24711APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPC' RTINO BUILDING - ELECTRICAL
APPLICATION/PERMIT PLUSIRING- MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO.
I� A f 1 aI
2 4 1 1 1
!!!B - PING ADDRESS:
SANITARYNO.
APPLICATI�O%N SUBMITTAL DATE
Y ♦�
I—/NS d/• UNIT# LOT#
i
' SNAMH: GH- '- W 1 P710NG:
CONTRACTORS NAME: �� �rL10C L0:
N/C
CONTROL#
ARC] TECTUNIGINEER: LIC NO:
AUp S
IS'. �O� SAAJ � V.1
/s/ le
CON'T'ACT: PHONE:
QTY. ELECTRIC PERMIT FEE
UILDING PERMIT INFO
BLDG ELECT PI M9 MECH
PERMIT' ISSUANCE
LICENSED COM'RAproSDECIARATION
with
I hemby aff tm thml am licensed undersamdvimexa fChaost and
gection?WO)ef Division3 of the Buviness and Professions Cade, and mylicrnseis in
APPLIANCES - RESIDENTIAL
pprygfs
JOB DESCRIPTION
'+
force and effect. z�,// (/
Licen�pT Lic.# 6 /o y66
011AMPs
, r •Nk
'�1
Dam Comracmra� ATIbbi
ARCIIIIT?CTS DCCLARATIDK—
I understand my plans shall he used as public records.
-� E/SQ. FT.
g�
R,1
I ll�
201 - limit
201 -IOW AMPS FJ N
OVI?R IOW AMPS /,
SIGNS ELECTRICAL' ,
j
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby mason. (Se that 1 am exempt from the Cason s Co License Law for the my
Professions Code: Any city or county
followimanisermii
SPECIAL CIRCUIT/MISC.
TEMP. MI-TI?N OR POLO ]NST.
/ATE
which in isms in permit to cmmtram, nine improve, demolish, of repair any structure
which toeintmel, after, improve,
tfor such pemdue se
sChmrnt
pat)ator is
POWER DI?VICES
Licele
thatmisncingwithSction700) of iiisinf the Ce Business License Law
licensede,alsopit ..... a meision, La
Profession Coal
9 that he eximir with m]od the Division Sof the cd exemption
onhnt heir 1.5 by applim Bmf the basPermit subjects
thedexemption. Any ivilsonalryobum ofSec
Bmapermitmbj«lithe epplicanuoarivil penNryof
SWIMMING POOL ELECTRIC
VALUATION
�%.6.� N61
OUTLETS
,,of morethanSvemy hundred
oat mT.asown five ffiepmA dollory ($51111).
❑ w«ndthepmpcny,ormy<mpendeeswiffered saathe(Scr.compcnsmion,
`-'W
V—W
NEW RESIDENTIAL ELECfR _SQ. FT.
STORIES
'IYPG CONSTRUCTION
othe
will dolhewons and the structureCom ivnot rsolapplyto
and Profusion Code: The Committees
e License La do es an owner
law does not apply lf rt owner of
nd who
pmpemyloyms,l videdproves alsuchempmvements notints such wdr arffeofraugh his
employres,p ohm ed for sale. IL
neymonded
OCC. GROUP
RES. UNITS
'TOTAL:
how or i
however, the building or improvement is sold within oneyem of completion, the owner -
buildingimprovement mpleti
Moving P purpnuo
builder will have the burden nf n that he did not build prim rave for f
QTY. PLUMBING PERMIT FEE
❑ Lasownermf the property,emexetusivelycomraaingwithli«nsW rnnlractoom
FLOOD ZONE
ANN
contract the poden (Sec. 71144, Rosiness and Professions Craft 1'he ContractorxPERMIT
Licen se law d«a nOt apply m an aw mer of pmperry who bu i Ids «int proves thereon, end
ISSUANCE r
who contracts forsncM1 projects with acoutrectonor licensed prmuanuuthe Commoner
License Low.
ALTIiR- DNAIN&VPNT -ATER PA
WI )
PEE SUMMARY
❑ 1 um exempt under Sec. , B & P C for this mason
SACK ROW PROTECT. DEVICE
SANITARY YN
RECT:IPTp
Owner Dae
DRAINS -BOORROOF. AREACOND.
, . .
WORKMAN COMPENSATION DECLARATION
SCHOOL'fAX Y N
FIXTURES - PER TRAPRECEIPT'#
��
❑ ]hereby affirm that l have a«rtificum ofoonsenno 4biream, or a«rtificate of
Warkers Compemation Insurance or a cmified copy themof(Sec. JIM, Lab C.) which
PARK PCI: Y N
covers all employee's under this Permit.
Palmy p
GAS - V.A. SYSTEM-] INC. 4 OUTLETS
RECEIPT#
BUILDING UIV1510N FEES
Company
GAS - EA. SYSTEM -OVER 4 EA)
PLANCIBICK FRE
❑ Certified copy is hereby famish W.
GREASWINDUSIRL WASTE INTERCEPTOR
GRADING ITH
❑ Central copy is riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS IEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20dF7.
ENERGY FEE
This section need not he completed ifthe permit is for one hundred dollars(SIM)
or less.)
WATER HEATER W/VENT/F.LECIR
I certify hot in the Ferfrmance ofthe work forwhich thivpesmiI iaiO d,l shall
not employ any person inanymapnnneer so as t t , the Worked
PAID
WATER SYSTEM/IREATINO
nsatinn lny�Af IAya /SGOt�N SH/ -AL [Y G
PP nt --
Dow Receipt Is
OTICFiTOAPPLICANT: IL after making this Cenificam of Exemption, you should
NEW RESIDENTIAL PLMB, SQ. FT.
TOTAL:
ectorm subject to the Wmker'v Compenvmim provision allhe labor Cade, you must
nnhwitb comply with such provisions or this pend. shall ba domed revoked.
BUILDING FEF.
SEISMIC FEE 050
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction Tending agency for the perfomwnce of
Ne work for which this permit is issued (Set. 3W7, Civ. CJ
Lender's Name
. —�
ELECTRIC FEC
Imi Address
QTY.1 ME Cl JANICA 1, PER M IT FEE
PLUMBING FE .17. �.a
I certify that 1 have read this application and state that the above information is
legree mcomply wi@all city and county oNinances vtd ¢am laws relating to
PERMITISSUANCF.
MECHANICAL. FEEnett.
building caritur tim. unit hereby uniform represenmases of rhis city menter upon the
move -mentioned property for inspection Purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(W agree In save, indemnify and kap harmless the city of Cupenino against
liabili sJudgmet ,aandcxpenses which may immy way accrueogainstsaid City
AIR HANDLING UNIT (M) 10,009 CFM)
in oscqu ace afit rami0 this permit.
Z%ATAIRIIANDLINGUNII(OVER]ILMOCFM)
Si nature of A,plicam/Cmaracm, Date
EXHAUSTHOOD(W/DUC)
PAID
HEATING UNIT (TO IW,000 BTll)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building«curynt store or handle haurdon material
es defined by the Cmmim Municipal Cade, Chapter, 9.12,and the Health and Safety
HEATING UNIT (OVER 100.0(h) RTU)
TOT L:
Cale, Section255J2(e)?
❑
11Yet ❑ No
VENTILATION I7AN (SINGLE RESLD)
Will the applicuntnrfmurcbuildingaccupam useeyuipmemanleviceswM1ich emit
BOILER - COMP (3HP OR 100.000 BTI])
ISSUANCE DATE
hmurdom air contaminants u defined by the Bay Area Air Quality Management
District?
❑Yes ❑ No
BOILER - COMP(OVER 100,000 BTU) '
(-y Q
Ir
NI?W RESIpIiNTIAL MliCli. SQ. IT.
1 have scall the hwrdous muerials requitementa under Chapter 6.95 of the
Culifomin Health & Safety Cole, Sections 25505, 2553) and 25574. 1 understand that
if the building Jas .,it currently have a tenant, that it is my mspicum bility to notify the
occupant of the requirements which must 4 me] prior to issuance of a Certificate of
Occapancy.
��� 27 199 S
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE