S 0695FILL IN INFORMATION WITHIN RED
`a`-- CITY OF CUPF.RTINO
BUILDING DIVISION APPLICATIONMERMIT
NAME:,
USE BALL POINT PEN ONLY
CONTACT. PHONE: '
T q/� �O/� ❑ Consultant Fees Paid by Applicant (Initial)
`v\ LICENSED CONTRACI ORS D(ECCLLARATION QTY ELECTRIC PERMIT
I hereby vOYm Ilial 1 am licensed rude, p of Chaptcr 9 (nommen utg
{0
500 with Section 7000) of Division 3 oflhe Bus ' tied Profession, pCode ltd my Rene is
Fly - in fall force and (,reel / p) O )
U ~ License Clu `- 3l0 Lic. a
aDale TS DI- nr
A, hall1'ECTS DELLA ON
OZ F �NZ. 1 undemand my plans mall he used as public records
-9Q
P 4 tfa] Licensed Professional
x�? OWNER-RUILDER DECLARATION
C fffr�yl1 a I hereby ulfiren that 1 am exempt it,,. the Contractor's Licenw Law for the
6V following reason. (Section 713L5. Business and Professions Cale: Any cayor county
to 3
P. F which requires a Permit In construct. alcor, improve, demolish, or repair any structure
1"Ir✓/��
prior it) its issuance. also requires the applicant for such permit o file a signed statement
IL Ny that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9
W 0 (commencing with Section 1")of Division J of the Business and Pmfeawinnw Code) or
dxy ea y' that he is exempt therefrom suit the basis for Ne alleged exemption. Any violation of
lL ram Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
nor mon than five hundred dollars (SSW).
�Z�y6 ❑I. as owner of the property, or my employees with wages as thou,ole wasps...... in.
5e. t•+Q wi 11 do the work, and the siucture is not intended or Mildred for sold (Sec.]IW, Business
yl m and Pr Ac"ions Code: The Contractor% License Use drew not apply to an owner of
63 pnpeny who builds or improves Ihereon, and who does such work himself or through
his awn employees, provided that such impmvemenks are net intended nr offered for
sale. if, however, the building or impmvemem is sold within one year of completion, the
ownefloolder will have the burden of proving Thal Ira did not build or improve for pur-
pose of wale.).
0 1, as owner of property, am exclusively contracting with licenced contractors to
asset the pmjecl (Sec 7014, Business and Professions Cod iO Thc ComLi-
censehuwJmsoataPPlYn)a^owner of property who builds or impnrvu lhemnmm:r'w n,and QTY.
who contracts for such projects with a conations) licensed pursuantmthe Cont ma's
Lice se law.
rl I nm exempt ander Sec. . B & P C I'aa Ihiv mason
'I owner nate
WORK17R'S COMPENSATION DITCLARAGON
1 hereby off rat under Comby of perjury one .. the folhwi mWm1,d`, Co
1 have and will maintain a tion 37am of Consent urCode, bat for W forma Co of the
stolon, as hick provided for mi Section issued. 39(HI of the Lnhnr Coda bathe pednnnance of the
work for which this permit iv orke.
❑ 1 have and will maintain he wrou Compensation Insurance, h required by Section
3700 aide Labor Cotic, for theperfnnnaneu of the work for which Ibis Imrmit is lnstted.
My
CarrieWorkcrsC lion ns icr and Policy numhrare
r. G rf%f�[.aL Policy Nn.:
C13RTIFI ATE
COMPENSATION INNSUPRRAONMCWE
(thiwsatanDeednabecarlood
ORKERS'
ifthepemlir is bmme hundmJ dollars (SI W)
it, loss.)
1 cenify that in the perbarnmesc of the weak for which this armil is issued, l shall
not employ any person in any manner so as to become subject in the Workers' Cnnspe^-
,Z action l.uws of Califomia. Dare '
ZO Applicant t
NOTICE. TO APPLICANT. IL after making This CYr iflG c of Exemption, you should
F't "NN become subject to the Workers Compensalion provisions of the Inbar Cade, you must
Wforthwith comply with such provisions m,his perout vhull he deemed revoked0.0,
CONSTRUCTION LENDING AGENCY
U'Z 1 hereby m arinat lthere Lsawoswmion leading agvary forum Mrforamnce of
us � he work for which Ibis permit is issued (Sec. 3092 Civ. C.)
