28895OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN REDLINES -USE BALL POINT PEN ONLY
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CITY OF CUPF,R7'INO -. •• '• I-
• BUILDI,NC-ELECTRICAL'"•
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r PHRMITNO
•. 'PLU.MIl -MECHANICAL' ^'
BUILDING DIVISION. - • APPLICATIONIPERMIT t'"
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BUILDING PROJECTiDEMTIFICATION
BUILDINGADDRESS: - Ns'•
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SANITARY NO.
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APPLICATIONSUBMI17ALAL DATE
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CONTACT: PHONE: -
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BUILDING PERMIT INFO
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E Consultant Pat Paid by Applicant (Initial)
DL .SCT -r UMH, CH
QTY ELECTRIC PERMIT
ITE
LICENSED CONTRACTORS DECLARATION
maZ`wimsemm�
1 hereby affirm that I m IicensW under pro ns of Chapter 9 (commencing
2nxry D' rme Basan CIA
JOB DESC IPTION
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of r3 aJl I, mylicensn'a
toren
PFRMIT,ISSUANCC -,
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RESIDENTIAL'
a�U�
mr and effect,
❑SPDWI. ❑ KITCHEN I2 EMODEL
inG
License Class Lic.N'
Land
Uad "' C,innicanr"
- APPLIANCES -RESIDENTIAL
❑ADDITION '- El PLUMBING RIi-PIPE
F.Drn
r ARCH[ ITC1'S DECLARATION
•'
PANELS.
0MULE 1 -UNIT '(]STRGCfG11AI,
'Zptr�7�.
Itnders_mnd my plans sM1vll be aseJmpuMin recnNs.
hi MODIFICATION
p'y—pp
E t?�LL1
Licensed Pf signal
UI'TO 2fxrAMPS
(]INTERIOR ," ❑CHIMNEY REPAIR
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a
OWNER BUILDER DECLARATION
.., 20I-1000AMPS
IMPROVEMENT
C G
1 hereby (firm that 11. exempt fir m the rams
OVER 10MAMPS Y
❑ BATIRFMODEUREPAIR 0DEMOI.ITION
Sd U
Ac ya t'
following reg i CIA,
(Section )031 5 Business and P f' C d Y tY c
ELECfRICAh
❑OTHERS
LLl a
hirl r d, pe u t I cl r p v le ,I , y I are
a .c
psigned
SIGNS
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prion i- .. 1p... y'rca the applicantf such perminofl s8 dswm m
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throb I eJp u u th p ar fth C t t I n La (Ch pt 9'
SI'CCIAhCIRCUIT/MISC.'
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p0(cramg
withS f ]IIW) fD" 3 IB Business'JP f..' :CJ) r
- TEMP. MHT OR POLE INST.
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that h' pt ah f f thebasis ( IIalleged exemption Anyviolation of
'l0315hy
E1 yW)HLDG/ADDI N� MONITION '
1y
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Sen yuppl Iforupeama subjects the impartial,anvil penairy of
not more noun five huntlrcd dollars (SSIkI).+ -
PDWE ICF_S ,
:NANIPF (r 1 SERVICE
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q dQ
with wages
the propmy,mmyot
salec04.Business
nNothe
SWI TNG L .F.LTRIC
1 ROVIiME `y �'��'J
6262''
fosaleir
work, the ctum intended offered Rosiness
mors
will Jothewon;
❑OTHBR
0;.
Corms
vara CI o no,apply91W4,
code: no Commodes uad
Lirvpl Law
11w d«s nm apply Ip an owner of
uTLe "-scot Flx'I'uars
�.
eat,.simns
progeny aha builds or improves thereon, end who Joes such work himself or ttvnugh
w
his own employees, provided that such improvements ore not intended or offered for
NEW R:N1'IAE. ELECTR SQ IT.
silo If, however, the building or improvement is sold within one year ofcomplaion, the
SQ.PT.IBAORARHA 5/1Q. Fr.
ov cr-builder will have Me hmiden of p m that he did not build or improve for pur.
poo ended.
t,• ray, am exclusively
•' a
contracting with IleensaJ commem�s m
DT
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e
c street lh r' IIS sines
I'roressinnsCNeJlhe Coimmnors V-
'cc ¢Law snm plyman owner of progeny who builds of improves thereon, and
QTY. PLUMBING PERMIT
PEE
who comransfor arelt pmjorswhir a cmamctnro) Ilcensad pirsmmlo the Corrector's
r
License Law.
PERMIT ISSUANCH
El 1 oro exempt IerSec. If & P C for this m o
ALTER-DRAIN&VENT-WATER MA
VALUATION
Owner Date -
s' WORKER'S COMPENSATION DECLARATIO ',
HACKI-LOWPROTECCDEVICE
t^i f1
I hereby affirm under penalty of Nrju one of the following declarations:
iclIheve
(� (� It
and will meimainGCenilicaie o cnuoself-insurefnr Worker's CompmI.
DRAINS- FLOOR, ROOF, AREA, COND,
STORIES
TY PE CONSTRUCTION
.do., as provided for by Section of the alum Code, for the perfardaua of the
,
workrorwM1i6dakpermitisi ed.,.
'FUCURFS-PER TRAP
E] I have and will ..in,. dollars Carmarea an lmurancgds«quhed by Section
s
�Yl
3700afthe Las"Cad onnierl'omdnceofah workforwliiehihisperrltlsissue,l,,
GAS -EA. SYSTEM -1 INC.40VRETS -
-
OCC .G OUP
APN-
MyWorkeisCom s rirnihimmneecaArrund olicynumbdrare: -
Carrier. Policy n.:
GAS-EA.SYS'1'EM-OVER4(EA)
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CERTI AICA i
i'TION P ONE WORKERS'
GREASIVINDUSTRL WA-I<.RCEFTOR
7/'/F�
ATION ENSU NCE
BUILDING DIVISION FBIS
'y (Thiaaecl I I r
Iapicedifth .rp is fnche M1vodrcddrilms(SIM)
GRHASETRAP
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or I ss.)' I -
PI.ANCIIECK FIDE O
.Ideal aperformance a work for which this permit is issued, l shall
;GEWER-SANITARY' TORM IiM2W FT.
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not iploy any s n n any mann -so as m becomesubject to the Workers' Compen-,
ENERGY FILE ' -
C) Z,
satin LrwsofC it mea. Dames
t WATERHEATIERWAi R..
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Apple ant •� -
GRADING FEE
y
NOTE E TOAPPLIC NT: If, after making aids Ceniticnc of Excanptim, you should
- WATER SYSTIiMrrRRATING
burom subject m I 'W ark"'s C ' t p '. If 'he [,.her Codid, You must
"
SOILS FEF'
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fonhwit compl th.. hpr vr.' ns th pe t hall bed ed k d.
WATER SERVICE -'
CONS TRUCTION LENDING AGI?NCY
NEW RI SIDEP111M. PLMB. SQ. rE
PAID
Up
I hcrebyuflrm that is ii,therucuon lending agency bathe performance n(
D 'Receipt#
wr.
the work for which this pemi
rt is issued (Set. 3047, Civ. C.)
ats
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Lenders Nome
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TOTAL:
WLenders
Address -. •. •
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1 cetify thm 1 hzve rend this application and state that ]he alxwe madarmtian is
BUI 1 s
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corea.I agice to comply with all cityand cranny oNiiuncex end stele laws rclaain6 v+QTY.
MECHANICAL PERMIT
FEE
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building conslavntinn, and hereby amhorizerepraw atives of this city to enter upon the
SEISMIC F13E
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abovo-mindonesl progeny for inepcmiop faiguam. j)'
PERMITISSUANCE t
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(We)agod 10save, indemnify and keep harmlassthe City of Cupati no against
ELECT IC FEE
linbilities,judganeno, costs and expenses which may in any, aecme zgainsn sail Ciay
ALTER OR ADDTOMECH.
'/
in cnnuqucncc ol'ane granting of this permit.
PLUMING PTE mss+
APPLICANI'UNDERSTANDS AND.WILL;COMPLY Willi ALL NON -POINT
AIR HANDLING UNIT TO 10.000CFAH
MECH NICAL FEF. hit
.
SOURCE REGULATIONS.
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AIR HANDLING UNIT (OVER MAY) CFM).
CONS] tULTION'1'Ax -
SignalurenfApplicani/Comroanr .. Date
E%HAUSTHOOD(W/DUCf)'r
HOUSE GAIRIGATI(IN FEL'
HAZARDOUS MATERIALS DISCLOSURE
,j
Will the uppli<anl nr furore buildin6'as'cupenl annre or lmnJle hazurJoue mamri.l
HEXONOUNITITO 101.001ITU)
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as defined by the CapetianMumc A Code' Chapter 9,12, and rbe ITenhh and Safe(,
Cure, Section 25532(,)1,
HEATING UNIT (OVER 100,000 BTU)'..
❑Ye- No
VENTILATIONFAN(SINGLH RESIDE -`
PAID
will d ppT m hourebuilding occupant use equipment or devices whicha
a-
Date Receipt
dlhzlN .u'rasnt I defimd by tire Bay Amt Air Quality Management
�D'slt<L
BOH -HR- COME (3HP,OR I IIQ0110 BTU)
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❑Ys ,.
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BOILER- COMP EOVER 100,0011 BTU)
I have teal the hazvdovx materials reyuirems u
emnder Chapter fi.95 of the Cali-
AIR CONDITIONER
ISSU NGF; DATE
forme Health & Safety Code. Sections 25505, 25533 add 25534. 1 mis eatand than it the
- NEW RESIDENTIAL MRCP. SQ. 17.
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building does not currently have. Ienaat. In., in is myamis; sihilitynonetilythuoecupmt,
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If the requiremems whichantst band prior to issuance of a Cenificme of Occupancy.
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Owner or amhorired agent - Uate -
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ISSUED BY:
OFFICE