S 1305APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO RIIILDING- IELECCRICAL
BUILDING DIVISION APPLICATION/PERMIT 1'INGPROJECTICHANICC
nuu.Dlnc PROJECT n>ENnx'TcnTfoN
PE IT No
1305
BUILDINGADDRISS:
2.0 -too e�«k 131v S+� �-6 �G
SANITARY NO.
APPLICATION. IIMITTALDATE
7-2 r-9
OW ili'SNME: P ONI?:
i Ll1/V V
C N"ItACTOR'S RMF: LIC NO:
LA — 2 7.IC
CON 'IROI. Or
' A II IFCT/ENC)I NEER: LIC N ):
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ADDRG4' O
❑
CON'T'ACT: PRONE �p
D�,,,..C.ar,wJ-w�-+ C�� 3 L�.�J
❑ Consultant Fecs Paid by Applicant(Initial)
BUILDING PERMIT INFO -
BLDG EI.F'ClPLUMB MECII
❑ t?" ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afr to .bat l ant licensed Lauder, .......i afchapmr 9 beim iNis ng
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMITISSUANCE r
with Section 7000) Division 3ortita Bache.. and Parmsions Core, undmy lwer,els
in full bacchanal effect.
RESIDENTIAL:
DSFDWL ❑ KI'I'CHIEN REMODEL
APPLIANCES—RESIDENTIAL
[)ad Class Lica
Um¢ (I'S
❑ADDITION El PLUMBING RF, -PIPE
❑MDI:fIANIT ❑MODIFI STRUCTURAL
MODIFICATION
CHUAN OATION
C3 INTERIOR ❑CHIMNEY kF:PAIk L.
IMPROVEMENT SWIMMING POOLS '.
eSHC1ll'I'ac mea DECLAItAT10N
DECLARATION
nndecwand my plans sh:Jl ba used ax public records
I'ANIi15
011T0200AMPS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATIONthe, I mr,,emp, form the ., License Law for the
1 hereby ultirm
fallowing ocroona (Sccdo.t 70315, Raciness and P fe,imu Coda: Any city or manly
❑ BATH RIEMODEURIEI'AIR ❑ DEMOLITION
❑ 01 HFR
OVER I(XXIAMPS
SIGNS BLEU RICAL
which mg9ires a permit m cnnm... 1. An,, improve, deaumliah, or repair any amcmre
SPECIALCINCUIT/MISC.
prior to its issuance, also requires the applicant forsuch permit i File a signed stmemmnl
that he is licensed punaant to the provisions of the Comratoes License Law (Chapter 9
(ro moving with Section 7!X00) of Division J In Nc Razin,..aid l'mfes.inn Cale) nr
TEM P. MF,'I'IER OR POLE I NST.
COMMERCIAL '
dun It, is exonpt therefrom and the hasis for the alleged exemption. Any viol niau nr
� NEyOPL )G/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five lam doll ... (SSW).
Las owner of the pmpcny. or my nnployen with wages a. tbeinole compensation.
will do the work, and the structure is not intended or Whined for side (Seo. 9144. Broues
POWER DFVICES
NANV [I FOOD SERVICE
�,�
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
and H dfir,ian. Code: 'I'he Cmuranlo, License law doesn't apply to an owner of)UTLETS—SWITCHI3S—FIXTURES
NEW RESIDENTIAL ELECIIt SQ F1'.
pmpcny who builds nr impruss Ihne m, and who docs such work himself or through
his awn employees, provided that such improvements are not intended or nBered for
sale If, however, the building or improvement is sold within one year ofermpinina.Ne
SQ. 14. FLOOR AREA
$/SQ. rr
ner-builderwill hive the burden of pmving that he did not build or improve for p9r-
w nl'xalcJ.
i as owner oproperty, am Lha propum exclusively cnalmcdng with licensed contractor, to
I'D'I'A
construct Ne pojeo (Sec. 70,14. Refire, and Potessions Code:) ]be Commemrs Li -
sense Law Owes not apply to con owner of progeny who builds or impecoves thereon. and
QTY. PLUMBING PERMIT FEE
who commas for such projects with a comazi licensed Pursuant o the Contractor's
PIERM19ISSUANCE
Liam.. Law.
am exempt under Sea . B & P C fonhlx retmnn
fl
Owner Dae
AI.TFR — DRAIN fe VENT— WATER ILA)
VALUATION
WORKER'S DECLARATION
BACK FLOW PROTECT. DEVICE
oIi.NSATION
penally
I hereby afrrunder penuhyl perjury nnc nfthr, following dmlamtiinx'.
m
❑ Ibuva and will nutinlninaCmlEcnm of Cnnxnl to self-inxnm fir Worker', Cixa,a-
wino, as provided far by Section 3910 nr the Lehr Cade, faille performance of the
DRAINS— FLOOR, ROOF, ARCA, CON D,
STORIES
TYPUCONSTRUCIION
work for is hich this .it is isnW.
