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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO - Bun.DING-ELECTRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING. MECHANICAL
BUILDING PhlojEC1' Inivirt IFICA'rION
PEtil NO
V 1764
BUILUINGAODRESS:
SANITARY NO.
APPLICA'TIONSUBMITTALDATE
OS NAMI'HYNE:
C RAMO 'S AMC:
NIC
CONTROL#
❑
�Q[a
CI[IT 'ECT/ENGINEER:I toll
I
UIS. 'lL4aL.C•�_
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CONTACT
list t �; /�•-� 8 _ OQO
❑ Consultant Fees Paid by Applicant (Initial)31.DG
BUILDING PERMIT INFO
I IiC P`* IMF
LICENSED CONTRACTOR'S DECLARATION
I usually affirm that I um lwrawd under provisions of Chapter 9lco rdecir ns
QTY. ELECTRIC PERMIT FEY:
JOB DESCRIPTION
PERMIT ISSUANCE
wish SccG..I700),fDivisinn31dthl Business and Professions Code.and illy license is
in full have and effect
RESIDENTIAL:
❑ DWI. ❑KD'CHENREMODEL
APPLIANCES -RESIDENTIAL
Livenw:Claw Liconoacon.4
Ute it C
"h—
HUITION ❑PhUMBING RE -PIPE
❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMINGPOOLS
ARCHITECTS DECLARAT ION❑MULTI-UNIT
I ..demand my plum shall be mosi m public reccul,
PANEfS /
UPT020fAMFS r
Lree.ad 11 l'csxional
201-100AMPS
OWNER -BUILDER DECLARATIONOVER
I hereby affirm that 1 am exempt from the Contractors License I.. for the
following moron. (Section 7031.5, nosiness and Profession. Code: Any city or county
❑ BATH REMODEL/RIiPAIR ❑DEMOLITION
❑OTHER
IRRAMPS
'
SIGNS ELECTRICAL
which requires a hermit a) construct, alter, improve, demolish, or repair any structure
SPECIALCIRCUI'r/MISC.
prirtas i ..... ce.alm requires the rill far such permle, file axigned statement
that be is licensed pursuant,. the provisions of Ibe Comment's License law (Chapter 9
(commencing with Section ]100)of DlvLs.n3of the Business and l`wPessiuns Crsle)or
that he is exempt tbcrermm and the basis Ilm the apegcd cxemryfon. Any violation of
TEMP. METEROR I'OLT: INST
COMMERCIAL:
❑ NEW RLDGIADDITION ❑ DEMOLITION
Section 7031,5 by any applicant for a permit subteen the applicant to a civil penalty of
POWER DEVICES
❑TENANT ❑FOOD SERVICE
not more than five hundred dollars ($5(X11.
❑ Les.wner .and prnpeny,ar my. maycedwim amilfusale (See compensation,
will do the siod., and a 'Me Cim Isnot s Luded t offered s act apply ]814, owner of
and Professions Code 'Me Comaxmr'x License tow Jres not apply m an owner of
IMPR(IVIiMENT
❑OTHER
SWIMMING 1'OOL POOLE
OI/TLIffN- SWITCIILS- FI%TIIRliS
NI?W RESIDENTIAL CLIeCfR 5Q PI'.
prnpeny who builds or improves thereon, and who does such work himself or through
his own cmploycw, provided that such intpmvcmn is are oat lmende:l .r offered for
within oneyearufapmpaeon,the
sale,If,idevepll
SQ, FT.
$ISQ. FT.
offameeis,wW
owner -builder will have the harden of proving,hm he did oat hill nr improve fur pur-
have burden
•p•[�•���''���J
pme n
at,
(,A��
❑ 1, as owner of the prnpeny, am wobsivdy contracting with licensed con.ucmcs to
s ne
\A
ut Csdca The Cantmemrs Li
metro the es ..In ISec. ]1144, Business and Pmfesi ho build,
does plyman
,
QTY. PLUMBING PERMIT PEE
I'�
�/
Coma.and
ithusaummeywcemoddaorimprollbesual
who cantmes fur such pcoju�ts with a mmmcmHO licensed pu,smm mthe Conweor's
who conk
+ f•,�
q
PERMIT ISSUANCE
Liccnde L.W.
❑ I am estop, under, Sec .B&P C fonhis «eron
SS6S—
ALTER - DRAIN h VENT'- WATER (EAI
Owner Data
VALUATION
WORKER'S COM PENSATION DECLARATIDN
BACK IT(1W TBG 'CT. DEVICE
1 heathy alfsao under penehy of perjury ane o s'heelf insure ng deschersWarker ions:
❑ Ihuvc aced will maimaina Cenilicnm of Conscnu. wlf-insure for Worker's Compcn-
xa,ion, as provided for by Section 3900 of the Lubar Code, for The performance of the
�`y k fur which this .it is issued.
qIJ have and will n,uinmin Worker's Compnsatinn Insunnce, m requiud by Section
]011 of the lathnr Cuda, Lm me lwdarmanea of the work lirt which this per�lmit is i�ss(ued
'W
Wnr�yni'rgts' n Ins. nc. canter and taller y,'�aW:01907af'
Currier: TWV P.Iicy Na:9—•�U
DRAINS -FLOOR,'. AREA. COND.
