S 2815 ji
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF WFINO BUILDING-ECKcFRICAL PERMIT NO.
EUII.DING DIVISION APPLICATION/PBRIl PLUMBING-MECHANICAL S 2815
BUILDING,PROJF,CF IIIEN'1'IFICAI'ION
BUILDING ADDRESS: SAM PARY NO. AI'I'IICAlips SURMI FfAl.DATE
OWNERS NAME: PHONE: -II�J CONI'EAC I OR'S NAME: 1,1'X0'.
�cY .. SSG�S-fe S �J NIC CON'IROI.a
ARCI I I'1'P,CI'/ENGIN If ZR: LIC NO'. A PRESS: ❑
1�
CONTACT: PHONE: BUILDING PERA11'F INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG I LECI' FLUME
MECH
1:1 1:1L Y ❑
a LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT 193E
I hereby arfirm[hit[I am licensed under Provisions of chapter 9 Ronntumdngcalz JOB DESCRIPTION
�_� 6mhf+-�3-1le4,_ Gni1rnJl'rof.xiulvs CuJc,unJmylicence i.v RESIDENTIAL
X00 in G 1 PERMH ISSUANCE
F folllinceonJe e 51 IIb ❑ADITIWI, ❑KCNIRECHHN REE-PIPE
aVMODEL
V Liccnsc Class Lica APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE-PIPE
ARCH IECTS DECLARA'T'ION ❑MULTI-l1NIT ❑STRUCI'URAL
F to Z I understand my plans shall be used as public records PANELS MOD117CAI'ION
UPTO 200AMPS
OLtW [I INTERIOR ❑CHIMNEY
NIMINOREPAIR
POOL
Q�f-; hicen.cJ Prnfcc5innnl p ,It P(11-IIIINIANI'S IMIIROVBATHRIMODE' DSWIMMINGPOOLS
�yC f,U
OWNER-BUILDER DECLARATION S License Law fill OVER HWANUS El BATH HEMODEI/REPAIR ❑DEMOLITION
C 5 Q I herch,:dfimt Ih:n I ant chem 1 hour the Contractor
ly W ❑❑OTllli
6 following rens.... IScnion 7031.5.lamin-s mad P...le,nn,Code:Ni,cit,or usam, SIGNS ELECIRICA). A
LL 3
act-a whifh myuirec a pernit In constntn.alter,improve,dcmnli,h,ar rtpttir any strv<ture ,
'F"uva'O.2 prior m its sammae,also reorders the applicant for such Flood to file aslgrad alalemnn SPECIAL CIRCIIITIMISC.
that hcklirornavlpuwuanllolhfpnrvl,cinnx of the Cummdnr:s Cillos:Law(Chapter 9
W�00 (commencing with Section 7")of Div inion 3 of the Business and Professions CNet or TEMP.NIMTR OR POLE INS'll COMMERCIAI:
m f o That he11,nxumPl therefrom rad it,,basis fur the alleged lWeaplion.Any violation of NEW BLDG/ADDITION O DEMOLITION
Section 70315 by any oprifom Pura perm..whjavlr.mcappid,on m a civil lwnahy of IIOW17R DEVICES ANT ❑FOOD SERVICE
nonnore than five hundred dollars($500). 1 F_NEN'1'
SQ 711,aivarer of the prupcny,or my employres with angelic;their compen.mtion, SWIMMINGFOOLELECRIC
p- will Jo the work,and lliconucmrem not itttendcA ni ulYcreJ for wJe(See 71Md.Ousincsr OTHE
aasuiPmfessint,Code: neCounselor'sLicenseLaw does not ap�lytoaaowner OUTLIiTS-SWI ICHI45-FIX IORES
property who If ldc lir impmvev thereon,and who does such work himself ar through
his assn emd""',Vr oided that such impnrvetneno n,not intmuled or offered Ino NEW RESIDENTIAL ELECTR SQ IT
sale.IL M1owevcn IM1e building or improvement is%old within one vewnfcompladon.the SQ.I'P.IROOR AI<I?A SISQ.Pr.
ner-bullder will hale the burden of puling that he did not build or improve for pur-
"we If sal.J.
1,m nwncr rf the prnpcHS am exdusivelY<nnlsming with IicensJ comradon In 'I'OIAL:
n,nuel the prnjea Nor,7044,Business and Pn le,ions Code:)The Contractors I,i
se Lnwdous ata apply Inn owner of l'mpery whet buildcor mpmvcs t harcon.:md QTY. PLUMBING PERMIT FEE
x�hr crmsms fmsuch pmjccLv with a armrncmgq IicelrscJ Pursuant m the Contmaur'n
License Low. PERMIT ISSUANCE
E3 Innis inpl under Sell .B&P C lot this reason
ALTER-DRAIN&VENT-WNTER IRA) VALUATION
Owner Use
W01tKER'S COMPI?NYA'HONDIICIARATION BACK IlOW -ROTIiCI'.DEVICE
I hereby affirm under penally of perjury one of the Ii allowing declamations:
❑I have anJwill maintain a Certificate of Consenuosel6lnwre for Workers Comped- DRAINS-FLOOR.ROUE AREA.COND. SIORII-S IYPI?CONSTRUCTION
,alio,ax Vmv1Jed far by Section 371X1 of the Lam Code,fill the Pfrfomacme of the
w ilk for which this Pcrmil is isnucJ. t• {l XIL12E��aP1- 'rkAl'
1 have and will maintain workers Co n,ansnion Insurance,as rtouimJ by Section
I)not the Lalmr Code, IM1e lseefonum,,of lire work hd which this permit n-urd. dAS-I: VSI'B -I IN OIfT 'I' OCC.GROUP APN
My ,t .. J I'olicYput sne�ll,g�j7-DJ
Carrier
C,t cn its n.a ptccurit Policy No.:oragjl J II �1�1
r li 1 t
CERI'IPI ATIi UI'E%EMITION FROM WORKERS' (1REASIiIINDl1. RLW TTGINTL OR I
COMPENSATION INSURANCE BUILDING DIVISION Ililt,S
O'hi.ssection need not be completed ifthe permit is Intone hundred dollars(MBE GRIiASETRAP
or Ilex.) PLANCHECK FEE
I malty that in the Nifnmtxnm of the work for which dd,,nna is ixsaal.lshullWJ
C`
non crafts,an b'ccuo the Workers'Camper- Yt-S.l.__AIY ItM_—t T
p ) YIK.rn dnanYmau ENERGY FEE
, 'pX n sol
Z saline Lnwnnf Cabf .'are WAI ER HEArHR WIVIiNLIELECIR D e Q
2 N(TI'IGIi TO I'ANF:IL oho nuking this Ccnifcatc of Bxnttplinn.You should WATER SYSILMTRENTING
beculre,subject to the Workers Coml'cmarrn provisions of the labor Code,you most SOILS FEE
hmovall emnply with such provision,or it,,,Permit,Mill M+deanned revoked. WATER SERVICE
Q
n' CONSRUCTION LENDING AGENCY NEW R IDIiI'DAL PIMB. SQ.FF. PAID
TDate Receipt a
O
I hereby arfirtl that mere is a Conxtmcr..tl lending agency rat the Perlornnnfe of
U
U F the work far whkh TMs perred is issued(Sec.30ID.Co.C.)
TOTAL:
O Lcrder's Same
T(YI'Ah
W Landers Andress .
1 renily that I havorcad This application and,nate that IM1e uNice information ix BUILDING lila
correct.l agues comply withal]tiny and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
SEISMIC IIiE
oZ build ingct.utmOwn,end hcmby miNndm ¢
rtVcntaGth
ven of lhiscly ,,enter inns e
abuse mentioned Property fill inspection purposes. PERMIT'ISSUANCIi IiLECI'HIC TLE
(WU..gree imove,indcnmify and keep harmless the City of Cupeninr agaida
liahililics,jadgmmdrv,cnstsanJ expcnsc,ahichetay in y way Icer..against sairiCily ALI'17H OR ADD TO MFCH. PLUMBING 12EE
nws,racc of the gramil,of thin pc mil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIFGO Indian CPM) MECHANICAL %.
SOURCE RIiOULA I'to S,
AIR HANDLING UNIT(OVER 10.000 CFM)
fI
EONSIRUCf 'D,
Sm. met'f ApplicunllComorcert Date EXHAUSTHOODIWIDUCT) HOUSING ITR 'CION FEE
HAZSRDOUS MA TRIAIS DISCLOSURE
Will lhcapplicanl or future holdingercupant crecorhandle hasankss imed9 HEATING UNIT CFO[00.0100 BTU)
as ddined by om Cia,linno Municipal Code,Chapter 9,12.and the Health and Safcry
Code.Soction 255}21n)c H17AIINC,UNIT'(OVER 100000 It'I'U)
Yes VENTILATION FAN(SINGLE RF_SID) PAID _
L Date ReceiPlp
Will lira applifa I or fm rshullJin,nocepnnt taw eouipasn nr devices whifh 6OILER-COMP(?IIP OR IIX),INp BTU)
mil h ars dors air contaminants as&-fined by the Bay Arca Air Quality Management 'I O" 2_�
D"I'm BOILER-COME(OVER IIXk(Np H'I'U)
❑YII
1 have read the hasarJore ma trials re i is Imdcr Cha lar fi 95 of IM1e Cali- AIR CONDI'UON[R ISSUANCE DATE
y2 533 a p //r''''''��f
fitmia Hevhh&Salmy Cele.ea to a,25505,2551}and 45534,1 t odotily th mat II the NIiW RESIUI!NTIAI.MliCll, SQ.EL '
buildingJmv ¢urendy M1aveamwnL that it is my responsibility snooty the rccuPam
oftnJ•, in wni&n tMtst he mermi.slmme nr:t eLen3lQ�pany
Dustier orsummon agent Oate TOTAL ISSUED BY:
OFFICE