23141NZ
2: E2
R4
� �g: �t lu
11hN
OF
L
0z z
P 2
cc g
W >
0. a
D z
v 2
tL
0
L
Building Project Identification
Addat
�I V C V
PERMITNO.
23141joq((
UB.wildiag
one:
APPLICAHUNSUBMEITAT. DAM
CITY
OF curERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRTCALPLLTMBING.MECFtAMCAL
C
YT File. No:
CATEGORY
CONI ROL N
A,chimd/Togirmeo Lic. No:
'',AUILDING PER IT INFO
Address: vp- :51-J 'JJjzPERMITISSUANCE
t
LICENSED CONTRACTOR'S DECLARATION
I hereby affiranthat I amlicersed under provislosso(Chapterl? (couromenc-
IngwIth Sectim,7000)o(Division3ofthe BusinessandPanfesslonsCode, and my
license Is In force and effect.
License Cinss C 1) Lic N `5' 4, C,
APPLIANCESRIESIDENML
JOB DESLE11111 [ON
PANELS
Date-- Contractor ' 4'P i
Z01- 1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as pubilcrecords.
OVER I001)AMPS
SQ. Fr. FLOOR AREA $/qQ. FT.
SIGNS ELECTRICAL
Licensed Peakesic.1
Z—b—
SPECIALCIRCUIT/MISC
0
OWNER -BUILDER DECLARATION
1 h,rcby.ffl. that I am exempt from the Contractors License Law for the
following Mason. (Section 7MI.5, Business and Professions Code: Any city or
county which requires a permits, alter, improve, deroolish,or repair
any.tructum priorto Its Issuance, also requilreas the applicant for such permit to
file signed statement that he 6 licensed pursuant to the provialons of the
Contractor'. License Law (CIaptrr9 (Ccurnownclagwith Sectfix. 7000).f Divi.
skm3 ofther HuMnes..ed Preffe.W.Code) ortht he Is exempttheradromand.
the basis for the alleged exemption. Any violation ol'Seddon 7031.5 by any -WOUTLETSSMICHMIIXTURPS
applicant (on permit subjects Me appikanl to •dull Fealty of not more rsor
M ALE
AmPUTER
—�Lz
6T Is
VALUATION
—
TEMP. METER OR POLE INST.
POWER DEVICES
—
—
SWIMMING POOL ELECTRIC
(We hundred dollars ($500).
C] 1, as owner of the property, or my employees with wages as their sale
INEWRESID=ALELECTR _SQ.Fr.
STORIES
TYPE CONSTRUCTION
compensation, willdothe work and the strochare Is not Intended or offered for
.1. (Sec. 7044, fitudoess, and Pmf,.I.. Code: The Ccoututdo?o License IA.
—
does not apply to an owner of property who builds or I reproves thereon .and
who does such work htmartforth rough his own employees, provided that such
Improvements are not Intended oroffered for male. It, however, thebuilding or
—
TOTAL:
OCC'GRC`Up
ITS. UNITS
Improvement i3sold within oneyearofcom IsHoo,theowner-builderwill have
tkq,hurden of proving that he did nas bulffor Improve for purpose of sale.).
11 L as owner of the property, am exclusively contracting with licensed
contracm. to co.truct the protect (Sec. 7044, Business and Pomfeask," Code:
—
—FLOOD70NE
APNI
PFIRMITISSUANCE
The Contractor's License Law does not apply to an owner a property who
Wilds or Improves thereon, and who contracts for such projects with a
c t actor(s) Homand pursuant to the Cortatearm's License Low.
rj I am exempt order Sec. B k P C for this mason
—
ALTER -DRAIN & VENT - WATER EEA)
,FEE sUMmA Ry. ,
_
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AR11k COND.
SANITARY Y— N—
RECEIPT 8
Owner Data
......
WORKMAN COMPENSATION DECLARATION
of hereby affirm that I have a marifficate of consent to self -Insure, ora
anificateofWorkem'Compemailonlmuranaoracenifled.pythe..f(�ra..
lab C.)
