S 2618APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CI'PY OF CUI'F,R'1'INO HI BAINC. - F.LECrRICAL PERnu'r NO.
ISUILDING DIVISION API'IJCATION/1'ERhll'f n,arr Itself
r'uamdrs-nucunmc,al. S 2 618
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OFFICE
I
1 7'/ F
BUILDING PL'RMI'I' INFO
IIL1Ii2- PLUMB MF9?�
E�r
JOB DESCRIP1ION
lNA M I [K0 9i6 _ A0,6
❑ Consultant Fees Pail) by Applicant (initial)
LICENSED CON'I'RAC'IOEtS ECLARATION
1 hereby affirm that 1 am licensed under provisions of Clmpmr 9 montmencing
with Section70(Ilgof Division] afthe Businessund Prolession,CtAc.andmy limenwi.c
in full fume and chest.
Licca Class LIT''n
Dam Contraerar
AHCIR I'ECI'S DECLARATION
I undersmnd my plants shall be used its Pnhlic accords
QTY, ELECTRIC PERMIT FITE
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PERM1111'ISSUANCIi
APPLIANCES - RESIDENTIAL
I'ANIiLS
IJI"f021N1AMPS
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ActowdProf ,ionil
2111-1000AMPS
Q
6 C=
OWNER-BU1LDFR DECLARATION
I hereby offtnd that I am exempt fold the Contractor's Licemw Law for the
fallowing reason. (Section 7031.5. Business and Professinrls Code: Any city or county
OVER IINp AMPS
SIGNS ELECTRICAL
W y
'C,Q
which Inquires a permit o constrvct, altcq improve, demolish or repair any domains
gior to its i,xuance, rho requires the applicant tie such permit to filea signed statement
SIT IALCIRCUITIMISC.
�Nl,
ICO
oma
N
;=Q
;F.
nn
ntnl he is licensed pmntunt ha the nmv ,of the Conuucme, Licen,c Law OChuPm,9
(commencing ing with Sevtln^7000)ofDM,im30 the Ill ... u -s rad lYn1'u',Ioo, Codcl in
too he is asean" It...Ima and to bax:x Int the auegm c%Clnpdmt. Arty vi^Damn ^f
Section 7031,5 by any applirma for a Pemol subjects the applicant In a civil penalty of
am moo than five hundred dollar. (5510).
❑Las Duna of the pmpeny. or mY employees with wages as lheinnle annpsn.cation.
will dothe work.omf lhestmcmn; is mut annaledontlfereJ fmsale (See .]BW. Business
and IF.. ,um", Code neC.amorars Licesd Law fres mol apply. ;at ,dna, of
property who builtb or impnt e, thereon, and who does .wish work hln,eff or through
Its own enlployesx, pnwid,d dial ,such Inipmvenmms arc nut in.ndcA or altered for
sole.11;h^w alhubuilAlaag nl improv cutis sold sidlin't, ywndamnpinlon. the
own cr-builderw111havolh^huNen^I'pmvinglma clid nm build or in,od,c It, ur-
'I 17NIR MIT' ER OR I'D].]: INSr.
POWER DEVICES
SWIMMING POOL ELECTRIC
()IrfL[Sf5-SWITCIII!S-Ilk FURLS
NEW RI!SIDENTIAI. ELECfH SV EI'.
1 IT 61
(YG
pro1ofsalc.).
❑ Las owner of the Sed. 70y, . Business exclusively enntcacting with :, I On id contra..... m
nmwal the c% not pply. o an wneofand property ei Looe:) The CT thercors Li-
who buildsOtcreamanJ
wLawJ«s not applyoast awncc^fpropenywho bud
Ql'1'. PLUMBING PERMIT PEE
pursuant
oho IL for sac 'cls wnhns portly licsnsaJ punuummlM Contmcmh
License Law.
FIT st I ISSUANCE
❑lam exempt mAci$ L_ ,B&PC lore this rennin
ALTER -DRAIN k VENT'- WATER (BA)
Owner Da e
1
1KER'S I MPENSA'NONDECLA \TION
BACK FLOW PROIEC.. DEVICE
I hereby of n unser penallyul perjury m¢af the following deslaratiom:
J Ibavc and wi parin a Cenihcateof Cnnxmmwlf-inam, for Warkce,COmpen-
mbar, te, povi a fo by Section 37M of the Wbar Gnle, for Knicar anee of the
hour
work for which is permit is issued.
DRAINS R(H)I(ARIiA. CON 11,
PI%'1'IlRES-PF.R TRAP
GAS - FA.SYSTEM - I INC. d OUTLETS
0 1 have rad will maintain Work,,, Cnmtpcnanion Insurance, as mammal by Section
3710 of the LulwrCalle,t'or the perfnnnuate of l he work for which It xpcmtiluismct
GAS EA SYS'I HM
My Worker's Compensation Insurance carrier and Policy number arc: C
Canlcr: Policy N^�: P
C17107114CA11i OF EXEMI'1'ION FROM WORKERS'
COMPENSAHON INSURANCE
G ASP USER
ASTE i CEPIUR
9Ij•Ii�.SE'IRA�
'•
fMtis ac..linnn JnolMcomplelcd if the pcnnit iz forons hunJmJ Jollan(Slip
or less.)
