S 2423 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF:R'1'INO BUILDING-ELECTRICAL PERNI IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM NC-MECHANICAL S 2423
ItI111.111.NG 1'N(lJl!CI'IUEN'1'IF'IGTION
BUILDINOAUDHFSS. SANITARY.Q. AI'PhICAII(IN SUIIMIIT'N.IIAI'E
pi�b It f- ( Q' 1*
OWNER:S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
GC. Sly NIC C(lN'1'HOLp
ARCHITE( /EiNGINf:F:R: LIC NO: ADURESS: _ ❑
\y W 4h W U 1, C— 3bN
CONTACT. PHONE: HU ILDING PERMIT INFO
q`� -L hA1gOI1 �p. � P.�A� ❑ Consultant Fees Paid by Applicant(Initial) HL❑IlG ELECT PLUME h1E❑Clf
21
`T LICENSED CONTRACTOR'S DECLARATION "1(Jl QTY IiLEC TRIC PERMIT FEE
Cl a: 1 hereby at inti that 1 m,t Iire..ud under proemor,of Chapter 9(commenriag JOB DESCRIPTION
WC) h Sm
wish Sexton, DiAm....Sot the lto,measand P.,fsliunn Codu,and my l......c a RESIDENTIAL:
4100 in RMITISSUANCIi
F41• ease la undcNejl� -r ❑ShUWL [I KI kIiMUUEI.
License Class �^ 310 Lic.N
Q U
APPLIANCES-RESIDENTIAL ❑ADDITION [3 PLUMBING
'RE
-1IPi
p.Z4Dam 2^49 Commmar
m6a T ❑Mlla'I-0NI IEl IA.
_Ow ARC]11ILPANELS MODWICA1ION
m Z I undcnwnJ my plana shall he used m public remtrJs
OZ4� UP'I'O'_INI NIPS ❑INTERIOR ❑CHIMNISI'REI'A[k
�Ltej Licensed Proewional 201-I n(X)AMPS IMPROVFMENT E]SWIMMINGp001.S
OWNHR-BUILDER DEC
LARAI[ON OVER HXXtAMPS ❑RNHIRF.MODEI/RHPAIR [IDEMOijNON
C w Q 1 hereby mr.im that I am exempt Gem the Cmderch is Licence Law fur the ❑OI'111iR
gg Oyu following reason,(See, 17031.5.[1 mess and Prefivi,ons Code:Any cityafromny SIGNS ELECIRICA[,
W 3 4,y< which requires a prnnh m rmbauct.alter,in, I,dmmdi.h,or eepmr any'arwh m
t-=0.] pennon it,i.....ce,.leorequimslheapplicam Gorsuch permit to flea signed nammcm SPECIALCINCUI'I'/MISC.
E�}e, I and he i s l iccesed pursuannn l he provisions of the Common's License Law(Chapter 9
41 00 (comnrncing with Sanion](NNpof Division 3 of l he Business mW Noteasions CW0or 'ITEM P.ME'T1:it OR POLE INIS II COMMERCIAL:
St.E e C that he is exempt Iherefmnt and the basis for Ibe alleged exemption.Any violation of ❑NEW BLDG/ADDITION Q DEMOLITION
XmH Section 7031.5 by any applicant for a permil sutheru the applicant to a civil penalty of POWER DEVICF_S ❑TENANT ❑1'001)SERVICE
not mom than Five hundred dollars S5W). IMPROVEMENT
SD ❑l.an nwnerttf lire pm,ny,ormy anplo,ce,with wages as theirsnle eompeloal r. SWIMMING POOL ELECTRIC
F- will Jas the wnrkamd lhes4uhme titan imm�dcJ or oRemJ for sale(Scc.]B41,Business DOSSIER1;m Iutd[I 1—inns Cade:The Commocan,s License Lnw docs nm apply m initiative of OUTLETS-SWITCHES-FIXTURES
pra,dy who bunds e i t its thereon,and subs does such work,bintorlf ar through
his own employees.Fascicled that such improvements am not intended of offered for NEW RESIDENTIAL ELF.C!'R SQ I.-L
sah,If,however,the building or improvement is sold within one yearrdronplenon.the SQ.FT.FLOOR AREA $/SQ.IT.
owner-bodder will have the harden of proving Thal he did not huild or improve hili our-
Yrse nl m1e1"
1,as on net of the prony,am calasively contracting with licensed contractors to TOTAL:
pe
construct the proj,n(See.](D4.Business and Professions Code:)Me Contractor,Li-
"a-
i-c Y.aw docsool opply malt owner of propcny wba hwlob or i mpmves therov,n.and QTY. PLUMBING PERMIT FEE.
suns contracts Ga such pmlmrc with a comracmrts)IicenuJ pur.uannn the Cnnaacvtts
License Law. PERMIT ISSUANCE
❑ reneserssoder Sao. .B.PPCfor Thisreason
ACfER-DRAINkVE -WAITR(EA) VALUAT[ON
Oxmr UIO
WOR KEN9 COMVENSATI(INDECe JoHovON RACK FLOW P , DEVICE
beastly ukinn under punalry of perjury one of the Ibllnwing Jedkni-s Cs:
i]an;is and will far by Section 3eme of he
liteerformnCompere IlRA1NS-P 'AREA.COND' S'fOk11S 'I'YI'IiEQNSPkl1C'IION
sntion,xa Fascicled far by Section J]Ip of the Lubar CWe,for the pedammnce of the
work ba which at,permit is issued. 1H%TURES-PF.H'1'RAI
I have and will maintain Worker's Compensul inn Insurance,as required by Suction
3700olum isbnrCole.for the peRmmance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 . S )p APN
My Worker_'s C'o�mfjen_sm Inw. ce caricrsmal Policy number are:
Carrier: Policy No:bSl�Q16—R4 GAS-EA.SYSTHM-OVER4(EA)
CIiItT11BC 'lli OF iXIiMYT10N FROM WORKERS' GRF.ASI%INUUSTRI.WASTE INTF.RCEITO
COSIPENSATION INSURANCE: l INC,DIVISION IT
Thi—e...rn ncWn...hom.....red.tOdpcer...is Room hundred doHnn($100) GRHASE'I'RAP —or less.) b li
Imnify that in in myexmancwdlhewnrkfor me hichobject
It mmit orae lCurnahall $IiWEN-SANITARY-STOP h1 F"A.21X1 YP A
not rntploy any peons in any manner so as m bcmme xuhjen to the Workers'CamErn" ENRHGY FTili
ZZ snuun Laws nl'OJiGnma Ilan, WA'T'ER HEADER W/Vl: .1.l?C'1'N GRADING FEE
O APPIiculn
NOTICIi TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMORENTING
F� ? become'tioccl In did W..l ar's C.... ao,iilioa previsions of the Labor Code,you must
Uj molividt comply with such pro—sKna Or perm.shall be deemed etwoked. WAS 12R SRRVICE
a CONSTRUCTION LENDING AG17NCY NEW RESIDENIIN.PLMB. SQ.FE PAID Dmc Hemipt It
U 0 Ihcrcby ldhnnlbunhcrc lsncun.wnion lcnJingugcnryfrlhcprrlinmm�ccul
O PShe wad for which this permit is issued(Sec.31191,Civ.C.) I OTAL.
lenders Na '1( 'A,.
lands"s'Adih.. BUILDING FT C
y I crnify Thal I have read this.ap111cminn and one that the above intenaasan is I
,F. N correct l agree to comply with all city and county ordinances andsmte laws relating un QTY. MECI IANICA I.PER M IT FEE
V Z building consmmJnn.and hereby amhorve representativm ornia,hyla enter upon the SEISMIC hili
ahavo-nmeet IS ptnperty for inepcction pugntsca. 1'ERMI'I ISSUANCE ELECTRIC it
(We)agree or save,indemnify and keep harmless the City of Cupenino against
liabilities,judgments,costs and expenses which may in anyway ammeagainst said City ASTER OR ADD TO MECIL PLUMBING FF. (�
gacoce aaf
Aide gaming anas
da pe ,
APPL.eIC TI]NDGN S'1'A NDSAND WILLCOMPLY Will]AI,L NON-POINT AIR HANDLING UNIT(0 10.000CFM) MECIIANIC ,PGE
SOV Cl tEGULCI'IONS.
AIR HANDLING UNIT(OVER 0,000CFM) CONSTRUCT R TAX
Signature of A'pP ' ra
tt/Contcmf Ome I2XHAU3T HOLD(WNUC'IT HOUS INC,MI'1'IGATION LEI?
HAZARDOUS MATERIALS DISCLOSURE
Will rhunFpliramt or future huildm,dcu,mt.mrmur handle hvynlnus material HEATING UNIT TO 0E,0(XI BTU)
as detinW by the Cupenino Nl.nicipa ole,Chapter 9.12,and the health and Safety
Code.Section 25512(a)'! HEATING UNIT(OVER 10(.(X0 BTU)
\
El Vies NoPAID
VIiNTILATION I'AN(SINGLE RES IUI U:nc kccciplp
Will the applicant or future building occupant use equipment nr devices which BOILER-COMP(JIIP OR 100,000 II N)
mit bamrdnus air contaminants n. mal by the Bay Ands Air Quality Management
��✓ Dismill BOILER-COMP(OVER 10k0NI it'1'(3)
❑Vic ❑No
I have read the lueanluu.mom- s m mens n undee Chapter 495 of She Cali- AIR CONDITIONER ISS73 DATE��
Lima IEnhh h Safety Cly,11,i 255(15,c55- and 2.5534,1 undnm nd Sale lie NEW NHSIUIiN'IIAI.MECII. $Q.PI'. / �(S
buildingdeasnntpwt fa.eam aI lhaY m,,n di flay am t,thcuccup.I r
oath,re,mronsnl hie my Mimi Enc eta Cradle. 'If u e
/
Ower or amhnfiecd agora TOI'A L: ISSUHII If Y: I
OFFICE
o = x
w i
-1 ti O
N T A
A 4.
C
A'
1
0
y (11
� FSI
A
O yy
3 �
0
rn
a ,'a
0
z
" o
r P c mow `' I zoy
O
CD
N D
cc,:) o Z-o
t m
0 oT 1
�J
R�
Z