99110033APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY q-1 i 10 0 21-S
CITY OF.VUPIsRTINO BUILDING - ELECTRICAL
BUILDING DivNION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDFNTIFIC TION r
PERMIT NO.
BU1LDINGADDRESS: In� ( r
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SANITARY NO ION SUBMHTcA�L DATE
e3Ou5-30
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OWNEON
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ACTOR'S'SNAKE:
CLIC NO�l
�3"okk,.�-VUL�IA�K.1-�I lj 200 I
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/CONTRACIOR'S
❑ConsultanlFcesPoidbyApplicant(Initiap
BUILDING PERMIT INFO
BLDG ECT PLUMB MIiCH,
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1+100
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LICENSED DECLARATION
1 hereby infirm thin 1 am licensed under provisions of Chapter 9 (commencing
NSeni..n](XYJ)of Division 3..nne Business and Professions Chile, and my license is
wt
n fullf...amid efregk )of"!
.� v(� s"1 'u
I,iccnsc Class L' hic.a J
Unto Cnmrnelm
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SIUWL ❑ KITCHEN R1iMODEL
[I ADDITION ❑ PLUMBING UiPIPE
❑MULTbUNIT ❑STRUM ORA].
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
❑ BATH REMODEUREPAIR El DEMOLITION
C1 OTHER
PERh1IT ISSUANCE
APPIJANCIiS-It ESNEN'HAL
ARCHITECT"S DECLARATION
1 understand my plans shall be used an; public records
PANELS'
UPT0200AMPS
Licensed Professional
OWNER-HUILDER DECLARATIONOVER
1 hereby affirm that I am exempt front the Contractor's License Law for the
Billowing mr,on. hemion'1031.5, Bushes, and Prefe,sion, Code: Any city or crmmy
which o,t im, a pmnit m asromucL neer Impnry dnnolixh, or npuir nay sweunc
prior to its issuance, also requires the applicant for such permit to file a signedma¢menl
that he is licensed pursuant to the provisions of the Contractors Licem. Law (chapter 9
lahmmencing with Stttinn]BIIO)of Uivizionl of the Business end Professions Cadc)ar
that he is exempt theref verb and the basis for the alleged exemPtion. Any violation of
Section]011.5 by any applicant for a permit subjects the applicantto a civil penalty of
rn an rise more Ne hundred dollars ($50(p.
01.as owner of the property. or mycnnployces with wage, .as dminole mh'isaline,
mSce9siness
will dothe wmLard the,truure is out in¢•nJW nndTered fur snlel 044[monies,
Profeoiuns Code The Cnnlmenes License Law dons nm apply to an owner cal
who builds or improve\ thereon, and who does such work h:mttlf or through
201-HICOAMPS
1000 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. METIIR OR POLE INST.
9
COMMERCIAL:
❑ NEW BLDG/ADDITION DEMOLITION
❑TENANT FOOD SERVICE
IMPROVEMENT
[10 ]HER
POWER DEVICF_S
SWIMMING 11001. ELECTRIC
OUTLEIT- SWITCHES - FIXTURES
propcny
his awn employees, provided that such improvements arc not intended or offered for
sale. If, however, the building m on,frovetmn ismld within one yearisf,maplmimerthe
NEN' RF_SIDENTIAL ELECTR SQ FF.
SQ. Ff. BOOR ARBA
SISQ. FT.
owner -milder will have the burden of proving that he did not build or improve for pur-
TOTAL:
pnsc of sale.).
Las owner of the pmprrty, nm escluoorly contracting with licensed .omits lis m
momet ,he buccr (Sm.91H4. Bnsietw and 1'rofe,cros Cars,..) ire Contractor, Li.
ceire Law does not apply toanowner it( proper who builds or improves thereon, and
QTY. PLUMBING PER FEE
who commets far such projects with a cnm rchaus) licensed pursaam 1. Ne Canuncmrs
PERMIT ISSUANCE
License Law,
O 1 am exempt under Sec. . B & P C for this mrsan
ALTER -DRAIN&VENT -W *Ek (EIV
viner Unto
VALUATION
WOR COM PENSATION DE CLARATION
BACK FLOW PNOI'IiCF. DE I'
1 hand w nllinn under Cerny teperjury one al the following talker's C r.
nder
I have and wilbnuinmina Cenificum oBCnn,ennu selFinsum for Workers Cumpen-
.,tion, as provided for by Section 3700 of the Labor Code, for the perfmmanee of the
work for which this permit is issued.
