S 1023 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPF,RTINO BUILDING-ELECCRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONA'ERMIT - IIIUUIJNG PROJPLUMBING..MECHANICAL S 1023 0 2 3
IIECT IDENTIFICATION kJ
UILDIN6 AUIlRESS: SANITARY N(l. APPLICATION SURMI'TI'AL DAG
,
OWNER'S NAME,:• PHONE: 5� CONTRApJ�_R'S NAM I� ,(LIC NO:
t h Qrr I I , ` IµMp 75 No' CONTROLp
ARCHI'117C'OFNGINHER: LIC NO: ADDRESS ❑
1 N 5 v_
CONTACT PHONE: � UUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PFRMIT FRE1 hereby dfiml that 1 am licensed under pmvisam of Chupoe 9 mommmabtg JOB DESCRIPTION
DaZ with Sarins 11001 ofDivizi0n3ofthe Business anQ Professions C. end my license iz RESIDENTIAL,
WOO U C PERMIT ISSUANCE
Fs in full farceand efat. [�'-] s O CSFDWL CKI'UMBIN RH-PIPE
aUV Live.Class tar.a APPLIANCES-RFSIDEN"I'IN. ❑ADDITION ❑PLUMBING RE-PIPE
ZZ Cmlmcmr
In 6 C MULTId1N1'I' ❑MODIFSTRUICATION ARCHITECTS DECLARATION PANIiLS
ZO � Isndcrstnidan,,o,dill heraddvs publ'mrecords UPT0200AMPS MODIFICATION
OZ � ❑INTI?It10k CCHIMNI?Y til?PAIN
rr4tM Licensed Prolissional 201-100AMPS IMPROVEMIiNT E]SWIMMING POOLS
�X�' OWNER-BUILDER DECLARATION OVER lots)AMPS ElBATH REMODEUREPAIR ❑DEMOLI'I ION
C G 1 hereby affirm that I am m m
exempt froe Ctmmrr
d 's Liccnm Law for the
ib o y V followan
following reason.(Section]031.5,Business d Professions Cade:Any city or crumY SIGNS ELECTRICAL �OTHER
W 3 W yFy which re,mrs,u Permit 'I cnnrtnml,alter,improve,demolish,or repmr any atructme
��06 pactions isamnce,al,cou,irea the applicant lnrnuh permit ,,li le no,ned Chmat,ltl SPEC I AL Cl RCUIT/MISC,
H�yN that he is licensed pursuant to the provisions of the Contractor's license low(Chapmr9
yp 2 (commencing with Section 9801 of Division]oOhc Business and Pmlvssions CadcAtr 'CP.MP.AtITfi?R OR POLG INST. COMMERCIAL
a y o that he is exempt therefrom and the b r is for the alleged exemption.Any violainn of [I NEW HLDG/ADDITION ❑DEMOLIT]ON
�LL11
Section?031.1 by any applieamfar.permitsuhn
jects,he applicanna civil penally nl MWIiR DEVICES
Q Ll TENANT C3 FOOD SRkVICIS
ZZy not m 01.ore than five hundred dollars($50 '
`J• C l,mnwncr nfthe propcny,sir mY empinycoz whh wngm os Jmio xnlc compenswinn, SWIMMING POOL ELECT RIC THf?MENT
IR
willdmhewnrk,andthestruvmmis nm Intend,dorollereJ tarsale lSec.]IW4,Bu.ines ❑OTlllik
G 3 and Pmfessinas Cade:The Contractor's License Law docs nor apply to an owner of OUTLETS-SWITCHES-FIX'IORES
property who builds or improves thereon,and who Jens such work himself or through
his own employees,provided that such improvement,are not imendcd or offered for NEW RESIDENTIAL ELECfR S'
sale.IL however.the building or improvement o,rd widdirmeyearofcompleam,me S 41-40FUREA, 5/SQ.IT.
owner-huider will have the burden of proving mar he did not build or improve for pur-
ptaosowne I OCT 13❑I,as owner of the propcny,oto exclusively Protrusion,with Iiecn.mJ nmtmmon i- D[I1ry11
consWalIMproject(See.o an Businessand Professionsds ori profim ves thereon.Li- IR�[1I!!Y
whom Law dmor suapply mts ith acntra ywhosedporimpnsvice thereon.and QTY. PLUMBING PERMIT EE
who
enselacu for such projects with econhactolsl licensed Pursunmmthe Cnmracaors illy Ur UUYckIINU
License Law. PERMIT ISSUANCE
❑I um exempt undo Sec. ,fl&P C for this reason
ALTER-DRAIN&VENT-WATER HCO VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby aRrm under Penalty of perjury one of the fallowing deductions:
❑ Ihave and will maintain a Certificate ofConsentto self-insure for WorkefsCmat DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONS'I'RUCIOI
.cation,as provided for by Section 3700 of the Lubar Code,for the performance of the
work for which this Permit Is Issncd PIXTU It I!S-PCR TRAP
C I have and will maintain W..kers Compcnwtion Insurance,as mtrimd by Salina
3700ofine halt Code,fimhcpcuumamce ofihe work for which Ibis Pamir is issue). GAS-HA,SYSTEM-I INC,I OUTLETS OCC.CROUP N'N
My Wmkel. a 'e I Policy n
C Grim. am Policy Na: C�T✓3(7/J/I�• GAS-Hq.SYSTEhf-OVIiN4(EAI
CERTIP�ICATI'�.t0'EXeEMIPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDIISTRL WASTE INTERCEPTORBUILDING DIVISION FE13S
(Thosceaion need not bennnpleted ifthe tomtit is foranehnndred Joilan4($I(K)1 GREASE IRAP
PLANCIIIiCK PEE
or le"')
I sanity that in Ne performance ofmc work forwhich this permit is issued,l shall SEWER-SANITARY-3'IOItM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers Comped- ENERGY IT13
Z idiom Laws of Califomid.Dam WATER HHA'I'ER WHEN-VELECfk
O 0 GRADING IY
Applicant FEE.
NOTICH l'O APPLICANT:IL ufttt staking This Cmilicam of ExanPlinn,you shoal) WATER SYSTENUTREATING
H become xobject to the Worker's Compea@mion provisions at the Lnhor Cade,you nmsl SOILS FEE
forthwith comply with such provisions or this pennil.sholl he dammed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENI'IAI.PLMN. SQ.17. PAID
UQThereby off rat that izvconslmainn lending agency forth,performance of Uma KecciPab
me work fm which mis pemot is issued(See.300P.Civ.C.)
U.
Lender's Name ' TAI.:
C..I Lender's Address 'r(n'AL:
C1 cenify that I have read Ibis application and state that the above inomination is BUILDING hili
(q crame,lagmemPomPly wills all city and county rNinances and state law,.[air.,to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hemby aurAodze mpmwntarives ofthis city tacnmrupam the SEISMIC PER
above mentioned property for inspection purposesHRMH ISSUANCE
(We)agree to save,Indemnify and keep Imon ass the Cay ol'Cupcnlm against FLECIPRIC FILE
liabilities,' umtsenstx nnA uxpmscs hick m: In anyway accrue against said City' ALTBRORAIIDTOMECII,
cn a dl g'tminW
o #mcui
PLUMBING I'IiE
SAPP OS.
UR(C'N ! LI 1WITH ALL NONN-POINT AIR HANDLING ON]TGO 10.LN0CFM) MECHANICALI:E
( _ AIR HANDLING UNIT(OVER 10,01)( ) CONSTRUCTIO X
Ignamro ofA s Date EXHAUS'I'1I00D(WIDUCI') HOUSING'MI'I'IGATIO t13H
AZA BLOCS MAOSURE
Will mea licam err future buildir handle humorous material HEATING UNIT(TO IfNUllq OU)
as defined by the Croatia Municipal Code,Chapter 9.12,and the health and sale',
Code,Section 25532md? HEATING UNIT(OVER 100,000 RTU)
E]yes CNn PAID
VENTILATION PAN(SINGLIi RBSID) polo Hacipt k
WIII the npplicam or('utmr hrildin,occupant use equipment sir Jsvias which
emit huyNous air contaminants as defined by the Bay Area Air Quality Management HGILHN-COMI'(3HP OI111NkIN)II RTU) TOTAL:
District? BOILER-COMP(OVER 101,000 BTU)
❑Yea C]No
I have read the be,armas materials reynimmews under Chapter 6.95 of the Cul i- AIR CONDITIONER ISSUANCE DATE
fornix Health&Safety Code*Su Jens 25505."I'd and 2.5' matudun""ohthe NPWRESIDENNT1ALMECH, SO 'IT
building Arcs nm currently have a roam.that it is my responsibility to nmify the occupant
of the requirement,which ma>I he net prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE