99110014APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Q vl O Ii
CITY DI CUPVISION BUIhBINO • ELECMECHANICAL
ECH NICA L&WPERMIT— N
BICAL
UILDING DIVISION APPLICATION/PERMIT ^.,•-PLUStRINr;°; n„te^xnIT�cn1.T.,`u /+�—M�
OFFICE
101152 M I /l,la
I//- L - 4
OWNER'. AM& �.
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ARCHITEC (ENGINEER: LIC NO:
CON R I' NAM r/- LIC NP:
AI URf o c sr t o s
NIC
❑
CON'1'ROLM
CONTACT PHONE:
BUILDING PERMIT INFO
l.� t ` E N iF X 2_7` _07 •�
rn lrJ /7 (L
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB M,E�C
❑ ❑ ❑ I�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am limosed under Provisions or chapter 9 (commencing
with Seminn](IOB)nl Divisinn3nf the Business and Professions COJc, and mylicenu is
in full force and IT
License-' Lic.g
Umc Contractor
QTY. ELECTRIC PERMIT FEE
-
JOB DESCRIPTION
RESIDENTIAL:
❑SPOWI. ❑KITCI{I?N REMODEL
❑ADDITION E3 PLUMBING RE -PIPE
Cl MULTI -UNIT []STRUCTURAL
MODIFICATION
El INTERIOR ❑S CHIMNEY
MINGPREPAIR
IMPROVEMENT SWIMMING POOLS
OL
❑ BATH REMODEUREPAIR ❑DEMOLITION
[]OTHER
044
900
FW
�UV
F W
NF�Dh
Z O - Z
OZ—�
a4t�
S. C 'n
i1pi5$O 6 U
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
ARCHITECTS DECLARATIO
l undcrsmnd my football be used as blit mcoNs
W
PANELS
UP T0200AMPS
LicenuJProfessional
OWNER -BUILDER DECLARATION
I hereby alarm that I am exempt from the Contrucbr's License Law for she
following reason. (Seeinn 703 1.5, Business and Professions Code: Any city or county
201-IOOIIAMPS
OVER IOW AMPS
SIGNS ELECTRICAL
tas F
�y
which requires a permit to construct. Otter, improve, demolish, of repair any structure
prior ns its issuance, also requires the applicant for such permit it) lite a signed statement
that lie is licensed puramnttothe pmvidearsofNeComractodsLicense Law (Chapter 9
,
SPECIAL CIRCUITMISC.
COMMERCIAL:
W
Rae
m.Section7071.5
>.
=Z
(onmmenem, with Seeman 7000)of Division 3 ofthe Business and Professions Code) or
that he is exempt durefmm and the basis for the alleged exemption. Any violation of
by any applicant for a permit sabjeen the applicant to. civil penalty of
.,it
not more Nan five hundred dollars (S5W ).
I, es owner of Ne property. nr my employees wiN wages as Neir sole compensation.
wH) do the work and Ne minvit re is not imeade] oroRemil hirsute (Set, 71144, Business
and Professions Cade: The Contractor's License Law does not apply to an owner of
TEMP. METER OR POLE INS'E
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[:]TENANT❑FOOD SERVICE
IMPROVEMENT
[]OTHER
POWER DEVICES
POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
4
whe bonds or improves thereon, Oad who does such work himself Or through
prnpeny
his own employees, provided flim such improvements am notintended or offered for
sale. It, however, the building or improvement is sold within one yew of completion, the
NEW RESIDENTIAL HIXCTR SQ
SQ.rT. FLOOR AREA
SISQ. FT.
nwmr-builder will have the burden of proving that he did not build or improve for put.
'
pose of sale.).
Fl I, in owner of the progeny, am exclusively convecting with licensed contractors to
convect the project (Sec. 7044, Business and Professions CakU The Contractors Li-
nse Law does not apply to as owner of propery who builds or improves thereon, and
QTY. PLUMBING PERMIT F
who comment for such projects with a contra tions) licensed pursuant to Ne Commerce,
PERMIT ISSUANCE
License Law. t
❑ I am exempt under Sec. . R & P C for Nis reason
-
Owner Dane
ALTER _ DRAIN & VENT - WATER (EA)
VALUATION
,�/-t '
�-
25W
WOR KER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declarations:
I have and will maintain a Ceniricam ofConscm to self -insure for Workers Counter-
sation, as provided for by Section 3700 of the Labor Cade, for the performance of the
work far which his permit is issued..