DRAINS -FLOOR, ROOF. ARE .CON
STORUBII
TYPE CONSTRUCTION
FIXTURES - PER TRAP
0 1 have and will maintain Workcry Compensation Insurance, as required by Section
ti Cde, lin the pe the work fit,which this pentat is,,`sa
3700ofthe Labor mun
My Wark Cn:p satialn..,.lp,k
!caom Cauia�P.lhity PNr I ` V
CCRI'IFWATE OF IiMI'I'ION FROM WORK17RS'GREASI%INDUS'1'Rh
COMPENSATION INSURANCE
GAS -IiA. SYSTEM -1 INC. 4 OUTLEFS
OCC.GROUP
07
O Z
GAS-IiA. SY5T1iM-0VERY(EA)
WASTE INT"ERCIiP1'OR
BUILDING DIVISION FEES
(This seninn neeJ nm beenmplmed if the permit is forone hurhdred Jnllars (SI W)
or less)
GREASE TRAY
PIANCHF:CK FEE
SEWER -SANITARY- STORM F.A. 200 FT.
ENERGY FEE
I certify that in the performance ofthe work for which this Permit is issued, )shalt
our employ any person in any manners as to become subject o the Workers'C.e,,n-
WATER HEATER WNF.NTMI-ECTR
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xatinn Laws of Cullf...mis Doc
GRADING
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Applicant
NOTICE TO APPIACAN1': If, after uml,m, this C'coificam of Exemption, you should
become subject rolls, Worker, Cnmpemmion provision., of the Lahr Code, you Inuit
forthwith comply with such provisions an mit his pershall be deemed revoked.
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a consWaion lending agency for the performance of
the work whirr this Peron is issued (Sec 109], Civ. C.)
sur nders Name
WATER SYSTEM/FREA'I'ING
WATER SERVICE
PA 1
NEN' RESIDENTIAL PLMB. SQ, FT
, Re<nplp
'fOFAL,
'TOTAL:
lender', Address
BUIh INrCt hEE ��-
I cenify that 1 have read this application and stain that We above information in
correct, t agree to umnply with an city and county oeinaacex and .gate taw, mixing in
building construction. and hereby authorize representatives of this city to enter upon are
QTY. MECHANICAL PERMIT FF.E
-.•�
SEISM hY.B'
PERMIT ISSUANCE
ELECTRIC FEE
ahwe-mentioned property for inspection purpose,.
(We) agree to save, indemnify and keep harmless the City of Cupcnino against
ACI( ER OR A DD TO MECH.
PLUMBING PET,
liubi If v,,md,.aa..covs and axpeow, which mny in any way n¢mc again.,, said City
sequence of Dc counting Nix permit.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,100 CFM)
CONSTRUCTION TAX
Signature of ApplicamUCammcmr Date
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIA S DISCLOSURE
Willrhe up'I'cans or famrc buitdingnctmoor,ne or handl. hvardmi, outlined
HEATING UNI T(TO 100.000 BT U)
in defined by am Cupcn'mo Municipal Corte. Chapter 9.12, and the Britian and Sabi,
Cale, Section 25532(.)?
C3 Yes r4riPAID
HEATING UNIT (OVER 100.000 BTU)
Q
b -% ! O
VE,NTILATIONFAN(SINGLE RESID)
Date Rariplx
BOILER -COMP CHP OR 100,001 BTU)
NSI( Ne apliaor future building re r,cout use equipment or devices which
t hazard..., air pammmimmmx as defined by the Bay Arca Air CoallIF Management
TOTAL:
ntricr^
Yes &r
BOILER - COMP (OVER RX1,(XXI it GO)
AIR CONDITIONER
I have read he thrombin, material, rc is under Chasur, 6.95 of Ne Cali-
such p
forma gdoes&t cum Coda Sections t 505, 25533and25511,t understand Nmitthe
tit ismy me p.m
CertiyIn
gnimmetcurcmlyhose
,In
ISSUANCE DATE
/� ^) I
( /) Yr 1
NEW R[SIDEVI'IAI. MECH. SQ. FT.—
cate 4(erialify
issuance afa Certificate of Qcpgpancy
nBhM mnnirenhenr\wFiehnnu,t lh[taJ nr uace of.
affix, th,..
OFFICE