99070071APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING - ELECTR
BUILDINL'UIVISION APPLICATIONIPERMIT PLUMBING - MF,CHAI
ryslout'yr c"
OWNER'S NAME:
CONTACT. PHONE:
I,SI�rJ i�a4S $(oG s
LICENSED CONTRACTOR'S DECLARATION
I hereby offort Nat 1 and licensed under pmrisinns of Chapter 9 (commeming
with Section ]f10(I) of Division 3 of me Business and Professions Code, and my license is
in full force and effect. /
License Cl as �_Lia1 7
if
DateCamDDCL
RCHITECCS DECLARATION
1 understand my plans shall Be used as politic records
❑ Consultant Fees Paid by Applicant (Initial)
QTY ELECTRIC PERMIT FEE
PERMIT ISSUANCE , S
APPLIANCES -RESIDENTIAL
"I'PANELS #r sq'R;ZZ.
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OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt loom the Commodes License Law for the
following reason. (Scation'/031.5, Business and Professions Code: Any city or manry
which requites a permit to construct, altar, improve, demolish, or repair any strums
prior to its issuance, also requires the applicant for such permit to file a signed statement
thin he is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Smtion ]000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($500).
C I, as owner of Ne property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for, -----------
a, Business
and Professions CodeTo, Contractor's License Law does not apply to an owner of
property whit builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements sere not intended or offered Int
sale. IL however, the building or improver cut is sold within one year of completion, the
owro,builder will have the burden of poising that he did not build or improve for pur-
poa of sale.).
C) 1. as owner of me pmpen, am exclusively contracting with licensed accountants to
unswct the project (Sm. ]BW, Business and Professions Crdea The Contractors Li -
ore law does not apply M an owner of proon
property who builds or improves there, and QTY,
who contracts for soon projects with a cotmmatur(.) licensed pursuant to the Committees
License law.
1 am exempt under Sec. , B & P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty orperjury one of the following dealamlions:
I have and will maintain a Cenificate of Conant to self -insure for Workers Compen-
aminn, as provided for by Section 3701 of the Labor Code, for the performance of the
..,it for which this permit is issued.
C I have amt will maintain Worker's Compensation Insurance, as req led bgectio
3]00 of me labur Code, for performance of the work for whiSlsfbia�iann is issued
My Workers Cmia,mmrion In m carrierandl'olicynum rr�t
Cartier. Policy No, ..//
ERTIFICATE OF FXEMPIIONFROM ORKBRS'INIj'j&g_
COMPENSATION INSURANCE
(Tbisseaion neednm be completed tribe permit is(oronehondmddollars(IO )
or less.) ry [,I .1
loyalty that in - performance of the work lou which this pcqmtd is ®hull
not employ any person in any manner so as Io Ixmmu suM1Jam ro thttl'o'rkCdompen-
% nationanws of California. Ume
Applicant
y N come subject
APPLICANT: IL utter making this Cisions or
Exemption. Labor
Code,
should
a become subject m the Workers Compensation Permit
she] of me Lredr Cade, you must
� Bmhwirh comply with such provisions or this permit shall Be dmmetl revoked.
Q
UO CONSTRUCTION LENDINGAGENCY
1 hereby which
thi that Nem is o conduction lending agency for Performance of
� �clic work for which mos permit is issued (Sec. 3107, Co, CJ
U Lender's Name
>� Uj Lender's Address
{,. 0. 1 certify that 1 have read this application and state that he shave information is
LI y correct. 1 agree to comply with all city and county ordinances and state laws relating to QTY.
U
on lding construction, and herehy umhorize representatives of this city to enter risen the
ubnvv mentioned property for inspection purposes.
(We) agree to save, indemnify and keep broad... the City of Cupeninn against
liuhilities,judgments,cots a'a expense whidnnoy in any way mane against said City
in cnnscqucnce of the grnmin, of is rmit
APPI.ICAN'T URSTAN WIL CO 'LY WITH ALL NON -POINT
SOU
RCE RF I.ATIONS. 'a
Signaturco pplicandCom"we"built
HXR00 M ERIALS DISCLOSURE
Will theapplicam or fuwre ulld tg oecupantsmreor handle hazertlous materiel
as defined by the Cupeninn Munin ufe, Chapter 9. 12, and the Health and Safety
Code, Section 25532(x)?
El yea dCNo
Will the applicant or future building occupant use equipment or devices which
emit numrdous air contaminants as defined by the Ray Area Air Quality Manvgemcnl
Dinner?
C Year �No
1 have read the hamNous materiels y�lvimmems under Chapter 6,95 of me Cali.
fomia Health & SafefOCode, SmionaYrSil�. 255)3 mal 255M. I mdersmnJ that if the
building
of the m
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING PeOL ELECTRIC
OUTLETS30
ES-FIXTURES
NEW
SQ PT.
NITARY NO.
N/C
EDL
PERMIT
BLDG/ ELECT� PLUMB
Z a LFA
JOB DESCRIPTION
RESIDENTIAL,
CSFDWL C KITCHEN REMODEL
CADDITION C PLUMBING RE -PIPE
C MULTIUNIT ❑STRUCTURAL
MODIFICATION
C INTERIOR C CHIMNEY REPAIR
IMPROVEMENT
El SWIMMING POOLS
TATH REMODEUREPAIR ❑DEMOLITION
HER v N
CNEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
C OTHER
PLUMBINGPERNTT
FEE
Sj.I
SEWER -SANITARY - STORM EA. 200 FT.
ENERGY HE
�
PERMIT ISSUANCE.
ALTER - DRAIN & VENT - WATER (EA)
l
/
VALUATION
O Q 0
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA. CONE]
:
crnRtrc11
TYPEC(
12--r sf
C. GROUP ��j /
9�-2-"P
MECHANICAL PERMIT
PLANCHECK FEE
Sj.I
SEWER -SANITARY - STORM EA. 200 FT.
ENERGY HE
III 0
-)
/ ' Z
WATER HEATER W/VENFfULECTR
GRADING FEE
WATER SYSTEMTREATING
SOIIS FEE
AIR HANDLING UNIT(TOW.WCFM)
WATER SERVICE
PAID -. a ___.-.
��•
NEWRISIDENTIALPLMR, SQ. FT.
MECHANICAL PERMIT
pE V
no
II 11!
E
III 0
-)
/ ' Z
PERMIT ISSUANCE CL -C
ALTER OR ADD TO MELD.
P U-MRXIIIEFE
E' O
AIR HANDLING UNIT(TOW.WCFM)
13)NECHANI
L -FEE
I 3Z5-. 5_Z
AIR HANDLING UNIT(OVIIR 10,0100CFIN)
CONSTRUCTION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,00) HTED
NESTING UNIT (OVER 100,080 BTU)
PAID
Data Recei IN
T L
VENTILATION FAN (SINGLE RESID)
BOILER-COMP(3HPOR 100,0001ITU)
BOILER - COMP (OVER 100,000 BTU
AIR CONDITIONER
ISSUANCE DATFnn
ISSUED LveG'
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL:
OFFICE