S 2268 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
CITY OF CUPEwr1NO Ran -ELECTRICAL PITt11'NO.
BUILDING DIVISION APPLICATION/PBRMIT PLUMBING-MECHANICAL 2268
`V
BUILDING PROJECT IDENTIF'ICA'TION, " ;SANITARY
BUILDING.ADDRESS: _ NO. APPICATIONSUBMITI'A1.DATPTo �OWNERS NAML: PHONE: CON'TRACTOR'S NAME: LIC NO':5tin le At4-L"e e 72 cDNTRDI.ARCHITECT IINGOIiIiR: LIC NO. ADDRESS:
1.3(c0"1 Vitr r,&q R1 23
CONTACT': PHONE I I I I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FLF:CT PLUMB MECII
❑ O.-- ❑ ❑
LICENSED CONTRACT OR S DECLARATION QT•Y,
' t EII. Tlik PIPI : PFF
Ihcmby ollrt fair l I ' d I ICl T '9( y C , J0I3 DESCRIPTION
_
ClCZ whbbecr on7IXIR)ofD va'on5 note Rtx ,aa.d Pn tie.:ln:e lie attemylia Geis RESIDENTIAL:
W p O i PERMIT ISSUANCE S'S t/
FW P: ..full force and,fee 723375 ❑SFDWI, Cl KITCHEN RFP[PE
sC U, DHL
I)ccme Cl ll Lica
H Til Uwe Cnnlreaur�/t/FTS�Ha_ I—L APPLIANCES-HLSIUF.N'1'IAL ❑AUDI'I'[ON El PLUMBING [,PIPE
mQa ❑MUCI'I-UNIT ❑MODIFSTRICT CATIO
ARCHITECT'S UIiC1.ARATION
ZONN Iundersmadnry Nareahall M used as public records PANELS CHIMNEY
O Zen UPTO 200 AMPS ❑INTf;R10R ❑CHIMNEY REPAIR
�.V7y� U,,crd Prnfuesional 201-HUHAMPS r IMPROVEMFN'P E]SWTMMINGPOOLS
OWNER.BUILDER DECLARATION OVER 1000 AMPS [I BATH REMODFIJREPAIR ❑DEMO LITION
C C Q I hereby affirm ffin L am exempt from the Co....or 's License Law for the
iy(O G U Inllowing r......,(Section 70315,Business and Pr..fe,,ions Code:Any it,or countyMENS LLECfkICAL DOTHERR y
W a W y whish ommul,a permit m,onartiO,alter,improve,denlolieh,or repair any,enclare
p.,WOQ
prior to its issuance,also 4 the pplic t for such Permit file a signedsulenenl SPECIAL CIItCUI'I'/MISC.
dedu he is licensed t he Pa.,knuouffieContractor's License Law(Ch.px,9
Wp�'gp
(commencing with So, 7000)(it Or sit B fth Business I I ,Cde)or I EMI'M TIER OR POLE I NST. COMMERCIAL:
d As p a' Ihnt he to exanpt Iherdlam and the fill,lira the alleged—,mm in Any vinbnin i of ❑NNW BLDG/ADIIITION ❑DEMOLITION
^y Section 7031.5 hyany.pplicanl for.peari, .bjecrOlwa,filind to.civil penalty of POWER DEVICP_S ❑TENANF ❑FOOD SFRVIC17
FpbQnot morn than fee hundred doll...(5500. IMPROVEMF:N•T
❑ Lsnwncraflh...... ny,ur my cmpinyae with wages as their ynlo compcnxation, SWIMMING POOL ELECTRIC
2 fS.0 will do thcwnrk.and llicarmunrclxnol inl,nd,c roRered forxalo Bee 91313.Rusiuesx ❑OTlilili
Cao m er OUTLETS SWITCHES-FIX]URES
a3= and err Cade: Dc cmm1rn1 1 1 ,nt khit i tlit breath
,,,Perry h h Tris lir' p tM1 I h d .m k h If tr lhmugh
lie I I y es,pr 'J d Than h In p t: m 1traded Ifcrcd for NEW RESIIII:N'TIAI.PL i-CIR SQ PI'.
mle.If,bnwcver,the hu'dding or lmpmvemem is said widdnonc yen,of cont,110 1,he SQ.FI'.FLOOR ARBA 5/SQ.W.
unwinchuilder is of have th barden ofproving ththe did radWld(it impluort for pr
"W"ad")
ow E )
TOTAL:
❑ 1 f0 P rYexclusively' contracting ode d a t m T O
cont 10 I j tp ,71W li 11 f Cd 'J fl C t t li
wlax Jrosnulapplytoan twnerofpmpvnywho bond, lip nvsstherco d QTY.-' I ,, PLUMBING PERMIT' PEE
whit lea rners m,Bach prstjeca wish o..trus torn)hrva xd puamm m the CnnmacmdaOf
I:¢cwe Law, PERMIT'ISSUANCE
❑ I am exempt under Sec.