DRAINS- FLOOR, ROOF AREA, COND.
• STORIES TYPECONSTRUCTION
FIXTURES -PER TRAP
❑ I have and will maintain Workers Compensation Insurance, to required by Section
3700 ofthe Labor Code, for performance of Ne work for which this permit is issued.
M Work ..fi�rr °}' 1p.u_mpc artier and Policy•BGG/P
C, 1%=n l/Y Policy No.; P�izap
GAS- F.A. SYSTEM. I INC,. 4 OUTLETS
OCC. GROUP / AIYi7
GAS -EA. SYSTIIM-OVER4 HAI
CERTI FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This rection need not becompleted Ease permit is for one hundraddollan(SIM)
Or less.)
Icedify Nat in the performarraimnhe wok forwhich this pernal is issued. I shall
nm emPlay any person in any manner so as to been a subject m the Workers' Comprn-
❑REASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
_
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 2nd FT.
ENERGY FEE
WATER HEATER WNENTgiLECTR
GRADING ITE
OZ;
0
G Vy
(•"
{aTi
Q
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U 0
W s'
F
0
satin. Lows of Cduamiv. Date
)
Applicant
NOTICH. TO APPLICANT. IL it,, ranking Nis CeNficwe of Exemption, you slmulJ
become subject tothe Worker's Compensation provisions of Ne Labor -Code, you must
fonhwithcninplywilh such gin ... has or,his permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
l herebyaffinn that isaconswnionleading agency fornheperftnmance of
the work for which this permit is issued (See. TNT, Co. CJ
Lenders Namc
WATER SYSTF.MaREATING
WATER SERVICE
H FEL:
_
_
Date Rcceipng
A
NEW RESIDIN'TIALPLM H. SQ.P.
TOTAL.'
BUILDING ME
w
S
In
L)�
Lenders Address
information is
I certify than 1 have read this epplara o r end note that the above
correct. l agree no comply with all city and county ordinances and state laws reading In
building construction, and hereby amborim representatives of this City to enter upon the
ubove-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep formula. the City of Cuna against
liahiaitics,judgments, costs and expenses which may in any way uceme against said City
granting of this permit.
QTY. MECHANICAL PERMIT FEE
16Jt•'
ELECTRIC PEE
PERMIT ISSUANCE
ALTER ORADD TO MECH.
PLUMBING FEF.
AIR HANDLING UNIT (1'O III,(g10CFM)
MECHANICAL ME
Aconsequence NNE
AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
SOURCP. REGULATIONS.
AIR HANDLING ON] 'I'(OVER I0,000 CFM)
CONSTRUCTION TAX
I_1 �ffia
wlO-/ It -1—
sismatrecf n nM Date
IfAZANDOUS MATERIA6SD CLOSURE
Will the building norcor hanand
EXHAUST HOOD(W/DUCG
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 it
"
to Health an Safe[,
Carg
ns defintl by the Cupenina Municipal Code, Chapter 9.12, and the I{CnIN and Safety
Cada, Scedan 25532(a)t
E] Yes n�
HEATING UNIT (GVHR 1110.00s) 81 U)
PAID part Reailnx
VENTILATION FAN (SINGLE RBSID)
BOILER-COME(7HPOR 100,000 BTU)
Will da, applicant or building oecupanl use equipment or devices which
emir hardcommands, au commads, as definW by the Buy Area Air Quality Managcruenn
m
District?
Elynx ._./
TOTAL:
BOILER - COMP (OVER I00,(XIfI BTU)
CONDITIONER
1 have read the humorous muredalsAIR
requirements under Chapter 6.95 of the COIi-
h mid Braldr & Safety Costa, Sections 25505, 25537 odd 25534. 1 understand that if the
huildin does not curently huv^mount. Ndit is my respsnnihility tonntify the oxcupam
ISSUANCE DATE
// _ 41
NEW RESIDENTIAL. MSCIL SQ. Ff.
til the m Is which mus tncyinor lq mssy ncc fu Cctificulf ft]ccu
�s
ISSUED BY:
- TOTAL
Own er
!�� I Date y
or unnamed agent
OFFICE