S 1170TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPRR'1'IN
BUILDING DIVISION
APPLICATION/PERMIT
IZo"t74 L,Af
a,wnr:nan^„n zvzF-vCyoe- /VA Sy6�/&T 1
�-77� „ �11 6 ❑Consultant Fees Paid by Appliren[ (Initial)
LICENSED CONTRACTOR'S DECLARATION QFY
1 hereby .,a.
that 1 am licensed under provisions of Chapter 9 (commencing
M{y�%Zwall Section 00th Id Division 3 ofthc 11 incaaond Pndcaslons C... andmy lieome is
�Iy2 in full forcemd street.
ItF..UV License Class Lie.x
F.Z, Dam Contractor
ARCHITE'CT'S DECLARATION
V. I understand my plans shall cord usas public records
OZ�
Fon F-
I Licensed Professional
CCCQ444 OWNER -BUILDER DEthe C otem
uW] I massa .(Sera that 1 tun eBasin Rom the Conlmemo License Iatw for rhe
C, V following roues (Semon 7031.5. str Business and Prnfessinns Code: Any city or county
Irl it C N which regmres a perm m umatrua, alcor, improve demulish, nor repair any v ac,
tn.Q,1 unions no nclunce.alsnreyuircx the applicam forsmh permilmfilensigneJ umem,or
WWCthat lie is licensed model] Intoe previsions ofthe Conoucmrts hicunw Low lChuptu9
C (commencing with Second 7000) of Divislan 3ofthc Ruslness and Pmfesxinns Code)or
d 6 qo that he is esempt therefrom and the basis for the alleged exemption. Any vinWtion of
.. m Section 1031.5 by any applicam for a permit subjects the applicam It, a civil penalty of
IIgF......act ,am than live hundreddollars(5500).
CZQ ❑ I, as owner ol'the property. or my employees will] wages as their sole coripemutma,
•C2 p.. will do the work, and the structure is not intended or offered for sale (Ser, Holiness
and Professmns Code: The Convamnr s License Law does nil apply man owner of
property who builds or improves thereon, and who does such work hhnseif or through
bis own employees, provided that such iunpmvenmcn]x ore not Intended ar ollcmd for
sale. If, however, the building or improvement Is sold within ane ye rrof complaint, the
owner -Wilder will have the bmJen of proving that he did not build m improve for P.,
,,b of sale).
1, ns nwnor of the pmpeny, aa, exclusively cataract, with Ikemed amlmcmrs to
e s duct the project (Sec.1044. Business and Prol ... om Cade) The Contractor, nsLi- .
cee Law does not apply to on owner of propeny who builds or improves thereon, and QTYl
who contracts for such pmjecls with a commands) licensed pursuant in the Committers
License Law.
I ran exampl under Sec. . B & PC fill his reason
Owner Date
WORKERS COMPENSATION OF:CLARATION
I hereby affirm under Naalty of'pe,juryme el' Ihu rnlh]wing Aeclurationv:
I have and will maintain a Certificate mConsenun self-imure for Worker” Compen-
sation, as provided for by Section 3100 of the Labor Code, for the performance of the
walk for which his permit is issued.
❑ I have and will maintain Workers Contpensotion Insurance, ;is acquired by Section
3700 orthe Labor Code, for perrodurace tithe work for which this pemtit is Issued.
My Workers Compensation Insurance carrier and Policy number we:
Cartier: Policy No.:
CERTBICA'1'H OF MEM P`DON FROM WORKIRS'
COMPENSATION INSURANCE
(This section uncertain be complered if the permit is forone hundred dollars (8100)
or Icv)
1 anally the in the perfnrmanov of the work for which this pencil is issued, l shall
rte] en]ploy, any nelson In any mann n ns m haemo xuhlunn the Worker' Cnnspen-
z soon laws of caGromio `_
plicam
NOTICE TO AI'i'LICA f, after mekin6 t 's Certil ate of Exemption, you should
W)
a trocome suhi to the \ 'leer's Compensminn provisions of the Lnhnr Code, you most
61 E) town,
amply with such pruvisinns nnha permit shall be dcenmed revoked.