Policy#
FTURES� PER TRAP
SCHOOL TAX Y_ N
RECEIPT
9YSTE1 INCA
CAS- EA. M-OUTLETS
ER,
PARK PY_ N_
RECEIPT al
c -Y
og".
GAS. SYST[M-OVSR A (EA)
G.
BUILDING DIVISION FEES
artfified copy b hereby Furnished.
Certified copy ka filed with the city inspection, division.
CREASE/INDUS1RL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 2CM-7.
COMPENSATION INSURANCE
(Thissection need not be completed if the permit 6 far one hundred dollars
Dale Recelptil
WATER I WATER W/VENT/ELECTR
ENERGYFEE Y N—
PAID
(91IFE) or ho
I cartify that In the performance, of the work forwhich this permit is issued,
I shall not ..play any Pa.. In any manner so as to became subject to the
W.,ken;'CmnpsrmtI.o Laws.f California. Data
WATER
Applicant
NOTICE TO APPLICANT: lf,.ftar making this Ca"Ificam.1 E". of you
should boarminiblect to the Work..' Compensation provial ". oftheLabor
Date Remipt#
NEW RESIDENTIAL PLMS. _SQ.ET.
TOTAL
Code, you roust forthwith comply with such provisions orthis perraft shall he
deemed revoked.
—
MILDING -r
SEISMIC FEE
CONSTRUCTION LFN01NC AGENCY
Ilmmby.ffima that them Is a construction lending agency for the perform,
ance of the work for which this Forms Is Issued (See 30137, Civ. C.)
leaders Name
LanderxAchdratut
I cedifythat I have read this appliestionand Mate thatthe above information
1.5coreart. I agree to comply with.11 city and cooroyardinarm, and Asia laws
TOTAL
—
E LECTRIC FEE
',MIECflAWR:AL W& I
-,�+rEll
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEESPAID:
relating to building conotruction, and hereby authorlm representatives of this
dlyt..nterup..Ih.abov,.nll.nedrlvrty(minspedionpurpows.
(We)agree irteave,lodurrelty.ed keep harmless the City ofCopertlex,
against liabilities, judgments, anstsand expenses which may In anyway accrue
against dCpyiqc.n7. f1hear!5insofthl.pearrit
;I(Q I I I
P w " o - It (
Signatun4of'ApplIant/Contractor Data
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (170 I9,000CrM)
SUBTOTAL:
I jAK �14
AFRHANDtJNrUNIFTQVERI0,0WCFM)
—
CONSTRUCTION TAX
EXHAUStUOOD(W/DUCT)
—
CONSTRUCTION TAX PAID:
HA7 RDOUSMATERJALSDISCLOSURE
Will the applicant 'or future building occupant store or handle hanadous
as dcfi and by the Cu petition Municipal Code, Cha pier 9.1 7, and the
I Tralth and Safety Code Section 25532(a)?
qYea r! No
HEATING UNIT (TO 100,000 BTU)
Date Revel IHmaterial
I ELATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
a .
lII the pplEcart or future building occupant use equipwat or devices
which soot h.rand.,Mr watarnin.at,.. defland by the Bay Are. Ale
Quality Management District?
No
'�'Yhyrlread
BOILER -COMP OIIPOR 100,0<10 FIELD
MOILER -COMP (OVER 100,0M JIM)
the buRs materials requirements under Chapter 6.95 of
the California I lealth & SafetyCode, Soolons 25505,25533 and 25534. 1
underaland that Ifthe building does not currently have a tenant, that It Is my
I
F Fk I LIE
—
NEW RE-TDIENTIAL MECI L—SQ.FT
rmp.axiblifty to actilythe amapart of the requireareads which must he net
—
priorto Issuance of a Certificate ofOcaupancy.
A 0 1 32
ISSUED BY.
r,
Ownpror authrolmd agent Date
I
I
-
I TOTAL.-
OFFICE COPY