S 0158 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMITNO.S
BUILDING DIVISION APPIACATION/PERMIT PLUMBING.MECunNICAL 0158
BUILDING PROJECT IDENTIFICATION V
BUILDING ADDRESS: SANITARY NO. AP�CATION SUBMI I-IAL DATE
/d ydo e`l� eve
OWNC SHAME:_ .` N PHONE: CO TRAL7�0 N ME. LIC N(�:
t ' Y/�/.J VvN1V S b N/C CONT OL#
<CHITECf/ENG}[JF.ER: LIC NO: ADORES' ^ !//- O
CONTACT:
•`l PHONE: LS (f C_ / BUILDING PERMIT INFO
I�e ,- / - ���' y�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG_ ELECT PLUMB MECH
I V LICENSED CONTRACTORS DECLARATION QTY. ` - ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed d p dons of Chapter 9(commencing •• _ ]OD DESCRIPTION
+X with Sectlou 7000)ofD v'smn3 of the Bus ne Pr fes.vions od ana mylc se RPSIDENTIAI'
Ptv O p PERMIT ISSUANCE -
R� in full force and effect. ❑SFDWL El Kit cmN REMODEL
F' fecenso Clas LIC,#
6 U 3 APPLIANCES-RESIDENTIAL ❑AUDITION El PLUMBING RE-PIPE
F W Uate ��(-� --r--ContDECL
m y - El MULTI-UNIT El STRUCTURAL
ARCHITECT'S DECLARATION PANELS
F'�Yt - MODIFICATION
O z 4` I ondentand my plans shall be used as public records
UP T02UOAMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-10)(HAMPS IMPROVEMENT E]SWIMMING POOLS
aY '-I
OWNERBUILDERDECLARATION
g tC OVER IIIIXIAMPS ❑BATH REMODEWRBPAIR ❑DEMOLITION
I herehy affirm that 1 nm exempt from the Contractor's Llcenxe Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER
F. O 1yy' which requires a permit to construct,alter,improve,demolish,or repair any someone
F,.f�6 phone its iasuanw,tllso requireslheappliconlfor such permit to Hlcn signet slulemout SPECIALCIRCUIT/MISC.
pr's Ihathrisficensedpurmantsothopmvisions nfthe Contmdors License Law(Chapter 9
W QOC (commencing with Section 7000)of Division 3 of the Business and Professions Code)(it TEMP.ME TER OR POLE INST COMMERCIAL
d y e tE that he i.exempt therefrom and the basis for the alleged exemption.Any violation of ❑NIiW BLDG/AUDITION ❑DEMOLITION
$YG7 V, Section 70315 by any applicantforapermit subjects the applicant rise civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
>� not more than five hundred dollars($500). IMPROVEMENT
I,asowner of them norm In eexwithwu Ihei...[a comensalim, SWIMMING POOL ELECTRIC
C ❑ t Int Y Y emp Y gewv F ❑OTHER
will do the work,and the nwcwrels oat intended nrnffercd for sale(Sec 7004,Business
�3m and Professions Code.The Contmanrs License Law does not apply to an owner of OUTLETS'-SWITCHES-FIXTURES
property who huilds or agialwcs thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RP.SIDENTIALELECfR SQ PT.
sale.If.however,the building or improvement is sold within one year ofwmpleaon,the SQ.IT.F(�ORR AREA $/SQ.FT.
ncolnuildet will have the burden of proving that he did not build or improve I'or par- g/A , D
pose of.stet. TOTAL "
❑ erry,1.as owner of the pmpam exclusively contracting with licensed contractors to .
