S 2629 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYx
CITY OF CUPEKI'INO BUILDING.ELEM RICA PI RMI TNO.
HIJI1,DING DIVISION APPLICATION/PERMIT PLUMBING-NIECHANICAL �` 2629
BUILDING PROJECT IIIENNFICA'PIIN J
BUILDING ADDRESS, SANITARY NO. PIACAI'[IN SUBMI'MAL PAT I!
10 r—
00 IDCVIEAI'
W G-r- " Za c �(
OWGOAA PcQ I'DoNH: CgAII R'S NAM]! LIC NO:
IN00 1� NIC l/f caxfuol.«
' AR'IfIECIIENG. IA!R: LICNO' ADDRESS ❑ / / 7 3
Ig=G G 1 Iv S
COMA T: I•HUNE: 13U ILDING PERMIT INFO
�1 , _ ❑ Consul[am Fees
Paid by Applicant(Initial) BLD(. ELECT' PLUMB NIFCH
-22G-�7 ❑ ❑
LICENSITDCONTRAC'IOR'S DECIARSOON Q'rY ELECTRIC PERMIT FEE
I hereby eJ under promm�a
visions of Chapter 9(coming JOB DESCRIPTION
ffinn that I:nn Iiceme
Q=Z with Smrion]Iga)nfDivisionJnfthe Ru%inesa unJ l'rofasions Cale.and my license is RESIDENTIAL:
W p 1117RMI I'ISSUANC1i
�nt0 in full lbmeand effect. ( ❑SFDWI. ❑KITCHEN REMODEL
QVO Licenc Class Lie.it AITI.IANCES-RESIDENTIAL ❑AUDITION [3 PLUMBING RF:-PIP1i
F-I G W Dalc Courn"I'l
yQp, ❑MUUI'bUNl'I' ❑STRUCI'URAI.
ARCIIITI!CI'S DIiCLARA'1lON
F p h 1'ANI!LS A10DII7CA'I'ION
OZ C)Z='Z luadcnend,nyplmn. I sdo.pub]icrea..d. lll'ID 2(S AMPS
❑INTERIOR
❑CHIhIN1iY REPAIR
H on 201-1100AMPS IMPROVEMENT C]SWIMMING POOLS
dna : ILDIIR DECLARAIION OVER IINM)AMPS BATH RIiMOUP.IJRF.PAIIt ❑DEMQ1.1'IIQN
yCC 0.' Q hereby ullinn Ihul um..entry]rum IM1c Cnnlruelor'x Lice,Te Law fel'the
x p L U foldaunt.Send nOl.5.alland Prtde.,inns Code Any oily ur county SIGNS ELECI'RICAI. OTIILR
m 3 ai- which requires a permit m sonnet.alter,improve.aearminM1.of repair anU
y mm ne
0g
prim lr :' Iso rc,mm,me applicantf such permit file a signed.emmenf SPECIAL CIRCUIT/M ISC.
f 4,- that he is licenwal p rsua t l the proo,isions of the Commences License L (Chapter 9
tea C, (sant b won Section VIOa ❑
) )' ori f
3 the P i
.nx P Jf ,Code)pr 'rRvfi.METER OR POLE INS'1'. COMMERCIAL
d y p1 that hu I.uunipt Ihavtmm inti Tho hmi.fnr the alleged excnlnuon.nnY"okolion of ,J'� ❑NF.W IILDGIADDITION ❑DI?MOLI'fION
,c I+' See rmr703L5h,mr,.ppl,mai ,.,...lil eubjcct.v the annllcom lou civil pcnnHy nl IN1W'ER DEVICES ( (% ENAN'I' EJ 17001)SERVICE
^N nm more than rive hundred dollars;(5500). MPRUVEMIiNT
ESG DLav owner of lM1c fropcny,nr my cmpinyncs wifM1 sago as lM1cirmlc amtpcnsaion, SWIML' YR)1.ELECTRIC ❑OTfiliR
F- will do the work,and thextracrure n not intended proffered for sale N,c.7144,Bss usine
m and Pnsle.siom Core: [he ConnucmG.Licunsn Law erne%not nifty m an owner of OU _ 'I'rC11E5-FIX'NRIiS w
pro,n,who builds or Inill wvc,.licneen,and who Joe,..nth walk hlm,selfur Through FQC N T
hi,own employee.,provided Bun such ingmwcomom arc not immndW or offeral If,, 01W XisIDE .E CCTR SQ Pi'.
sale.If,honeve ,he building or irromwemenl is sold winhinonc year of canpletion.'he SG.PI'.FLOOR AREA $ISG.FT.
ae
a
food
crbuilder will have the burden of proving than he did fol build or ina mae for fur.
po a df rale.). OTA 1 O
1,u,owner rd the pmpenY,un,Gael omcly contmcta,w'ah licensed contractors to
n.fact Iha p nc,11 Sc,.](94.Bnxinc—and ProllWon,Cale.)Ice Comn,uor...i-
cc..c Law docs am anplymunowncrol p,,,,,,y who huildvor imWove,0undon.and QTY. PLUMBING PFRMLI FEE
who contracts fm such projacu with a connacten%)licensed pursuant o the Cpntmctors
License Law. PERMIT ISSUANCE
1 an,exmnpf under Sec. _ .B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALIINI'[ON
Owner Ilulc
WOHKEN'$COMPI.NSSFION DECLARATION BACK PLOW I'RU"Ii0 UI!VICI!
