS:
OW SNA E: PHONE: CONI AC'I'OR:S AMI:: LIC No NIC CON'I'Rol,or
iii¢ y L Si o W a�2-S11-27 oA3 ❑
CIIITI!Cf/ENGINEER: LIC NO: ADS I'Sn / 2 tel . S•./
CONTACT. PHONE: / d BUILDING PERMIT INFO
❑ Consultant Fees Pail by Applicant BLDG LO PLUMIt ML❑Chl
A945,
/j p 5, &19P)92 J`_6, v
L.ICBNSED CON'TRACEORS DI!CLARATION QTY HLECTRICPF-RMI'1' FEE
L herchy affirm that I am licensed under parnewons of Chapter 9(commencing JOB DESCRIPTION
C d'Z 1M1 genion 7(XXII of DivisianJof the Business and Sessions CNW andm licrnce is RFSIDENTIAL:
,p0 w' PERMIT ISSUANCE.
FW• full htneand cb 1. Q ❑$FOWL ❑KITCHI!N REhf0Uli1.
Q,UU hiamse C-1 -Lica nPl'LIANCI!S-RESIDIiN'I'IAL ❑ADDITION ❑PLL1MItING RIiI'll'li
N Q a D'Jle— COnlrattnr
R IIITECTg DECIARAII N PANELS ❑MULTI-UNIT ❑STHl1C'I'URAI.
Z~O o Z I understand my plans shall Ie used as public records MODIFICATION
4)—Q Oil TO 810 AMT'S ❑INTERIOR ❑CIHMNEY REPAIR
L==F'OW LicumceJ Profecsinwl 201-1XXIAMPS IMPR TINT E]SWIMMING POOLS
OWNLiR-BUILDER DECLARATION OVER IgXl AMPS
[ H 17MODELIREI'AIR ❑DI!h101.11'ION
q q Q I hereby offirm that I um exempt from the Contractor's License Law for the ❑OTHER
6 U following reason.(Sectio^7(GL5,Business and Professions CMe:Any city or county SIGNS ELECTRICAL vy1, TVD
Y131L vii wEleh mocuirc,at pcnra ,,connmmt atter.improve,demolish,or minor any structure
Q priorto its issuance,also rnyuirex the applicant for such In:rmitmfleasignN slmcanrnt SI'ILCIAL CIRCUIT/MISC.
tbut he is licensed potation to the previsions of the Co^trunnr's Licensc Law(Chapter v - COMMERCIAL
(commencing with Season 7000)of Division 3nf,he noxious,and Professions CMe)ar 'TEMP.METER OR POLI!INST.
L c q
that W.,oxmnpl therefrom and the basis t...the alleged exemption.Any violation of [I NIiW BLDGIAUUITION ❑DEMOLIT[ON
X mu+ Section 7031.5 by any appliemn I'll aspermia subjects She applicant In a axil penalty of POWER DI!VICES 0 HNANT 01`001)SERVICR
rn sol more Nan live humtreal dollar,($500) 1 PROVHMI3NT
SD (]Las nwnerof the pmPeny,army<mployux wilt wages as their sole cnmpensaian, SWIMMING POOL ELFCTRIC HER
S,^o will drdhe work,and lhe,tucmm is nm interded OrnRemd far.1, Sce.7001,Business
3 w and Profexsionc Ctde:'[he Cnn mesal Licensc Low Jxx sol apply m an owner of OUILCTS-SWITCIIES-FIXTURES
prnpcnY who haikk o,in prows the omt,and who docs,such wnrk himself or through
his Own employees,provldal nonsuch improvements are not intended ar offered for NI!W RESIDL!NTIAL 171PI'.FLOOR ARIA &S0.PI'.
.1!CfR SV I'I'.
wle.If,Enamor,the building or improvement is sold within oneyearideampletiarflam SQ.
owner-huilder will haze the burden of proving that he did not build or improve for put,
fa se of cola.). TOTAL
0 1,os Owner of the property,nor exclusively rotational with lice mod coonmaors ,I
construct the project(Sec.70u 1.Business and Professions CMe:)The Cuntocmr's D-
nseLaw rivals not apply u,an owner of propsny who build,or improve,Nerean,and QTY PLUMBING PERMIT FEE
who cammos Thr such poojecis with o eantramm(s)licensed pursuant m the Contractor,
Licence Law. PERMIT ISSUANCE
0 1 am exempt under Sas. .B&P C for this rennin
ALTER-DRAIN&VINT-WATRR IRA) VALUAI]ON
owner Date
WORKIERS COMPCNSAHON DECLARATION RACK FLOW PROTECT.OEVICF, FA -3 8
L hereby aftian under Penalty of perjury one of the blifuwi^g dualaraian. KJ--
I have and will maintain a Commeate of Cnnsenl to aribinsure for Workers Confer- DRAINS-FLOOR,ROOF,AREA.COND. gTORIFS IyIT CONS"I'It UC 1'10
conal.a provided for by Section 37(X1 of the labor Cools.for the pcefummnce of the
wnrk for which this parrot k issued. FIXfURGS-PER TRAP
❑ 1 havo most will aneianin Worker's C...npenxmir Insane,as oc,oned by Section
3700afe"INITCe.forthe perforamenfthe work farwhich lhpermit rmit is issued. GAS EA.SYS TEM-I INC. OG'1'LIfTS
tiMntOCCGROUI AI'Mj/
My N'Orkei s(' - ' n 1 err d Policy�nu/ym��M'y��/'.����=�//�'��,p's�em�'�p- •.•77
Cunice:� ccs i Policy Nu.: 0 GAS-W.SYSTEMOVT:H afFA)
CI!RTIPIC 'TIi OF E%1!MPTION FROM WORKERS' GRF.A51J1NUUSTRLN'n5'TF,INTIiRCBITOR
GOMPENgA1'1(IN INSURANCE IIUIhD1N(i DIVISION IBES
(This uclinn newt nm he complemdil the pennon is fnnme hundred dollars($11X)1 GREASE TRAP
I'LANCI11iCK I:IeG
m lexsJ
I malty thin inthc perfarmanccnOhe work farwhich Nis permit is issvM.l shall SEWER-SANITARY-STORM EA.2(p FT
nal employ any Pcwm In any munncno ns et bccnnm,object ut the Workers'Cuntpcm- ENERGY FEL!
Z cation Laws ul Celdomia.Date WATI!R HI!ATI!R WNI!NTICLEC'I'N GRADING 171FF
z O nfpheant
N(Yf10E TO APPLICANT:If,after making Nis Ccnificate of ExemMio^.You shnulJ WATER SYSTeFVfR[ATING
P ^ SOILS FEE
^� hcuma suhjcennaha Wmkvr'c Campctrsuunn provisinnx of the LohurCMe,you must
1aT;F.a IOnbwilh sunnily wiN such provictoes tar Thi,permit shall be dwnmJ rcvaked WAI'P.12 SERVICE.
a QPAID
Z)Z CONSTRUCTION LRNDING AGENCY NEW RESIDENTIAL PLMIS. SQ.PT Date Reecipl a
U O l hereby aBirm that hem is a construction lending agency for the perfiormaace of
F" the wnrk for which this permit is issual(Scc.3M9 Civ,C.) TC1'AL:
O Lends,,Name TOTAL.
r ]-orders Address BUILDING IRI!
1 comfy that 1 have read this application and state that the above infonnetinn is
v0.) cnnccl.I agme in comply with all city and county ordinances and state laws relming to QJ Y. MECHANICAL PERMIT FEE SPISMIC FEE
U Z huildi^gmnonsolun.:nd hcrcby amhuri,emmcxmwaivcsof dr,,ny to cmerupon the
eMnn.mconlaned property for inspection Purposes. K
IT NSUANCI! 171.I7CBIC Il!I;
(We).,me to save,indemnify and kap hamdess the City of Cupcninn against
Iiabililies,judgmems,cm¢and expenses which may in any way ac cmc commua.mid City OR ADD TO MECH. PLUMBING ITE
' n,e,moocof the grad.,of this form.1.
APPLICA N'I'UNDERS"I'ANDS ANI)WE LL COM I'I.Y W IT I I AL1,NON.1101 NTANDS.]NO UNI'['1'1'01 IL(XX I C17M) MSCIIANICAL FEE
SOURCE REGI IONS. /Q
ANDLING UNIT(OVER Id.IXq CFM) CONSTRUCTION TAS
Signa m A Applicnnt/Commcme / DaleUST HOOD(W/DUCT( IIOUSINC MITIGATION PEE
HAZARDOUS SEAT TRIALS DISCLOSURC
Will the applicant Or lumre Building^tTupamsu,m or handle harvdous material ]NG UNIT('1'O I IX),(XX)BTU(
as defined by the Cupcairm Municipal CMe.Chapter,9.12,and the Health and SafelyING UNIT(OVER I00,IXXI BTU)
Code,Section 23532(a)'I
C]Yet [:1 No ILA'OON PAN(SINGLE'RESID) ('AID
Dem L iP
Will the applicant or future building occupant use e,t ipnmm or devices whichER-COMP UH11 OR RsL0XI IT I"O
�'
It,hvardnus air a mominams as defined by the Bay Area Air Quality ManagementTO t
Mricr! HR-COMP(OVER IB),0(XI BTU)
❑Yes ❑Nn
AIRONUITIONCR ISSUANCE DIVE 17
1 have road the hvallous materials requires an under Chapter understand
of the Cali- is
Etmia Health&Safety CMc Sections 25585,25511 and 255:11.I undcntnml aha if the NEW HCSIDENTIAI.MECH. SQ.IT.
holdingdtcu not can as nonan.do,it,,my re,cov ihillty a motif metfam
of the requirement, ousted and poor to k—unccof a Ccniti m yy1'IYyy.
or Orn bed ogent Da¢VTOTAL: ISSUED BY-.
OFFICE