combed the jujest(Sea 7044,Buainesa ana Professions Code.)The Contractor's Li- -
c se Use does not apply W an owner of prepeny who builds or improves(hereon,and QTY s PLUMBING PERMIT FEE J�'V.ryryYY.� am�]
whocentracts formch eto
projects with araccalm(s)licensed pursuant the Contractor's Y/`
License Lew. PERMIT ISSUANCE C/]`I'Uh LUr
❑1 am exempt under See. ,B R P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
caner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE b n�Ii
I hereby affirm under parity of perjury an of the follmving declarnfiona:
❑ Ihave and will maintain xCerrificateofConsent to self-inurefnr Worker's Compos- DRAINS-FLOOR.ROOF,AREA;COND. STORIES TYPE.CONSTRUCTION
sotiom as provided for by Section 3900 of the Labor Cade,for performance of the
ork for which this permit is issued FIXTURES-PER TRAP
❑I have end will mnlnwln Worker's Compensation Insurance,as required by Section
3710 ofine Labor Code.for the per form nca. he Work ill'which this permit is issued. GAS-EA.SYSTEM-I INCA DO'[LETS OCC.GROUP APN
My Win '�oa pe: °RTf'olicYNoyL �re ��� GAS-EA.SYSTEM-OVER 4(EA)Carraan -
CF,RTIFICATE OF F.XENIPTION FROM WORKERS' CNEASF.IINDUSTRL WASTF.INTERCEPTOR
COMPENSATION INSURANCE sXBs " '=z`B,UILRINO DIVISION P885
)(This section need sollwcenplemd i f the pemdt is for one hundred dell...($100) GREASETRAP
or lea) PLANCI{ECK FEE
I terrify that in the performance ofthe work forwhich t1a,urand is issued,[,hall SEWER-SANITARY-S'FORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE
z cation Laws of California.Date WATER HEATER WNENT/PLECTR
z O Applicant 1 GRADING PEE
NOTICE TO APPLICANT:If,after making this Pannone of Exemption,you should WATER SYSTEM/TREATING SOILS FEF.
become subject,.the Worker's Compensation provisions d of the Labor Code,you most
4ai1 a�.a .foncomply comply withxuch provisions in this permit shall he deemed revoked WATERSF,RVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ,FN. PAID
I M1erehy alBmUhanhem isauinswction lending agency for theperfnrmancsof D° °c°IVIN
V � the work for which this emit is Issued(Sec,3097,Cls.CJ
0 N Lenders Name - TOTAL:
Leaders Address 'BWAL
I certify that I hive mod this application and state that the above nomination is
_ BUILDING FEE
rail cored.l agree to comply with all city and county ordWances and state lawn rela0ogfo QTY MP.GHANICALPERMFF 'FEE
building constriction,and hereby authodae representutives or this city to enter upon the SEISMIC FP.B
ISO-
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ogre,to save,Indemnify and keep htnmless the City of CupeNno against ELBC'1'ftIC PE8
liabili0es,judgments,costs and expenses which may in anyway accrue agarose said City AITFRORADDTOMECH,
ill eyuence of the granting of this permit PLl1MBINGp '
APPLICANT UNDERSTANDS AND WILL COMPLY WITHAL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
OURC REGULATIONS. � � MECHANICAL FEC
✓ AIR HANDLING UNI'I'(OVER 10,1100CUM) CONSTRUCTION TAX
Signolure of Applicant/Connveffr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cavitation Municipal Cale,Chapter 9.12,and the Health and Safely -
Code,Section 25532(a)p 11 EATING UNIT(OVER 100,000 RTU)
7Ycs E]No VENTILATION FAN(SINGLE RESID) PAID '
Date Rereipt#
Will the applicant or future building occupant use equipment or devices which gQILER-COMP-(311P OR 100,000 BTU)
at baxarduus air contaminants as defined by the Bay Area Air Quality Management TOTAL:
DixtrictY BOILER-COME(OVER 100,000 BTU)
E-]yes ❑Nn -
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDI'TIONBR ISSUANCE DATE
fomia Health&Safety Code,Sections 255115,25533 and 25534.1 understand Thal if the NEW RESIDENTIAL MECH. SQ.Pf.
building dons not corenlly have a tenant that it is my responsibility to notify the rampant
of the rrTmarments whichmusl W met Her to issuanreofa Cerona eoI Occupancy. '
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE