27675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO PERMIT Na.
APPLICATION/PERMIT PLUMBING27675
BUILDING DIVISION BUILDING PROJECT,II)EN',1'IFICATION
BUILDIN�G]ADDRESS: //.� SANITARY NO. APPLLIICCATIONSUBBMITTALDATG
/ S�- 41 UNIT# 1.01 It p(-19�— /S
S NAME'
I PHONE:
OARCHITELT/ENGINE[ LIC NO: of(.?
ADDRESS:CONTRACTOR LIC NO:
V/R�.s+n_ C.�ONp.,�l ��-Vf� P Q N/C CONTROL#
e
ry►t vsQ I ❑
CONTACT: PHONE: ,v 1 f* s»a x a.:.-a ",� +' ^' «" 4#AUILDING PERMIT INFO
QT+Y. S, ELECTRIC,PERMIT f - FEE x I "
L s& '#rice a d Y E#8 t i a u BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC PITON
Or6Z I hereby affirm that l am licensed under provisionsof Chapter9(commencingwith
�00 Section 7001 Division define Business and Professions Code,and on,license is in PANELS
W full force end effect.
< 1
W VVG y hued License Class Lir.# UP TO 200 AMPS
or E'6 or Date Contractor 201-1000 A)APS
XOrnz ARCHITECTS DECLARATION OVERT AMPS SQ.ET.FLOOR AREA $/SQ.FT.
O Z—O I understand my plans shall be used as public records.
r rn W SIG ELECTRICAL
�9W Licensed Professional
OWNER-BUILDER D ECLARATION ECTAL CIR T/MISC.
0 ii r- I ngherebymos affirm that 1 am exempt from the CD Professions
Cs License Lew for the
'+W ma following reason(Section 703L5,Business and Professions Code:Any city......ty TEMe. R LE INST.
0.] which requires a germine construct,eller,improve,demolish,or repair any strucm
aoY:� prior to its issuance,also requires the applicant for such permit to file a signed stn at POWER Di��)V
GNet he le licensed pursuam m the pmvislona of the Commemr's License Law parr,
4xeP, 9(conimencingwith Section](N10)of Division3ofthe Business sod Profits' ns Code) SWIM CIRI VALUATION
Warn nr that he is exempt therefrom and the basis for the alleged exemption.Any ioladonof TGHE$ XTURES
CSection?031.5 by any applicant for a permit subjects the applicamtm ecivl natty of
not more than five hundred dollars($500). RESID ELECTR -/—SQ.
El1.mownerofthepmperty.ormyemployeeswithwagesastheirsmecompensauo Q FT.
STORIES TYPECONSTRUCTION
pW,3� will do the work,and the structure is not intended or offered for sale(SecJOW,Be,am's Business
Th \
and Professions Code: e Contractor's License Law doeo
s not apply to an owner of
Impurity whobuildsorimproves thereonand whodoes such workhinrselforthons.ghhie
eforse.If, OCC.GROUP RES.UNITS
own empinyees,proviJW thin such improvememsare not lntendedoroffred al
however,the built ingorimpmvement is sold within ono yearofcompledon,theowner
builder will have the burden of [bathe did not build or improve for f TOTAL:
proving p purpoeeo
xolc) Pfvrfi r -,F`L .v..
❑ las owner of the property,am exclusively contracting with licensed eontracm t QT4_•^CA ,PLUMBING PERMIT; p4k;d. tQP68 F8 F1.00D zoNB APN
nevuct the prefect(Site 7014,Business and Pommisioe,Code)The Centraelerq
License Lawdoes nota 1 manovmoofPrePe n who builds orimP roves thereon,and PERMIT ISSUANCE
ppY licensed
whocontracts for each projects with a convacmr(e)Ilcwsed pursuant in the Convector's
Liceneo Lvw. ALTER-DRAIN&VENT-WATER(EA) -�PEE SUMMARY, ., ,
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE v OU I SIDH FEES
SANITARY Y N
Owner Dae RECEIPT#
• c DRAINS-FhOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ihombyaffirm peouni nInsuancat I have a eortlficammf eonsumn pythmod(Sesum,oT Lid,C.)ade whit f FlXTURES-PER TRAP RP,CEIPI'#
Workers'ComperrsatiOn lnauraneeoracenifiedcopy thereof(Sec 3800,Lab CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 HDO PLANCHECK FEE
❑ Certified copy is hereby Ihmished.
❑ CertiliW copy is filed with the city inspection division. GREASEANDUSTRL WASTE-INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need notbecompleted ifthe permit is for0nehumdred dollars($1ft SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I cenify that in the performance ofthe workfor which this permit is issued,I shall WATER HEATER W/VFNT/ELECTR
not employ any Person in any manner so as to become subject to the Workers' PAID
Compensation Lawsof Califoroia. Dore WATER SYSTEMrFREATING Date Receipt is
Q Z Applicant
NOT ICE TO APPLICANT:If,after dealing this Cerificatc of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
p] become subject to the Worker's Compensation provisions of the Labor Code,you most
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that there is a construction lending agency for the performance of
the work for which this pelma is issued(Seo.3097,Civ C.) ELECTRIC FRE
u" FLender's Name yxs= aI +* d
Lenders Address QTY. ° 1s'_!MF PCRMIT, ;