99080125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PER T
BuaDINC DIVISION APPLICATIONIPERMIT PLUMBLNG-MECHANICAL SOOOI
BUILDING PROJECT IDENTIEICAI'ION
BUILDING AUUHESS: SANI'IAHI'NO. AI'I'LIGI'ION SU13h11'1"1)\1.DAT
/065-6 "72116
OWNS@:S)NAMP PHONfi / COM' A T 'S N h1L 11 NO: If
ILJ. NA NIC CONTROLp
GHITECUENGINEER: LOU NO'. D ESS: " E]
CONTACT: PUONE: Il UILDING PEIi MIT INFO
��/ ��X/`�� ❑ Cons'ulfam Fecs Paid by Applicant(Initial) N❑ LECT I { Ai❑1
LICENSED CONTRACT ORS DECLARATION QTY ELECTRIC PERMIT F.EE JOB DESCRIPTION
1 herchy shins that 1 am licensed under proviniom of Chapter 9(comtrencing
Wal% D tvistondot'the
Commcmr call I'ml'csdonvCodc,and ntyliccnscls RESIDENTIAL
C w,th Section 7(XXpol'D' "
01 p ('lilt Ml'I'ISSUANCI:
W-I= stall fonnonJ effect. 1`6 ❑AEDIII ❑KI'T'CHEN GI=MME
<—U L;ctenc Clans Lim. v� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIiI'IPE
ARCHITECTS DECLAR, O PANELS ❑muTxbUNIT C3 STRUCTURAL
F n Z I understand my plans shall be used as public record. MODIFICATION
CZ—c UlIT02MAMPS [I INTERIOR El CHIMNEY REPAIR
rr�CW Licnnwd Prokvdonal 201-10)(HIAMPS IMPROVEMENT SWIMMING POOLS
�.1 ; OWNHIO-BUILDER DECLARATION OVER USDAMPS C1 RAE REMODEUREPAIR DEMOLITION
C C 6 1 herchv andiron Nat 1 aa,exempt ham the Contractor's License I.aw for me
X 3 ad VF following remote.(Section 7031.5,Business and Pm exsinns Code:Any city m ammY SIGNS ELECTRICAL ❑OI HLR
W LL N which termites a permit to consumer,.Imre improve,demolish,pr repair any euvemm •�'e
E_!4:01 prion,its ivnuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUt'VMISC.
oe
that he is licensed pursuanto the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL;
a do�0 (commencing with Section 7axp tel Divisiun3nf the tluninmsonJ Profevsinnx Code)... 'IFEMP.METERORPOLIi INS('.
d y m yv Nat he,exempt ffiembom and the basis loot the alleged cocianion.Any viol pion of N'W BLDG/ADDITION ❑DEMOLH ION
W 0 Semon 701I.S byany t,,
ny applicann i .anti,subject,fl a npplicaut to a civil inceml of POWI7R DEVICES T .44 El FOOD SERVICC
not mans than five hundred dollars(SSIX), ^ (YIP
_� ❑Lmowncr of the pmpcny,or my employces with wages ax Ncir sole compensation. SWIMMING POOL ELECTRIC Y
F will dathe work,and Ne structure is not intended or offered hostile(Sec.AW.BusinessEOT :.R
13�^
and Poficeionx Cade:The Contractor's License Law docs not apply to an owner of OUTLICfS-SWITCHIS-19kTUR[S
property who builds or improves flumen,and who Jaws such work himself or through
his own employees,provided that such improvenenp are nun intended nr olmied rot NEW RESIDENTIAL 1?LECI'R SQ FL
sal,.IL LoiOist, b,holding or improvement is sold within one Yens of ammlction,the SQ T.MR�ARI:AsISQ 19'.
owner-Imilder will have the burden of proving that he did not build or improve for put-
pa c of salc.F TOTAL
h as owner of the pmperr,am exclusively roareaing with licensed comoomi s to
construct the project(Sec.7011.Business and Professions Csde:)The_o Hee I I-
crime Law does not apply toan'owner of property who build%or improves thereon,and QTY, PLUMBING PERMIT FEF,
who contracts forsuch projects with a contractor(.$)licensed pursuant to the Continuous
Littmsc Law. 11I?RMI'iISSUANCE
1 am exempt under Sec. .B&P C fur this mason
AFTER-DRAIN&VENT'-WATER(EA) VALUATION
Owner [)ate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECIl DEVICE
1 hereby affirm under penalty of perjuoy one of the following declarations:
41I have and wil l maintain a Cenificam of Consent o self-Insure for Worker's Compeer- DRAINS-FLOOR.ROOF,AREA,CONE). S ORI PS 'TYPE CONSTRUCTED
an,as pmvWcd ku by Scenes 370)althe LaMar Calc,for are peUomuame or the
work for which this permit is issued FIXTURES-1'ER'1'RAI'
1 have and will maintain Workers Cntnl'ensation Insurance.as requital by Section
J700nff�tlhye��"�k/)resCapCP/ird.ffnn�h��,,ffon�n°a'nfl fNewnrkkfforr�whiiOhaaispcmtitkissued. GAS-EA.SYSTRUIINCAOUTLETS (KC.GROUP AP
Clamct(fTat lis n `L`�PalryNos""^�`��W2 GAS-EA.SYSTEMOVERJ(EA) O/'
CERHFICATE 017 EXEMPTION FROM WORKERS' ORF.ASfUINDUSTRL WASTE INTERCEPT OR �P
COMPENSNVION INSURANCE' MRLDENG DIVISION FEES
(Tobin section need not he compl sed ifthe permit is fur true hundred della IS I(N0 GREASETRAP
PLANCIIIiCK P1dH
or les")
Ioyany Pershat on
Ne any mannce rofn,totwwork far
%mwhich tbis the Permit Wrlacre om,vin SEWEH-SANII'AHY-SIDHb1 EA.21X11'1'.
not employ any person in any manner m as w become mbjm to the Workers Compeer- ENERGY Ftili
,Z OrionsLaws of Culif enol,Date WAVER HEATER WNUNT/ELECTR GRADING 193E
Z O Applicant 1
NOTICE TO APPLICANT':It,after staking this Ceriticme of Esemptinq You should WAI ER SYSTEM/IR1?AI'ING
-y y SOILS PI?I?
l'a'm funhwilaconicn c op m the Worh pro...on,nsafion pmvit hal of Ne rubor Code,You most
W fonhwiN nnnply with such provisions err Nis permit shall he Jccmed revoked. WATER SERVICE
S PAID
CONSTRUCTION LENDING AGENCY
NEW RI?SIDENTIAL PLMB. SQ.FT. Date Be, pa X
U 0 thereby offtm arm them is a comweaiou lending agency for the Performanceof
Us P the work far which this permit is issued(Sec.1097,Civ.C.) 'TOTAL:
O Lenders Nanta TOl'AI.:
IUtI Lcri Address BUILDINGITEE .111
cedrHy than I have real dus up,11rumn and seem that the above habituation is
N 0,.,1ag. ,,comply with all city and comply a dinasccs andante lawsfdming to QTY, MECHANICALPERMIT FEE SEISMIC PEE
U•Z building construction.and hereby anchorite representatives ofthis city to enter upon the
shoe-mentioned poupa.Y foo inspeerinn purposes. PERMIT ISSUANCE ELECTRICRIM
(We).glia tet save,indearaf and kcep harmless she Ciay of Cupeninu against
liabil'iics,judgmenti.costs and expo . s which may in any way amrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
incoasc r he antingof this p mit.
AYI'1,1.ANT IJ E TAN)S AND ILL COMPLY WITH ALL.NON-POINT AIR HANDLING UNI'I'('1'0 I0,000CFM) MECHANICAL.FEE
SOUR Ii1IG I- (NS.
AIR HANDLING ON)POVER 10,000 CFM) CONS'ERUCI[ON TAX
Signmumof Applicam1C ntmcmr D:c EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FET:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor fnlum huildingoccupantseenor handle Mrsaplomunenal HEATING UNIT(To I M.000 BTU)
as doNred by she Cnpepintr Mtmic'Ipul Calc.Chapter 9.12,and the Ilcalnh and Safay 11FAfING UNIT(OVER 100.000 BTU)
Code,Section 255320)? .�
El Yes u'�" VENTILATION FAN(SINGLE RFSID) PAID
Dam Reel tN
Willthe applinneor future building occupant use equipment or devices which BOILER-COMP(JDPOR H10.000BTLD
tit Meanlnux air contaminanrs as Iefined by the Bay Arca Air Quality ManagementNo 'TO 1.
tmricrr BOILER-COMP(OVER 11)0.0X)Bi U)
Vcs
AIR CONDITIONER ISSUANCE DATE
1 have read the hazvdnus mea, 1 5.M3 anis under Chapter bran of the Cali-
he
forma Health&SafctY Cak.$cetions 5505.SSI]and 25534.I umlcrsmnJ that if the NEW RESIDENTIAL.MECH, SQ.Irn
building Jatcs nrnc termor thea it is my rcnry'nnibilitymnmifv Nca)Ccupana r�
m1di rtyuiremn �mtay� 1F�y1 Ir ao is my 0 of a Cenif to asuff,the/'
✓/ 11\e rTJ/ Ll/ TOTAL; /
Ownererr:nnhon dagent tee ISSUED LIN.
OFFICE