31149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTI NO ' BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVI510NN1 APPLICATION/PERMIT PLUMBING-MECHANICAL. 31149
L' BUILDING PROJECT IDENTIFIC'A'TION
- BUILDINGADDRESS: t SANITARY NO. APPLICATION SUBMITTAL DATE
/OZ Qt. e s C �71�11
OWNEIyS fJAMB: 'AirHONE: CONRACI'OR'S NAME: LIC NO
_') NIC CONFROLN
ARCHU11C7VL'NGINEER: LIC NO:Ge ADDRESS:10 1 ❑
37 A* set.,
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - B je ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm that 1 am licen.ul under provisions of Chapter 9 Icommencing JOB DESCRIPTION
Dat with Section]Itlkll of Divi' nJofthe Business and f4a(essions Codc,and mylicenu is
.100 , PERMIT ISSUANCE
C ra p m full force and etf F SM ❑KITCHEN REMODEL.
RUU Ltcrnu cs Uc.M MQ VS6 pppLIANCFS-RFSI➢F.NTIAL ADDITION El PLUMBING RE-PIPE
rF a a Oatc Contractor -
ARCHITECTSDECL ATION e ❑MULTI-UNIT ❑STRUCTURAL'
F O m PANELS'
'Z O7J. 1 understand my plans shall be uses!as public records MODIFICATION
OZ-, UP TO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
F4LVj Licensed Profeasmatto 201-I1100AMPS IMPROVEMENT
g� � OWNER-BUILDER DECLARATION - RC G PAIR ❑D M1 hereby affirm that 1 am exempt from the Commit.,',License Law for the
OVER 1gN1AMPg ❑BATH OLITION
bO L V following reason.(Section]031.5,.Business and Professions Codr:Any city or county SIGNS ELECTRICAL. ❑OT ER
W 3 4 F which requires a permit to construct,alter,improve,demolish,or repair any structure s
F-�O prior to its issuance,assn requires Ne applicant for such pemritto file a signed statement SPECIAL CIRCUIT/MISC.
that he is licanscP pursuant to the provi sions of the Connector's License Law(Chapter 9
X0q (commencing with Section land)of Division 3 of the Business and Professions Code)at TEMP.METER OR POLE INST. COMMERCIAL.' Isf
0
4 2 W that he is exempt therefrom and the basis for the alleged exemption.Any vblmiun of CI NEW BLDG/ADDITION ❑DEMOLITION
^' Section 703 L5 by any spideart for.permit subjects the sp,hounuo a civil penalty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars($500).
FZ'} SWIMMING POOL ELECTRIC IMPROVEMENT
[]�� ❑Lothe work,
pnrpeuy,mmyempinyeeswithwegesastble(sole compensation,
2 will Pathe work.ande:no ore isnotLicense
Lawdoesoredl apply to a4.Business O iR
d m and Pmlessinns Code:The Cs)ndactrco Licensc Law does not apply to if owner of OUT,FS-SWITCHES-FlXTURL.S
.. It
who builds or improves Hereon,end who Jces such work himself or through M'f
his on emplayas,provided that such imromm
pvecros anot intended or oDered far NEW RESIDENTIAL L'LECTR SQ FT P
sale.If,hawever,the huilding or impmvemmar is sold within one you ofeumpletim.,the SQ.FT.FLOORAREA $/SQ.E4.
owner-builder will have the burden of proving that he did not build ear improve for pur-
p0seofs:Je.). MA .L RECD
39
1,as owner of the property,am exclusively contracting with licensed ommuclors ill
TOTAL: RECD
construct the project(Sec.7044.Business and Profeasions Code:)The Conesenes Li.
cense Law docs not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PE RM IT FEE CITY yr l.Urth fIN
who contracts for such projects with a conductors)licensed puraparm to the Contractor's U
License law. PERMIT ISSUANCE -
❑ I am exempt under Sec. ,B&P C tar this reason
Owner Date ALTER-DRAIN&VENT-WATER IRA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE 9cs
1 hereby.firm under penalty of perjury one of the following declarations.
❑I have and will maintain o Certificate of Consent to self-insure for Workers Camper. DRAINS-FLOOR,ROOF,AREA,COND. -
shown,as provided for by Section 3]00 of the Labor Chose,for the performance of Ne STORIES TYPIi CONSTRUCTION
work for which Nis permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Nation
39110 of the Labor Core,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wnr 's C, nsutiog Ery ace carrier and No num r g�
Cartier: Polic No. 7iC GAS'-G.SYSTEM OVER 4(EA)
CENTII' 'ATE OF L'XEVEeG0'PROM WORKGRS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION I£FS
IThissemianneed nm he conspletal it the permit is fur ane hundred dolims(11 WI GREASETRAP
or less.) 1'LANCHUCK PEE
I rarity that in the pencomnce ofthe work for which this pemrit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
nut employ any person in any manner so as to become subject m the Workers'CannotIiNERGY FEE
O Z satlon Laws of Colonia.Date WATER HEATER WNEN IELEC IR
O Applicant GRADING FEU
szi y NOTICE TO APPLICANT.IL after making this Conneaut of Exemption,you should WATER SYSTEM/IRFATING
abecome subject to the Worker's Compensation provision of Ne Labor Code,you must SOILS FEE
ELI forthwith comply with such provisions or this permit shall lx deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY
NEW RCSIDF.NT'IAL I'LMB. SQ.FT. PAID
L) O Iherehyaffimsthat them is.connotation lending agency for the performance of Elm cciptN
Ij. tr the work for which this pemrit is is000d(Set.309],Civ.C.)
L-� Karats Name TOTAL:
O W Landers Address TOTAL'
1 cantly Nm 1 have read this application and state that the above information is BUILDING Fh
T0.) correct.l agree to comply with all city and county ordinances and state lawn relating to Q•py, MECHANICAL PERMIT FEE
U� building construction,and hereby nmhtrizerepensentatives mfthiscily to enterupon the SEISMIC FEE g
above-mentioned property for inspection purposes. PERMIT ISSUANCE - -
(We)agree to save,indemnify and kap harmless the City of Cuperin,against 4ELECTRIC FEEliabilities,judgments•cueisad expenses which may many my.ccroe.,mom suit City ALTER OR ADDTO MECH.in consequence of the granting ofthis permit. MBING FEE
APPLICANT UNDERSTANDS AND WILL•COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM)SOURCE GULATIONS. HANICAL iE
AIR HANDLING UNIT(OVER 10.(KKICFM) STRUCDO TAX
Signawrc ofA anVContmcar L Date EXHAUST HOOD(W/DUCT)I IAZARDOUS MATERIALS DISCLOSURE. SING MITI N FEE
Will the applicant or future buildingcecuparm smreorhandle haseadous material HEATING ONI'1'(TO 100,000 BTU)
- as defined by the Contains)Municipal COJa.Clefeer9.12,and the Health and Safety
Coda.Section 2553200? HEATING UNIT(OVER Ross)BTU)
❑Yes ❑Nn PAID
VF.NTIIA'1'ION PAN(SINGLERESID) Doc ReceiptM
r Will the applicant m future building occupant use equipment or devices which BOILER-COMP(JHPOR IOO,IXp BTU)
emit hea,m1 us air co armtrums as defined by the Buy Area Air Quality Mtmagement TOTAL:
Drsmm]
❑Ya 0N BOILER-COMP(OVER 100,000 BTU)
1 have read the homrdnos mmedals rcquiremenms mule,Chapter 6.95 of the Cali- AIR CONDITIONER - - ISSUANCE DATE
font.Unn le&Safety Code,Sections 25505,25533 and 25534.1 understand in.,if the NEW RESIDEMIGAL MECH. SQ.PT.
building does not currently have a tenant,that it is my responsibility to notify the occupant -
ofther is whit be t nets. of.Cmifica f nay.
�n 3�li� l
Owne or oaths)' agent 7Derc TOTAL: ISSUED BY:
OFFICE