0. 0
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a construction lending agency far the perfornumce of
W (~ the work for Much this pennll is ieaual (Sea 3099, Civ. C)
0 V Lenders Name
W lenders Address
Au 1 certify that 1 have read his application and stats that the uMwe infonnmion is
rA correct.I agree it) comply with all city and county ordinances and state lows relating to
U building construction, and herchy amhnriea representatives of this city to enter upon the
simse-meminned property fill inspection purpnms.
(We) agree to save, indemnify and keep harmless the City of Cupeninn against
Ilohilitoo, judgments, costs and expenses which may in any way avenue againxl said Cay
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
/1,1 the applicant or fine re building ocoupunt store or handle hazardous national
as defined by the Cupeninn Municipal Code. Chapter 9.12, and the Ileallh and safety
Code Section 25532(.)?
❑Y<s Fl No
Will the applicant or future building me<upanl use equipmovn "device. which
emit hazardous air commodities as defined by the Ray Area Air Quality Management
District?
[3 Yet, C1 Nu
I have mut the haeoolum materials requirements under Chapter fi 95 of (hu Call -
hand. Health le Safety Coale, Sections 25505.25533 and 25534. 1 nmiemwnd In. if the
building does nn] currently have a record, that it is my responsibility to notify the occupant
of the rrgeirements which must be me] poor to issuance of a Certificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUI'f/MISC.
TEMII METER OR POLE INS'C
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES - FIXTURES
NEW RESIDEN'I'I AL ELECI'R SQFT
TOTAI
P , PERMIT
PERMIT' ISSUANCE l
ACIF.R-DRAIN -WA 'A)
RACK FLOW PROTEC : F,
DRAINS - FLOOR. ROOF, A G,21D.
FIX, USES -PIER TRAP
GAS - EA. SYSTEM -I INC.4 OU'I LEE S
GAS -PA. SYSTEM -OVER 4IEO
CRI1ASIlINDUS'Bh WASTE INTERCEPTOR
GRGSETRAP
SEW17R -SANITARY -STORM F.A. 200 PP.
WATER HEATER W/VENT/EiLCCIR
WATER $YS'TEM/rREATINO
WMITE SERVICE
NEW RESIDENTIAL PUMP. SQ. FT.
QTY. MECHANICALPERMIT
PERMIT ISSUANCE
ACrER OR ADD 10 SPECK
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER I(OX) CI'M)
EXHAUST HOOD (WIDUCI)
HEXI UNIT TO jhdoe it Fiji
HEATING UNIT (OVER 100,um BTU)
VENTILATION FAN (SINGLE RESID)
BO[LER-COMP (3HP OR Un,000 BTU)
BOILER- COMP (OVER 1110,001 BTU)
AIR CONDITIONER
NEW RESIDENTIAL SUCH, SQ. FT
OFFICE
170
SQ. Ff. FLOOR ARI7A $/SQ. EL
PAI4
FEE
,1rIrY A# 22 gM9a
I BUILDING PERMIT INI7O
BLDG 11EC'I' PLUM 1 MITCH
❑ ❑
FEB
JOS IPTIO
R SIDDENTIAL:
U SFDWL U KITCHEN REMODEL
UADDITION ❑PLUMPING RE -PIPE
❑MULPI-UNIT USTRUCfURAL
MODIFICATION
❑INTFRIOR UCHIMNEYREPAIR
IMPRovFmENT El SWIMMING POOLS
U BATH REMODEL -/RFs R U� )LITTON
]OTHER
GRADING FEE
son's FEF.
PAID
Date Receipt N
COMMERCIAL:
❑NEWBI.DG/ADDITION ❑DEMOIATION
❑TENANT ❑ FOOD SERVICE
❑IMPI2OVEMIiNT
OTHER
TOTAI,:
SQ. Ff. FLOOR ARI7A $/SQ. EL
PAI4
FEE
,1rIrY A# 22 gM9a
BUILDING DIVISION FRES
PLANCHECK FEE
ENERGY PER
GRADING FEE
son's FEF.
PAID
Date Receipt N
TOTAI,:
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONS I'RUCTION '[As
HOUSING MITIGATION FEE:
PAID
Dam Receipt #
TOTAL:
ISSUANCE DATE
ISSUED BY: