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p BUILDING DIVISION APPLICATION/PERMIT9. vLummrvr.-
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ k ❑
LICENSED CONTRACTOR'S DECLARATION
1 beach, affirm bar 1 am her.,ed under pmvfomr, of Chapter 9 (commencing
withSectiouffladnf Divi'sion3milre Basiness and Professions Csdc. and my license is
in full tome and eR
Lsen- Lill p 3
Date Contin
ARCHITECI:S DECLARATION
1 understand my plans shall he used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RE IDFNTIA c
�=—�
❑SFDWh ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBINGRE-PIPE
MULTI -UNIT ❑STRUURAL
❑ LT
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT El SWIMMING POOLS
❑ BATH REMODEUREPAIR [I DEMOLITION
��I'HpF:^R �,/ SMA
PER MIT ISSUANCE;
APPLIANCES -RESIDENTIAL
PANELS
UPT02(MAMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby notion that 1 am exempt from the Contractor's License Law for the
following mason. (Section 703 1.5. Business and Pmfessiens Cade: Any city or county
which requires a permit to construct. alcor, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such l yonitto file a signed statement
that he is licensed Parostand to the provisions of the Contractors Licensc Law (Chapter 9
(commencing with Section 7")of Division 3 of the Business ind Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicantfor a pemtit subjects the applicant to a civil penalty of
^a. mute than five hundred dollars ($50a.
❑I. as owner of the pmpsny, or my employees with wages as their sole compensation.
will do the work, and the someone is not intended or offered for sale (See.](IJJ, Business
and PmfexNans Code: The Contractor's License Law does not apply to an owner of
Propeny who builds or improves thereon, and who days such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. IL however. the building or improvement is sold within one year of completion. the
comer -builder will hum the burden of proving that he did not build or improve for pur-
pou of tale.).
I, as owner of the property, am exclusively contracting with licensed amtrxcmrs to
constma the project (Sec 704,1. Business and Professions Cale., The Conuanor's Li -
Law does not apply loan ownerm,fropeny who build, or improves thereon. and
cataracts for such Projects with a commemtryd licensed pursuan to the Contractor's
se law.Sool
am exempt under Su. . B & P C for Nis mason
201-IM)AMPS
OVER HCUAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL
❑NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT El FOOD SERVICE
IMPROVEMENT
❑OTHER —
'
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR S
SQ. FT. FLOOR AREA
q
/
$/SQ.E,
TOTAL: v
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
(Owner Date
VALUATION
/� o Ji
Sl6& 8
WORKER5 COMPENSATION DECLARATION
I hereby e10rm under penalty of perjury one of the following delsrations
-1Ihave and%dl maintain a Cenifici ie of Conant to self- insure for Workers Cantles.
sation, as vole& for by Section 3]00 of the Labor Code. foi the performance of the
work! icM1 Nis permitis issued.
ve arM will maintain Workers Compcnvation Insurance, as repaired by Section
37004the labor Cede. knife perfcommocefthe work forwhich this permit is imuM.
My WmY,��s1lnppyyap 4 �.ymn�� `—arrivPoli y NoY u
Gamer ,�((CATE AJ
NN FROM WORKERS'
CERTIFICATE OF COMPENSATION
COMPENSATION INSURANC[
!This section need not be completed none permit is forone hundred dollars (SIM)
or less.)
Loy any thatpursnthe preany manero as fficwork for whichNis the Wrkers'Counter-
not employ any person in any manner s" as "r become subject to the worker: Counter-
moon Laws of California. Date
Applicata
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA. COND.
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
GAS -EA.SYSTEM-I INCA OUTLETS
OCC. GROUP
ppN
-Ps-wS
GAS - EA. SYSTEM OVER 4 (EA)
GRFASI%INDUSTRh WASTE INTERCEPTOR
GREASE TRAP
BUILDING DIVISION M. MS
PLANCHECK FEE
SEWER -SANITARY -STORM FA. 200 FT.
ENERGY FEE
WATER HEATER WNIiNT/ELECTk
GRADING IEE
TO APPLICANT: If, after making this Certificate of Exemption, you should
become sub ect to the Worker's Com
j ns or t ion provisions of the Lector Code, you must
foMwiN<nmpl}with such provisions or Nis permit shall be Deemed invoked.
CONSTRUCTION LENDING AGENCY
I for by which rin IN, pe on i iso ed (Seer 3097, ding agency for the performance of
work for which Nis permit is issued (Sec. J(N)], Civ. C.)
Lenders Name
WATER SYSTF,M/IREATING
SOILS FEF.
WATER SERVICE
PAID
Date Receipt p
NEW RESIDENTIAL PLMB. SQ. fT.
TOTAL:
Lenders Address
I certify that 1 have read this application and state that the above information is
comet 1 agree in comply withal] city and county ordinances and stain laws relating to
building constmctmn. and hereby authonze reprewmatives of this city to enteruponthe
aboveltiffomW property for inspection purposes.
(We.) agree m save. indnnni fy and keep harmless the City of Cup,mon against
habilitiegjidgmenu ,Rand expenses which may in anyway acme against said City
in consequence of egra of his peRon.
APPLICANT DF f D WILL MPLY WITH ALL NON -POINT
SOURC L N
1.
TOTAL:
BUILDING FEE
^-
FEE
QTY. MECHANICAL PERMIT�"I
SEIjI1B
��.JIC
~
I'EkMI T ISSUANCE
ELJ PP.F?ry U Int
ALTERURADDTOMECIL
PC IN
M ANNov 18 1999
ICAL FEE
AIR HANDLING UNIT(lp IQINXICPM)
AIR HANDLING UNIT (OVER 10.000 CFM)
C NfS�RUCTION TAX
Si a iff! AppilicainfolilliHot Date
HAZARDOUS NIATERIALS DISCLOSURE
Will the applicant or future budding occupant. store nr handle hazardous material
refined by the Cupcnino Municipal Code, Chapter 9.12, and the Health and Surety
'de. Section 25532(m l
❑Yes XNo
Will the applicant iha ore buildingby the B axe equipment or device which
emit haznNous air umtnminanty m defined by the Buy Area Air Quality Manegensnt
Dwrol
❑ Yes p �Nn
I hu,c meXy6c h:- A al ''Is req t. der Ch.pir, 695 of he Cal
buddanl{d les I f flyct atta25533 2�k5�53il p1t "mfyth h par,
ft fief s be tpri fn Cenifcw of -,Ouvp.
I
e agent Dam
EXHAUST FOOD(W/DUCT)
HEATING ON IT CTO I mLoo0 if Hit
BEATING UNIT (OVER I00,hX) BTU) '
II SINC.WIIGATION FEE _
PAID
Dom k«cipt b
TOUT,
VI7NTILAT10N FAN (SINGLE RF_SIU)
BOILER -COMP (91111 OR 1000)(0 BTU)
BOILER - COME) oOVFR I1N jxx)11'1'U) ,
AIR CONDI' I'IONEk
ISSUANCE DATE
// /
ISSUED BY.
NEW RCSIDENTIAL N1ECH. SQ. FI'.
T(YI'AL:
., OFFICE
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