99090028APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BuD.DmG. ELECT R
BUIL DING DIVISION APPLICATION/PERMIT r ani,? rtris thTECu,,,
ARCHITECl/INGINIMR: 1 NO:
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AN
❑
CONTACT. 81.W PUONIL
BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUM MECH
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LICENSE[) CONI'RACI'OR'S DECLARATIONQ'fY.
1 hereby aa fumn mI am fc<mod wader Provisions of Chapter v (commencing
with Secliro7alff iff Divisinn3oRhe Businessand Professions Codaaod myiicense is
in tell force and efeed P 2 lb
I.icenseC es l• Liap
Dele Coulmclet
ELECTRIC PERMIT FEE.
JOB DESCRIPTION
RESIDENTIAL:
❑SFl) TI ❑PLUMKITCHEN RITE -PIPE.
❑ADDITION 'PLUMBING RE -PIPE.
CMUUH-UNIT CSTRUCTURAL
MODIFICATION
❑INTERIOR O CHIMNEY REPAIR
IMPROVEMENT 0 SWIMMING POOLS
O BATT I REMODEL/REPAIR ❑DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECI.AR
1 understand my plans shall be used as punlic records
PANELS
lll'T020p AM I'S
Licensed Professional
OWNER-BUILDIik DIiCLARATION
I hereby aQien mat 1 am csemp tram the Contractors License Law for the
tollowing renann. (Scow. FDLS, Business and 11 ficaxions Coda Any city or conal,
201-I000AMPS
OVER Ig0AMP5
SIGNS FLECTRICAL
-
at?1++30IF
�ll
which rei nites a permit to conama, alter, improve, demolish, or repair any sbaceure
prior to its issuance, also requires the oPplicant for such permit o file a si,silslalement
SPECIAL CIRCUIT'/MISC.
n
f �,y
W �J0�0
t1 y m eL
LLXl LLy
F=0
p�
W "F" ago
a 3
that he is)iamsed,momnl lothe,nviourv;ofthe Convector's Liceme Law (Chapter 9
(commencing with Section ]Blp)of Division J of the Business and Pmfessfore Code)or'HEMP.
that he is exempt Ihcrcfrmn and do basis fm do, alleged exemption. Any violation of
Section by any applicant for a permit subjects the agplicannn a civil penally of
r more than five hundred dollars ($500)
01. as owner of Ne properly, or my employees with wages es lheirsele emmpensation,
will Jn the work, anA thexwcture is mol imendedor otfemJforsole(Set, 0014, Business
and Pndr..far, Code: The Contractors. Lit elnr Low does not apply m on owner of
builds nr improves Thereon, and who does such work himself nr through
METER OR POLE INST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[I TENANT C1 FOOD SERVICE
IMPROVEMENT
COTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
(IUTLf?'I'S-SWITCHOS-PIXY 8�
notecey who
his awn employees, pmvidO 0.1 such impmvanents ere not Intended m offered for
aide.IL hmwmen the building or lmprovenam isodd withal vc year of completion, the
NEW RESIDHNTIAI. F.LECTR S
SQ. F1'. FLOOR AREA
S/SQ. FT
mer -builder will have the burden of proving that he did not build or improve for Par-
pou of Sala).
0 1, m he, of the properl, am exclusively canuacam, with beamed cmumemrs to
TOI'AI.:
crs Li-
common the project (Set. 70aWU m incsx and Prdeseit s Code) T a, Commha
erne Law Jac% not apply to an owner of property who builds or improves thereon, and
_
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a continuants) liccmed pursuant o the Cormacmrs
PERMIT ISSUANCE
License Law.
0 1 am exempt under Sec. . B & P C for Ibis reason
ALTA - DRAIN & VENT- WATER (EAI
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
RACK FLOW PROTECT. DEVICE
t l hereby affirm under penally of perjury, one of die following declarations:
STORIES
TYPE CONSTRUCT ION
'
`'
❑ l have and will mainmina CenificareofConsed, to self -hostile fon Workers Camper-
salon, as pnwid W for by Section 3000of the Lubar Code, for the a rtonmunec ol'the
work for which this peranil is issued.
DRAINS- FLOOR. ROOF AREA, GOND.
FI%IURCS - PER TRAP
0 1 have and will nmirtam Workers Compensation Intoranee, as required by Section
31Wofil labor C, ,forde,p:rfimmntue thewmkherwhichtbisperannisissued.
DCC GROG
GAS -EA. SYSTEM -I INC. 40C,LETS
GASB-F.A.SYSTEM OVER4(EN
ot Pubic
Un We kq' o cep liyNo be -
Comic ` t lie, No.:
f
� Z
CRF.ASFIINDUSTRL WASTE INTF,RCIiI'1'OR
IEXEMPTION FROM WORKERS'
CERTIFICATE OFCOMPENSATION
COMPIiNSA,ION INSURANCE
- B1111.U1NG DIVISION FEES
(Ihissalion need mol be completW if me pemail is far one hundreddollars($100)
or Icaxd
GREASETRAP
1'LANCIfF.CK PEE
SEWER - SANITARY - S'IDRM EA. 210 FT.
ENERGY FEI3
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I rectify that in the performance of the work forwhich this pennitis cd.l shall
not employ any person in any manner so as to haeme subjeel to the Workerw Compen-
safion laws of C.1durniu. Date
Applicant )
APPLICANT': If, neer making his Cider, of of potentiator, iflaiayou should
become subject m We Workers Compensation provision% of the Labor Code, you muss
became object
lonhwith comply with such pmvinions nnhis permit shall6e deemeA rcvakcd
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a caiwaction lending agency for the performance of
the work for which this permit is issued 1Sce. 3097, Co. C.)
Geralos Nome
Lore?¢Address
is
Wgl'Iilt HEATER WNENT/F.LECTk
WATER SYS 'I'EMII'RP.A'fINO
WATER SF.NVICF.
GRADING PI?li
yhy
SOILS FEB
2
e.
`
P/UpaI�1—
NEW RESIDENTIAL PLMB. SQ. ET.
� Diu, `Reusplf�
.1
(�
TRIAL:
11LDING FIR
I cedify the, I have read this applicaim. and sate thin the miAr information
correct. I since to comply with ell city and county oNi marc and state Inw.a mhniag to
building construction, and hereby audaorize representatives of this city to enter upon 0e
QTY. MECHANICAL. PERMff ti .
SEIS!111 FEE
PEkMIf ISSUANCE
Ii1X TRIC F1717
171X&
abovomemtioned pmopeny for inspection purposes.
(We) agree matter, indemnify and keep hamdc%s the City of Cupmimi Boars,
ALTER OR ADD TO MECH.
.UMBING P
liabilities.judgments, costs and expenses which may in any way accrue against said City
co
in consequence of the 6m nting of this permit.
AIR HANDLING UNIT (TO IB,WO CFM)
NWAL FF.Ii
OINT
APPLICANT UN RSTNDS AND WILT. COMPLY WITW
SOURCE RjAJ1y10
HANDLING UNIT(OVER 10,M)CFM)
CON TRUCUONTAX
pAIR
ifA lcanr/Conv �/
MU MATERIALS DISCLOSURE
HA9AR
Will theapplicam or future building ocenPanl share on handle baaonlnus material
EXHAUS,HOODtW/DUCT)
HOUSING MI'I'IGAI'ION Plili
HEATING UNIT (T01(IO.WO BTU)
as dcfinrd by the Cupenion Municipal Cade, Chapter 9.12, and the Heahh and Safety
Coda, Section 25532(a)?
DYcsIOIYe"
HEATING UNIT (OVER 100,000 BTU)
PAID
-
VHNTILA'DON FAN (SINGLE RESID)
Date Recant
BOILER- COMP QHP OR 100,000 BTU)
Will the applicant (ir future building oecupam use equipment or devices which
c tit hazardous air contaminants as defined by the Bay Area Air Quality Management
TOTAL:
BOILER- CDMP(OVER 10111000',11)
District? gs /
O Yes 1141
AIR CONDITIONER
l have road tl tlpu.%malerials ymre ia. under Chapter 615 of the Cali.
fomia Heahh & tY Wr 5 iia s 355( 25533 and 25534. 1 unJemend thin if the
build, gJxsn cone yli v ile am.th It is my responsibility u)notify the oaupon(
Y IS$),IANCIj,f)(sT
``/
NGW RESIDIiM'IAL MECH. SQ. FT.
of the require np' missuance oda Certificate e (k
1T
TOTAL:
�')em
ISSUED BY:
Owner or omhorize cot
OFFICE