I herehy a(finn under penalty of l¢rjury nnc of rbc following dcdarenons.
❑I huvemal will mmntaina,mar,am,Cua,mkscR-insure for Worker,Ca..ram- DRAINS-PLO(IR. OOI'.ARPA.CONU. STORIES TYPECONSTRUCIION
xatmn,as provided for by Section dna of the lalmr code,for the Performance of the FlxruREN-rr: . r 2
work far which this pat is issued.
I h o,and will nmintain Workers Con,nem.alina Inmmmcc,as reywred by Seclion
370ot life labor Code.on the lmtlmawnce of the work for which fas permit is ,avd. GAS-EA.SYSTEM- '.4 'I' 4ls OCC(1ROUP AI'N/�//L1,�I
My Workers Comfcn%ation Insurance curmrrnd Policy numhcr arc: CAS-FA.SYSI'I!M-(VER 3I�i�OO/ U'YS
Camicc Policy No.:
CERT[PTICAT]°OFEXENI'TIDN1'ROMWORKI!RS' GREASUINDUSI'RLWA. :IMI! R
COPENSAI ION INSURANC17 BUILDING DIVISION TEES
('rh'o,eaionneed ten bacntnninedinbelmrmil i,fpr poc madmaidnnar.(s 15) GREASEIRAI' l2 __
r1,ANCIIITK]TEE
or less)
]lenity that in(lie l<rlinmance of the work forwhich this permit is issued.l.hall SEWER-SANITARY-STORM IIA.200 FT
not employ any fwoor in any claimer sec a,In hanm,se subject to life Worker,'Crnnpcn- :R( FEB.
O Z ninon laws of Calif nam Dene W'AIER DRAMS W/VENT?LE G G FEE
Z O ApMic:an
y NOTICE 10 APPLICAN'P,II after making this Ccnilicmc of E,anditiun,You should WATER SYSTEM/1'RI3ATINC, I S
becnn,c.u1 jeG ns the Wader's Cnmpcn.wtinn praviaipn,n1 the l,ihor Cosle.you must
1 Q fonhwuh n'mply wiN.such provisions or this sedan shall be decnmd revokal. WA'l l!R SERVICI!
LONS'IRUM ION LENDING AGENCY NEW RES]DEN1'IAL LPI-MB. .Q.Ff. PAI)
O Z' I hereby affirm that There is a constriction lending agency for the perbmnance of Date c pit
I.I.UO the work or which This Permit i.ixweJ(Nw.3097.Co.C)
C) Lcndcr,Name Y
r � Islander,Address BUILD] stili /
O. 1 certify that I have read this application and%lane that the above inforrhation is
t: 0.
comet.I agm,mcumply with all city and county oNinanco and stare law,palatingm QTY. MECHANICALPERMIP PFh NETS1 Pr ! O
U building camemction.and hereby authorize representatives of this city to enter upon The
ahpvo.manfinned pn,,ay fnr inspection pagan... PERMIT ISSUANCIC
(We) men, ooe.in lemairy and keep la,rndcxa The City of Cupenina found -
Iiabilitim..Rdgments,cussundeapenmswbicif may in any way ueaoeagna.0 said City ALT ER OR ADDD)MECH. P UIll 1 RG IT!E
in com"clarce of the grunting of this par nif
APPLICANT ON)1!RSTAN ON AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10,000 CFM) ME ANICAI.FEE
SOO all HREGO LAI IUM Q
I AIH fIANULINO UNIT(OVER 10,000 CPM) CONST IC'IION TAX
Signa colA vu runpr Dae I I:x HAUS'I'HOOD(WIDUCT) I]DOSING I'I'IGATION II!H
HAZARDOUS MATERIALS DISCLOSURE
Will nM1 .,heant orfummbuildingrmcapamsmm or M1wWle halordommmerm HEATING UNI['(TO 100,000 If IV)
as deputed by the Cupcnim,Municipal Cde,Chaser 9.12.and the Health and Safety
Code,Section 2553215)7 HEATING ONI'r(OVER 100.000 B U)
❑Y,, '-'-"O V IiN'IILA]ION FA N(SINOLL R I!SI Of PAID C
Dare t .J
Will
Ca hazardous
the air comm or future building by the B use Area
Air Qu or Manan which BOILER-COMP(3Hr OR Ibt1,100 BTU)
mit haaardnus air amtmmnams as JefnN Try the Buy Arcu Air Qualify Management TOTAL:
Donato BOB.ER-COMP(OVER 105.0001111-D
❑Yes o
I have read rhe hvnNomalawnals mquiremw,l,under Chapter 6.95 of the Cal l- At R CON Of I ION ER ISS] CIS DATE
fomiu 1lcabh&Safety C,a]c.Sections 25505.25533 and 255]4,1 understand that if rise NEW RFSIDIeNTI AL MSCI I. SQ.]e1'. i--`C
bu1]dingdoe,non a amount r nil i,,Z sry,mibilirynonmify menecusam �j r. 2 "'C
of the emenu which m c m isuunce of u Ce nl('cupamry.
Deane ea Z Du c 'I(n'AI., ISSUED uv:
OFFICE