0 U lenders Name
W Lender', Address
96 1 verify that 1 have read this appliedden and plate Nat Ile above information is
In correct, l agree to comply with all city and county ordinances and state laws eluting to QTY
eiZ building conslrucrion. and hereby mdmaiac aprr,courives id'dis city m coub,,mme
abovementioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless Ile City of Cupenina against
liabilities, judgments, cosi and expenses which may in any way accrue against said City'
in conces,ande of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT
SOURCL ONS A" ] /
amre nfA plictmt/Cornractar me
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building recep at store or handle huvablous material
its defined by the Cupataino Monte pal Code, Chapter 9,12, and the Ilculth and Sufetrl by the Cupvrlino Monte pal Cede, Chapter 9,12, and the Ilcnith and Safety
Coda Section 255321)?
EJ yea 11k4b
Will the applicant or future building wc.pc.t use equipment ,, devices which
emit h9a aloax air emaintinanrs as defined by rhe Imy Area Air Quality Management
District?
❑Yes [No
1 have read the laxunlous materials requinman , under Chapter 6 95 or 0e Cnli-
forms Health & Safety Code, Sections 25505, 25533 and 25534. 1 underhand the( if the
building does not tonearly have a amount, that it is my fianol flay to runty the occupant
of try; rrgniremenrs syjich nny�ljae owl pgagp issu own Ccnifiate of (Ncupuncy.
I'F.RMI'1ISSUANCE
APPLIANCES - RhSIDBNTIAL
PANELS
UP'TO 200 AMPS
SIGNS RLBCI RICAL
SITCIAL CIRC UI'1'/MISC.
'TAMP. MBfER OR POLE INST.
POWER DBVICHS
SWIMMING POOL ELIC` RIC
OUTLETS - SWI I CHFS - FIXTURES
N EW RIIS I DLN I'I AL F.LECTR SQ Ff.
PLUMBING PERMIT
IT RMIT ISSUANCE
ALTER - DRAIN At VENT- WATIIR (HA)
BACK FLOW PER 'pCr, UL'VICU
DRAINS - BOOR, ROOF, AREA, COND.
FIXTURHS - PER TRAP
GAS-F.A. SYS'I HM -1 INC.4 CIA LETS
GAS - CA. SYS 'rBM-OVIi t 4 (EA)
G REASPq NDUS'I'RE. WASTE INTIiRCEPIDR
OR HAS]: TRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATBR IIHATLR W/VENT/HLLCI'R
WATER SYSTEMRREATING
WATER SFRVICH
NEW RBSIOEN'I'I AL PI.MB. SQ, FT.
MHCHANICAL PERMIT
PERMIT ISSUANCH
ALTER ORADD TO MECH.
AIR HANDLING UNIT (TO 10,1X1(1 CFM)
AIR HANDLING UNIT(OVER 13,000CFM)
1 :XHAUS'r GOOD (W/DUCTHOOD I W/DUCT)
HHATING UNIT(TO 100,001) BTU)
HEATING UNIT (OVER 100,00013'1'0)
VHNTILATION PAN (SINGLB RHSID)
BOILER -COMP (3HP OR I W,00O BTU)
BOILER-COMP(OVCR RNI,OW BTU)
AIR CONDITIONER
NEN' RMIDENTIAL SUCH. SQ. FT.
OFFICE
FTSE
-1
0695
PERMIT INFO
■ ■ KI`■J
JOE DESCRIPTION
RESIDENTIAL'
OSPDWI,
OKOCHENREMODEL
❑ADDITION
XPLUMBING RE -PIPE
❑MULTI -UNIT
OSIRUCTURAL
MODIFICATION
❑IN'TERIOR
❑ CHIMNEY R17PAIR
IMPROVF.MEN'I'
[]SWIMMING POOIS
013AI'H RHMODEIIREPAIR 0DHMOL1'I'ION
T
DOI'HER 12
n
COMMERCIAL
O NEW RLDG/ADDITION
[IOHMOLII'ION
❑TIiNAM'
El FOOD SERVICE
IMPROVEMENT
O OTHER
STORIES IY11h
OCC, GROUT'
BUILDING DI IS10 d
PLANCIII.CK FEE
ENERGY FET?
GRADING PE13
SOILS ]FF.
PAID
Date Receipt a
IDTAL:
BUILDING PEI?
FEE- SEISMIC FEIi
ELECI RIC FfiH
PLUMBING FBE
JC . PEE
CONSI' 'f10NT
1 N FEE
I I h I IIVU
PAID
Date Reccipla
TOTAL
ISSUANCE DNI 17,
IVA_—
LSQ. FT.