31304APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
COERTINO BUILDING - ELECTRICAL, PERMIT N
VISION APPLICATION/PERMIT PLUMBING - MECHANICALO31304 w0
S
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm (ht. I am licensed under moi,irns of Chapter 9 (,no ido, - -
woZwith Section 7000)ofoivNion 3ofthe lommossnnd Professions Code, studio, license is 1
f- 1 B in full force and effect.
<U{tk]- License Class Lia#
Z a Da¢ Compact.,
F- W ARCHITECTS DECLARATION
pZ Z g I understand my plans shall be used as public records
r41— Licensed PmR,sienul
OWNER BUILDER DECLARA'I ]ON
I hereby affirm that 1 oat exempt fnm the Contractor's License Law lin the
3 d U following reason. (Section 7011.5. Business ant] Professions Code: Any city or county
aI- which requires a pcomil hr construct: alter, improve, demolish, or repair any structure
FN1 0;1 priortoits issuance,also requimsthe oppticamforsuclipermit to file a signed stammem
5006E that he is liermanipmommit nthe pmvitiansofflm Cmurni License law(Chnpmr9
�CJ'p0 (commnicingw]nh Section 7")of Dlvision3 ofthe Businessand Professions Codc)or
6 q o Y that he is exempt therofmm and the basis for the alleged exemption. Any violntiun of
I+XI Wy Section 7031.5 by any applicant for a permit snhlecb the applicantto a civil penalty or
�Qtransom than five hundred Jollnrs ($500).
❑ 1, as ownerof Ne property, ormy employees with wages as their sale compcn.satlon,
will de Lesions anile: he Contractors
nm s License a w dJ s notlepply to an Business
a 3 $ and Professions who
Code: The C es then is License Luo dues not apply nr if owner h
property who builds or improves thereon, and who drca such work himself n, though
his own employeese provided dingthat such mentis uld w am not immndW o, offered far
sole. [L however, Nc building ur improvement is salt within one year of completion, the
wm f,odc.) will have the burden of proving that he Aid not build or improve for pur-
0 1of sola).
I,aseasier ofthe property,ton ,Bexclusively coifeW is with:)'] he Contractor,
i.
nmeaum the pmjar (Sea. 7M4, 13usivess and Pnrfcesions Code:)'] Conuumnr'x Li-
cense Law does not apply toair owner of pmiperty who builds or improves thereon, and QTY
who contracts for such project, with a conhacmr(.$) licensed puauam lo
rm the C000lm s
I am exemry uRd,.SV, ., 11 ,B
( WORKER'S COMPENSATIMI K.CLARATIOj
I hereby affirm under penally f,,j., one of the following declarmiunx:
❑ I have and will mountain it Ceniticme of Conscnnn.wlbinsureforWorker'sCompen-
.vection, as provided lir, by Suftiun 3700 of the Labor Code, for the performance of tio
work far which this perm,( is issued.
❑ 1 have and will maintain Wini n's Compensation lo, mnce, as required by Section
3700 of the Labor Code, for the perfomunce of Ne work for which this Penni( is issued.
My Wrrkels Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed ifthe Perini( is forone hundred dollars 1$ Pit
or (testi 1
1 of Lytton in the performance of Ne work for which this permit is ioacd, l skull
not employ any person in any manner so as to become subject o the Workers Compen-
�Z sono. Laws of California. Dale
Z Applicant
.Na NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
become subject to the Workees Compensation previsions of the Labor Code, you mus(
forthwith comply with such provisions or this permit shall be deemed revoked.
Q
sasiz - CONSTRUCTION LENDING AGENCY
L) Iforby which rte#mina, issoe(See.3n lording ngcney funk, Ped'rnn:nroof
01-� thworke or which this perini(6issued (Sec 3007, Civ. C.)
Q Ll LendeAName
Lender's Address
1 1 certify Nat l have ,cad this application and stem res athend above cos misting is
If) concert. I agree ct comply with all city and county nNiences and stem laws relating In
e
C) buildmgconsuuniooand herebyim"fiorizereactrepresentatives of this city to enter upon rhe
above nrtioned an scan for imarify a keeph
(We)agree t. cove, indemnifyand keep harmlessthe City of Cupenst sI City
inbili(ies,jnde of the grans anddexpis which may in any way accrue ugninst sxiA City
APPLICANT
ce of UNDERSTANDS
Nof this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding escupam stem or handle huwAous material
as defined by the Cuponino Municipal Code, Chapter 9.12, and the Heahh and Safety
Cale, Section 25532(u)'f
❑ Yes ❑ No
Will (he applicant or Haute building occupanl use equipment or devices which
emit hazardous air contaminants as defined by the any Ana Air Quality Management
District? 1
❑Yes ON.
1 have read the harudous materials requitement., under Chapter hips of the Cali.
boom Health & Safety Cute, Sections 25505, 25533 eA 2.5534. I understand tent if me
huilding does not mendy have a tenant that it isnsy u,,,m,ihillty an notify the occupant
of the requirements which must he met prior to issuance of u Cenificane of Occupancy.
Owner or auNonuq agent Dam
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PAN17M
UP TO 200 AMPS
SIGNS F1.,C'IAICAL
SPECIAL CIRCUI'OMISC.
TEMP. METER OR POLE INST.
POWER DHV1CCS�
SQ PI.
PLUMBING PERMIT
`PERMIT ISSUANCE
ALTER- DRAIN "ENT-WATER(EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF,ARBA, GOND,
FIXTURES -PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS -F.A. SYSTEM-OVER4 TAd
GREASE/1 NDUSTRL WASTE INTERCEPTOR
GREASHTRAP
SEWER -SANITARY -STORM EA
WATER HHATE /VENT/F.1 .
WATER SYSTP TINA
SQ. FT.
AIR HANDLING UNIT(TO 10000 CFM)
AIR HANDLING UNIT (OVER 10.000 CIM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNI'I'(OVER 100,0(() B'TU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP PHP OR 100.000 BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RBSIDENTIAL MECH. SQ. fin
OFFICE
TOTAL:
BUILDING PERMIT INFO
clPX PLUMB MECH
eLM1`I„ 1:1❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
CADDITION
11 PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
11 INTERIOR
❑CHIMNEYRETAIR
IMPROVEMENT
❑ BATH REMODEIIREPAIR 0 DEMOLITION
❑ OTHER
F.W BLDG/ADDITION ❑ DEMOLITION
❑TENANT
-1 FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT FLW
VFA S/SQ. FT.
FEE
VALUATION
Com,
STORIES 'TYPE CONSTII UCT
R U APN
0
C 111 [VISION FEES
I A(J�'iU PEE
ENERGYFEE ` hivu
GRADING FEE
SOILS FEE
PAID
Data Receipt#
TOTAL:
FEE
BUILDING FEE
SEISMIC FEE
C:hF.CTRIC PEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dale Receipt#
ISSUED BY:
111411"M