99080087 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ae, b
RTINCITY OE CUPBISION HUMMING-F,ECHA CAL
ICA
RUILOwG DIVISION API'I,ICA'1'IONA'IdRMIT PLUMBING PROJECT
IDENTIFICATION ISUII.DINf.PNOJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
:335/ I-/iieA ✓ir 17 a 4/614 �Ii—fy
OWNER'S NAME, PHONE: COMI'RACI'O_R'SNAME: LIC NO:
/� �r e-59-l� �� . v�r,<pi� y�C N/C CONTROL#
ARCIIRTTE /ENGINEER: LIC NO ADDRESS/:'0 G ❑ '75-7Z,'75-7Z,LACK jk/6 /674t' N.(LL C
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultantees Paid by Applicant(Initial) BLDG .96err PLUMB MECH
3 9D_S/ ❑ ❑ ❑
LICENSED CON'TRACTOR'S Up CLARATION QTY, ELECTRIC PERMIT FEE
I hereby afford Nal 1 am licensed under prnvisinns of Chapter 9(commencing JOB DESCRIPTION
WO�Z with SOr1md]ORB)of Divixion 3ofneuan
rhel3mid Professions Caanmycense
dd liis
OO PERMIT ISSUANCE RESIDENTIAL:
C F- in fall Inerrant]egad. p 7/1 . ❑SFDWL El KITCHEN REMODEL
QUU Dte Clazs •L•J Lien 7 / APPLIANCP_S-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
h<i Dam Cmnmdnr -✓
FRCHTTECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z p H Z 1 unacrsmne my plans shall be usw as public recoMs PANELS MODIFICATION
OZ�O UPTO 200AMPS C3 INTERIOR El CHIMNEY REPAIR
<�~W Licensed Professional 201-UMAMPS IMPROVEMENT C]SWIMMING POOLS
CY
OWNER BUILDER DECLARATION OVER IOOAMPS ❑BATH REMODEUREPAIR C3 DEMOLITION
ti C 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
6a: h following reason(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
=0thUO Q which requires a permit m construct,almr.improve,demolish,nr iconic any swcmen I
F. . prior to its issuance,also requires the applicant forsuch pemtieo file a signed imminent SPECIAL CIRCUIT/M ISC.
E that he is licensed pursuant to the provisions of the Communes Licrow law(Chapter 1
Did W COO (commencing with Section](XIO)of Division lof the nosiness and Professions Code)or TEMP.METER OR POLE)NST. COMMERCIAL:
iL a p�' that he is exempt therefrom and the basis for the alleged exemption Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
ern
Section 7031.5 by any applicant for a peurit subjects the applicant m u civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
=C, Ol,aznwner of the ornpeny.or my employees with wages sex theinnle mmperomion. SWIMMING POOL ELECTRIC ❑OTHER
F- will do the work,and the structure is not intended or offered fnrsale(See 7044,Business
L 3 m and Proons fessiCede:The Cco ruaors License law does not apply it un owner of DU'I LETS-SWITCHES-TEXTURES
pmpeny who builds or improves thereon,end who docs such.,,,it himself nr through
his own employees,provided that such improvements are not intended or offered for NEW RPS IDEN'I IAL IEEE= SQ PI.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
prow of sale.).
❑ L as owner of the pnspety,am csclusivelY commerine with licensed comments m
emenu t the project(Sec.7044,Business and Professions Code:)The Cnmrsmr's Li.
cense Low does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a connections)licensed pursuant to the Contractor'A -
LicenseLaw. PERM .'SU .F.
El am exempt under Sec. ,B&P C for this reason
OwnerDam AL'I ER I VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BAC&A F.VICE
I hereby affirm under penalty of perjury one of the following dcclannions
❑ )have and will maintain a Certificate of Conseoto self-insure for Worker's Cuntpem DRAINS-FLOOR,R ,COND.
ST IES 11 TYPE CONSTRUCTION
workfns pmvldhi for by Section 3]OB of the Luhm Cnde,for the perfnrmnnee of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,work
h his Per by Section �-D�QL
My othe sCoLnborCodd,
pensaionhcperformanceofthework finewhich this permit is issue). OAS-EA.SYSTEM-I INCA GUILE
OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number sere:
Carries Policy No I GAS-EA.SYS'1'EM-OVER 4(EA) '
CERTIFICATE 01'EXEMPTION FROM WORKERS'
COMPI'.NSATION INSURANCE GREASNINDUS'1'RE WAS 117 INTERCE3PfOlt
HUR,OING DIVISION FEES
(Tho section nwdnm he wnmlmcA 11 the pemtlt is femme hundrdl dollars(810) GI213ASH'IRAP
nr Iess) PLANCHECK FEE '
I certify the,In the performoure of the work for which this pd toil is issued,Iahali SEWER-SANI'T'ARY-STORM HA,200 EW.
not employ any person in any ntmmcr m.,,a leunte adi., ,,tlm Wnrkcrs'Contpen- ENERGY FEE
1 O z saint Ed,,.1 California.Dale WA'113R 1113Ai fit W/VENT7FEECTR
Z Applicant GRADING FEE
h NOTiCE'TO APPI.ICAN'p If,after nmkhg Ihix Cetlf,am of Bxempion.Pa'snarl WATER SYS'I IMITREATING -
a become subject to One Wnrkcrs Cnmpcazaton movlsiro of the Lahor Cock,you must SOILS FEB
fethwi,h comply with such provisionso,dik,"nut shall he detmml resokul, WATER BI31tVICB
4a '
� z CONS'IRUC'I'ION1.IINDINCIACENCY NEW RHSIDENI ALP)-MB. SQ.F.. PAID
C..) p I for
rwhichinn that Permit
it.
sued(Sec.Tr ending agency fisnhe perfnnnunpc of Dam Receipt—1y .
h i,
U Ne work for which this permit is issue)(See.3fN)].Cie C.)
QL.ender's Name �4 TOTAL.
LendetAddress TOTAL: RIF
� s
a I certify te hI have reed this upplicminn nnA sem thin tentative in(nnnntion iFL
s - BUILDING B
fes. Z) corect.I agree to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE -
U Z building construction,and hereby authorize representatives of this city if enter upon the SEISMIC FEE —
above-mentioned pmpeny fir nsitecticn purposes.
(We)agree to save,indemnify and keep harmless the City of Cupcnino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acme against said City ACI ER OR ADD TO Ml
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM)
SOURCE REGULAT 5. MECHANICAL FEE
P AIR HANDLING ON]F(OVER 18,1)(1 CFM) CONSTRUCTION TAX
Signature afA ca mmdor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
Ay1RDOU5 MATJ,o S DISCLOSURE
Will the applf ing occupanumre or handle howshros material HEAONG UNIT(TO I OO.IX)HIT)
as defined by the Cuper inn Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532/)? moi�a�.._" HRA'I'ING ON]F(OVER I 00,0(k)00,0(k)BTU)
❑Yes VENTILATION FAN(SINGLE RESID) PAID
-� ' ` Dam Receipt#
Will the applicant oranfuture s a building by the Buse equipment ofdManales which BOILER-COMP(IHPOR 100,000BTU)
ren hazardous air contaminants as defined by the Buy Ann Air Quality Manngenem T r
District]
El yes NoBOILHR-COMP(OVER I00,(l(111 BTU)
I have read the hazardous formals requirements under Chapter AM of the Cali- AIR CONDITIONER ISSUANCE/DA�TEE�
fomio Health&Safety Code,Sstions 255115,2SSJ3 anJ 25514.1 umkrsmnd that if the NEW RESIDENTIAL,MECH. SQ.FT. —9 ¢
building does not currently have a tenant,that it in my respmsibiloy m notify the occupant l /
of there uircmenm which mu nmtpypmi' ufa Cetifco� upa cy.
Owner or emhorizeda m GJ J me TOTAL: ISSUED B'I�e'
OFFICE