FIXTURES — PER TRAP
$I have and will nuaimoin Worker's Compensation Insurance, as required by Section
I of the Labor Cole, for the Performance of the work for which this permit is issued.
OCC. CROUP
APN
GAS—EA. SYSTEM -I INC. 4 OUTLETS
My War s mpca'abon Ensu encu cu 'er unit Policy
Carrier lacy Nn:
W'CERTICA OPEXE I Ni,�nyVfZt i�6?�
Ie�l, IPENSATIONINSUHA'CE
Pf 'l
f
CAS — Park. SYSTEM -OVER 4 (BA)
GREASPIINDUSTRI. WASTE INT[RClil'TOR
IL VISION FFIES
(This.ectinn need cnnupletcd irthe preanal is for one hundred dollars (SI W)
tale's.)
GHEASB TRAP
I' C ',.
I certify that in the perfomtim, of the work for which this permit is issued, l shall
y any person o any manner the
SEWER—SANITARY—STORM EA. 2W PI'.
�ENERGY PIiIi
use
WATER fIEAT1iR N'NF;Mf/Ii1.fiCfR
sauon l.aw like. D
Applicant �y� C
l�ry'I tt S1
TOAPPLICA
GRADING T LE
5 n1 should
NOI'ICI•. .Ilea aur nu—int
neconc object main Workers Campeau this provisions of the Code, you muss
WATER SYS'I IIMlIREA'I'Wr1
SOILS FOIE
rnedr
f9nhwiN comply wish such provisions nr Nis pemuit shall beJamed revoked.
WATER SERVICE
CONSTHUCI ION LENDING AGENCY
hereby Minn lhnt Nes ixu amstrvctinn lundiagageney(mthrnrm,rnwnce of
NEW RESIDENTIAL PI.MB. SQ. Fr.
PAID
Dam Hecciptk
the wnrh far which this permit is issued (Sec. 3097, Ca, C)
Lenders Name
TOTAL:
Lenders Address
TO'T'AL:
BUILDING FIFE
1 certify that l have mod this application and sane Ibar the above infe noiian is
QTY. MECIIANICALPERMI'F FEE
SEISMIC PHIS
reel.Ingreetocan:plywirolalellyanecountyardinance.and.tateluw.mwlingm
building rsrmtnmll tion, unit herebyaac represanaivesof . this cry n, calen0the
PERMIT ISSUANCE
r�
ELECTRIC ILC ts
abovomcntim ed pmpcny for inspection purposes.
(We) agree to or, indemnify and keep h oth1c s the City of Capuchin against
ALTER OR ADD TO MECH.
'
PLUMBING PHIS
Liabilities,judgments, toss and expenses which may in any way acme against said City
A con acgnence or the granting of this permit
AIR HANDLING UNIT CIO 1(1,01X1 TIMI
MIECHANIfAI. I'cE ,
NT UNDEHSCANDS AND WILL COMPLY WE 111 ALL NON POINT
SOURCE REGULA'T'IONS. -
SOURCE
AIR HANDLING UNIT(OV1ER 10.000 CI -M)
CONSTRUCT ION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
ROUSING MI'I GAT10N FEE
HEATING UNI'C(TO purist) TO)
Will toecraTicanlorrmum bulldingaccupent score or handle hnmNnus nmtcrial
as defined by the Cupcninn.Municifed Cade, Chapter 9.12, and the Health and Safety
Cade, Section 2553201p
11HEATING INTI' (OVER 100.0 0 BTU)
❑Yes F7 No
PAID -
Dam ItuciplN
VHNTILA'UONFAN (SIN(iLERESIu)
Will Neapplieunt or future building oecupanl use equipment or devices which
emit hazardous air contaminants as definM by the Bay Area Air Quality Management
DisoietP
❑Yes 0 N
BOILERCOMP(JHP OR IgllgO BTU)
— ,
TOTAI 1
BOILER—COMP (OVER I WdM3 BTU)
AIR CON DI'I'ION HR
I have Sucail kl b osis, Serious 5505ls q 5533 a under Chapter 6.95att at Cali-
fomia Health .@ Safety Coda. Sestinas 25505, 25531 and 25534. 1 umksmnd that if the
building does not currently have a tenant, that o is my
Ceray hu notify the
ISSUANCEri
NF.N' RE51D1ENTIAL MUCH. SQ. F7.
ton,occupant
of the mgwremenls widen meal he tat pdarmixaa:mee aDl eemream nfQaeap;, y.
actp ceof a
-rE
ISSUED BY, q
Owner ar authorized agent Dam
TOTAL:
OFFICE