I<edd 9 that in the pc,f..mance of the work for which this permit is issued, l sha
nal cmpuy any I¢nnn in any manner so as ut beware suh'Icct m the W ..kers' Cnanpu
fn
_
If, IT e$ANITAFfW U 1 I .2004T.
Z
Z
,utiu 0laws of Calif ha. Da.
WAIL?R HENUTR WIVIiIS PIT - 'I
O
'x
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IL Q
U O
IL FTic
Applic:ml
NOI'ICIi TO APPI.ICAN'P IL a0sr making This Ccdificam of Exemption, You stand
Mmoane mbjwt Ir IM1c Worker's Compcn,muan prounion. of the Luba Cwls, you mus
unhwithcomply witbsueh provnutnsurlhispemtil shall he Jeemedervoked.
CONSTRUCTION LENDING AGENCY
(hereby affrof hal them it a construction lending agency f theperformnnecof
work for which Otis ON is issued (Sec. 3197, Civ. C.)
yam, ': t SYSTI MGTHiAI'ING
WNI'F:R SLRVICE
NEW RESMENTIAI. PLMB, Sp. IT.
) 1 L
U
F" ti
U Z
Lender., Want,
Isndcr'I Arrify
I sanity Ohm I Lane read this application and state )hal the ohne inlimm�tinn is
correct.) agree rot cmttply with a0 city and county ordinances and slam lase renting.
building comuunion.and hereby authorise oprewmmtivesofthis city number upon the
QTY. ML'CHANICN-PF,RMIT FEE
.hone -mentioned property for inspection purposca
PERMIT ISSUANCE
(WO) agree u, ... c, indemni fyand keep h are less the City of Cupeninu against
linhilltics.judganden, costs and expenws which amy in any way aseme against said City
AAER OR ADD TO NIEC11,
1 re I'the Grunting of'M1Ls mmtil.
AI'I'LIC/s N'I' IJ.II�HRYfAN US AND 'i .L `13011 WI'I'll ALh Nf 1N-1'UINT
AIR HANDLING ONI'1' (I'O 10,000 CFM)
S(NH<'Nr '"'BINS.
AIN HANDLING 11NI'r(OVER III,INNICITM)
EXHAUSI'HOOD(W/DUCT)
nature of I IicardConam Ir Dam
HA'LAR fU5 MAI ER Al_S DISCLOSUI Ii
W I ..applicant orfatum building occupant stare or handle hams—,material
Jctire y the Cupcnino Municipal Code, Chapmr 9.12, and the Ilcahh and Safety
;0aiSection 25912(u)7
HEATING UNIT (10 100,000 BTU)
IIIiATING UNIT (OVER IIX),IMNI BTU)
VEN'r1LANON FAN (SINGLE RE ID)
p Ye"
Will the npplieum nr facers b ]Jing naupum use eyuipn.m to Javiess which
il limmcb i, elf enntaminams as pefired by me Eay Area Air Quality Mara'daral
BOILER -COMP (311108 100.100 BTU)
ROILER-COn1P(OVER IUkIXOBTU)
ellin?
❑ Yee `�Y/,.//
pmr6.95otheCali-
I hive readthe baawdou, man.•rad, memo, catxfonder Chaf
AIN CONDIT IONER
NEWIILSIOIINPIAI. MliCll, SQ. PI'.
I'omia Hca�h S�sty Gula Sti'l't x 25505,25533; nd 25534. I unJummnA aha II the
hadhfma o"no"o, }Ilvheveaued1,mylitj,latyryg,^n,iblllly.mtthyntcoccupam
OFFICE
I
1 7'/ F
BUILDING PL'RMI'I' INFO
IIL1Ii2- PLUMB MF9?�
E�r
JOB DESCRIP1ION
RESIDENT1A1:
❑SFDWL
❑ KITCHEN REMODEL
EIA [ION
❑ PLUMBING RIS PIPE
❑MUCrI-UNIT
❑STRUCTURAI.
MODIFICATION
❑ IN, ERIOR
❑ CHIMN17Y REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATA REMODEUREPAIR
DEMOLI]'ION
❑ OTHER
COMMERCIAL:
❑ NEW IB,DG/ADDI'I ION ❑ DEMOLITION
OtfFISANr ❑170ODSERVICH
K
$ISQ. FI'.
t to
�
711 600
STORIES TYPECONS'1'R CI'10
DIVISION
u
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sfl •1 ANICAI, 171;U.G
C'( "fRUCI'ION TAX
IIt1115 'G AIII IGATION FEE
PAID
DOm Rcucietp
JANCF DATE
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