S'rol I,S
D
'TYPE CONS'CRU6TION
APN
PIXTUItF.S-1'BR TRA
GAS-I?A. SYS'CLM-1 INC.J i15
GAS - IIA. SYSTEM OVER J(EA)
GREASEIINDUSTItLWASTH INI'ERrmq
CIiRI'IFICAIL OF F,XEMPTION FROM WORKF.kS'
COMPENSATION INSURANCE
flu II.UI NGDI I
FEES
(Thosectlon need norbet:mpleled ifelefam,it isfonmehandreddollark($100)
or less)
Ioyaythetame perlimmfuv,.Ohework for which hla, 1. permitsissued. ' Co shall
not employ any pcwm in any coanncr e. nn m banns. xuh,icet to 'he Work"' Cncnpcm
GREASE TRAP
/
I'LANCIICC K I4iE i Vd
s
oa-
SEWER - SANITARY -S'IORM GA2W IT.
ENERGY FEB /
WATER BEATER WNIiN'DEI.EC'TR
sation Laws of California, Date
Applicant
GRADING ITF, '
NOTICE TO APPLICANTIf, allennaking this Cenilicae of F.xemp,im,, you sb.md
become subject m the Workers Compensation pmvinars of the ],.bar Cods, yon maty
WATER SYSTEM/rREAUNG
SOU -S F17E
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I heathy allimnhanhere is r,mmction lendin ilgeocy for the performance of
the work far which this permit is issued (Sea, 3097, Civ. CJ
WA'I'LR SERVICE
/
D 6 x57
Date ReceiplM � r
RESIDENTIAL PLMB. SQ. PT. 7 _
''��/y LJ
/%^ rV��` /(Jin/
X
Lenders Name
lenders Address
BUII. ING FEE
I certify thin I have mail this application and state thanbe above iofmmmion is
correct. I agree to comply with all city and county oninances and dile laws mixing to
Wilting c.ns.ueion.and hereby iuthorimaeprew•eeivesol this city to enter upon the
QTY. MECHANICAL PER MIT FFE
SEISMIC FEE �e -
PERMIT ISSUANCEt
ELECTRIC FEE s'6p�
move meramand prnpeny for inspection purpnces.
keep hapers the City.f Cupcnina against
(We)agree msave, indemnify and m
Iillbiilies,judgments, costs and expenses which may in any way accrve against said City
' nnsequenceof the granting nf,6is permit. k.
APPLICANT UNDERSTANDS AND WILT `.Y WI'I If At -I, NON -POINT'
SOURCE REOHLATI(]N' n�/
4-< -95--
A1,1ER OR ADD TO MCCiI._
PER -�
AIR HANDLING ON] 'T 0010010 CFM)
MGCIIANICAL ITE „OW
AIR HANDLING UNIT (OVER IB,IXOCFM)
CONS'I'RUCIIONT'A%
isr,nmurc of Applimal/Con
I tAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD t W/DUCO
HOUSING MITIGATION FEE
Wlllthea..iccm, nr fmnm holding oecnpamdmmor handle hurnmloac mmcrial
as defined by the Cupcuina Municipal Cad, Chapter 9.12, and the Heald, and Safety
Cale, Seeion 25532(uyl y,''
❑Yes r4N.
Will thea applicant or from hnildin • occu n use equipment or devices which
PP 6 win 4aiP
emit hmarJom air cranium nan,s as JcfineA by the Ray Area Air Quality Mana¢m
BEAT ING ON[ f(T(1100,000 BTU)
HEATING UNIT' (OVER 1(0,01X1 B'I'U)
PAID
Data keceipt p l9
V HIS I'ILATI ON I' AN ISI NO IX RESI D)
BOILER- COMP(3HP OR 100,000 BT U)gen
TOI'AI :
BOILER-COMI'(OWIUIXI,gXI BTU)
Dlshicfl
El Yes \Na
AIR CONDITIONER
I have paid he hmnoud materials rtquitemems under Chapter 6.95 of the Cali
reN
fomia Health as Salary Cale, Sections 25505,25537 and 25534. 1 uadersmnd that If the
huildingdor,ir nmmridyhaveatemm,that" ,y ne, mWibilitym.otifytbew,upam
ISSUANCE DAT:
NEW RESIDENTIAL MECfI. SQ. IT. �'� G
oftherequlmyI. M crmin.' acrol"Carficaus TOt unc.
ISSUED BY:
mar awhonecA age am
OFFICE