AI:I'ER-DRAIN&VF.N'I'-WAT (P- VALUATION
Owner Date r1
WORKER'S COMPBNSA'IION DECLARATION RACK FLOW PROTEGE,.DEVICE? �J �y
1 hereby.Ginn under penuhy n[perjury one of 1M1c lihlnw,ng Aaaamtinna 10
s�
❑lhavwndxilimainminaCenificateof Cotnernm.¢IGinsurefor Wnrker'.v Contpen- DRAINS-FLOOR,RORIE.ARE A.COND. STORIES TYPECONSTRUQ'ION
.anion,as provided for by Section 3700 of the Labor Calc,for the performance of the
Wk for which Ihie pemdt is listed. IT X,URE S-1'ER TRAP
1 have and will lommall Worker Compensation Insurance,us required by Seen
3IIIOoflhe Tabor Chic,lar the perfu,muncc of lite xod for which lhispcnnit is....ed, GAS-EA.SYS'I'Jim-I INC.4 OUTLE IS' OCC.GROUP APN
\l My Warktf}C pq,_}am Insur:,nce catrierlad cy N"y l_ 64c GAS-F,A.SYS'rEM-OVIiRJ(EAI
/l� Cnnicr I MER A/WI+-
/ C[NI'IFIC O ESP SATIONIINN FROh1 WOHKIiHS GRIiAsI]INDIISTRL WAS'1L LU'I'ERCI-PTOR
COMPENSATION INSURANCE Hit B.DiNG DIVISION FEES
('I his acdien aced not be eomple¢Ail'lhepetmit is for one hundred dollars 1$100) GRIiASF.TRni'
or less) NCHIT Eli
I eerily that in the performance of the work for which this permit i,issued,l shall
EIWIR-SANIARY-SORMF.A.2(p T.
ENERGY FE
� notemployanypcotm inanymname,soamtmexubjem .,he Worker,'Co.,.Compn. Inil
ctien Lawlor California.Date WA'I ER HEATER WIVE VI/1iLECPR IQN
dMI% 11 Ill
z O Applicenl I , - A
all 11 11,
U1 NOTICE'IG APPLICANT:IL a0er making Ibis Ceriticate of Exemption,you ahuuld WXrleR SYST'IINIT'RF.A]'INC,
EtN•' 5: hecoltte.ubjem m tM1c Workels Campemuuon pmsisions of the tabor Cods.you mus SOILS FEE
F.t fmhwith comply ,,It an It provisions or lhiepermit shall W dmnmdrevoked. WATER SERVICE
a. Q
= z CONS'IRUC]ION LENDING AGENCY N EW RES I DEN'I'[A].PLM H. SQ.IrI'. Rcccip(#
Vp t hereby afftrn lhatcrdi
0crc iso mmuction lending agency for the wifnnn...cut
the w.Tkfl, hilh i Numi,, .used S3W7 Cie.C)
ry/y; Led Na 'I'O'TA.:
] TOTAL:
L Leader'sAdi BUILDING FEE
y 1 rtfYh IM1 ldn pplcr d.ttth tth M ' f tone
Vcorrect.I g 1 ply all 11 'ly E ty I' i LII l tiny to QTY MECHANICAL FERMI I FEE
Uz hull 6ca lorel r,unitherl5 anal or as vl e,e e'I' sol thwtyIli xntlrpt rhe SEISMIC ILC
above-memiuneJ pntper5'for inepcnion purposes. PERMIT ISSUANCE
(We)agree it save,indemnify slid knT hamdess the City of Capt against EL[CI'ItIC SEF. ,Bio
liabilities,j tldgmealx,costs and expenses which limy in any way accrue againsiseid City AMER OR ADD TO MBCA.
In oonxcgncnce of Thu graming of this"noir PLUMBING FRE
APPLICA T UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'1'('1010,00h CFM)
SOU P .F.Gt -AI NS. Q,yn MECIIANTCALigili
Signature of Applicant/Contractor� AIR HANDLING UNIT 10,000 CFM) CONS'DRUCTION'(AS
Date BX HAUS'1'110UD(W/DUC'1) HOUSING MI'TIGA]'[ON PE E.
I fAZARDOUS MATFRIALS DISCLOSURE
W III the upplicunt or tmum building uscupanl xatre or handle haeardnm nntlerial [RATING UNIT I TO Bitola)BTU)
m demo by the Cuticula Munro pall Cade.Chapter 9.12,crud the Ifcnith and Safety
Curie Section o55321a)9 ��/ I12ATING UNIT'(OVER 100.00f)It I of t
11Nn VENTILATION FAN(SINGLE RESID) all
PAID
Will the app oat a ar fumrc building 1y the B sec ea Air Qu of Mint. which
emit hmanl.vs air ammminunta as defined by the Nay Area Air Quality lfanugemem ROILER-COM I'(3HI'OR IOB.UUII B'TU) - TOTAL:
79 Cfo
District?
❑Ye � BOILER-COME(OVER IW.INM 13 W)
I have read the haeareutu nmmrials ox iremenn under Chapter 6.95 of We Cali- AIR CONDI'110NGH ISSUANCF DATI? `
India IIuE1h&Suter,Code,Sections 25505.25533 and 25534.1 undersmnd 11un if rhe NEW RESIDENTIAL MEGA. SO.IT. J
buldmg t tin rnenlyhuvearena hill it 1.my rest initially tonohly thencamp.nl
of 11 r�i rpt 9y lichtlw mel ' m issuance of a Cerhi'me of Occn
rt, w LCye�dpnar r/R
a wnermanthedacdagem Date TorAL:j ISSUED Byatt
OFFICE