S 0485 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF,RTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0485
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: lrl(J 1N�7 ^ _ SANr1'ARY NO. APPLICATION SUBMI'I-I'AL DATE
IOS�,2� AlofL�t, Wo _�_ uaxL�/��a_
OWNS 'S HAS F.,r , . t �` .�1 ,
PHONE �� 0 RTIC/'OR' NAIYIE:G1_,ij 6 �IC.1J 157 NIf. CONI'NOL N
/011 TECf/F GI ER: !�/ LI Y - AD R'NS: 6 ❑
out ,> \ AtA c16137 O' CODU � I-N 4a&ToSt-_
CONTACT: PHONE: HUI LDING PERMIT INFO
5•rFl, 1 ��`F�. �& A,
B ✓ /1 po OIQq ❑ Consultant Fees Paid 6y Applicant(Initial) EL PLUrgllt mECH
'�+ V CONTRACI'OR:S CGCLARA3TI-ONN (Y QTY ELECTRIC PERMIT FIiE
. I hereby affirm that 1 am licensed under pro�tiions of Chapter 9(commencing JOE DESCRIPTION
aZ with Section JIXX)orOn,...u.3oNw Basine1sun1Pr -a'ms Cem.mdmyIntan,e is RESIDENTIAL'
�� full force and OlImt /o�A rye PERMIT ISSUANCE
KUF p 7 � ❑S OWE, ❑KI'I'CHEN REMODEL
Q U U hiceosc B.ic.p
In6a Date Commctnr a' AI'I•LIANCF.S-RBSIUCNTIAI. ❑ADDITION El PLUMBING RE-PIPE
AR HIT[C'I';S DECLARATION [I MULTI-UNIT ❑STRIICTURAI.
ZOy2 tun rsmnJ my plan.awhall be used as public rmorJs PANIAS MODIFICATION
UlIT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
Fmk Licensed Profe,email 201.1000AMPS IMPROVEMENT (]SWIMMING POOLS
that I am c,cemOCyou the onus \ OVER 11%X)AMPS ❑BATH REMODEURF.PAIR ❑DEMOLITION
O e Q 1 heresy alarm that 1 am exempt from the Cessions c :Anye city
for the
'3 06 U following reason(Section JW L5,Business and Pmfessionn Code:Any city or wumy SIGNS ELECTRICAL [I OTHER
F which requires a Permit to construct,alter,improve,demolish,or repair any smmmm
poor it)its issuance,also inquires the applicant for such Permit o file h signed swtemut, SPECIAL CIRCUIT/MISC.
f } thin he is licensed pursuant o the pmvisions of the Contractors License Law(Chapter 0
W �� (commencing wins Section J(XxB of Di vision 3 of the Business and Professions Code)or '>,� THM R MB'TER OR POLE INST. COMMERCIAL:
d y M Y that he is exempt therefrom and the basis for the alleged esempnion.Any Aoletiun of ❑NEW BLDG/ADIJITION EIDE A10LITION
^m Section 7031.5 by any applicum far npcmtit subjuns the applicannna civil penalty of \'POWERDF.VICES ❑TENANT ❑FOODSERVICE
t more man five hundred dollars($50tp. - IMPROVEMENT
-F+q<
1,as owner of the
❑ pnupeny,or no,employees with wages ux their xnl¢eompvmsminn, SWIMMING POOL ELECTRIC \
C O will do the work,and the structure is not intended muffered R4r.sule(Sm.70M.Business ❑OTHE
u, �^ unit Professions Coale:Toe Contractors License law does not apply to an owner of OUI'LEtS-SWITCHES-FI%TURES
propcny who builds or improves thereon,and who does such work himwlf or through
his own moployem provided that such Improvenico s arc not intended or aflered for NI?W RESIDINTIAL 1J,ECTR SQ FT.
sale.ILw-even the building or improvement is sold within one yearnfmmpletian,the v` \ SQ,FC FLOOR AREA $ISQ FT.
uilder will have the burden of proving that he did not Wro
humid or improve far por-
poseer-bor WIIC.).
❑ I,os snviam of be p peo lusi ly trawfir,with licensed madicusam 'I OPAL:It A 'o
mounted the project(S L/m Business and Pmf. :Cade:)Th C n sur-L'- si\ - - n -4
censeLaw does not apply n owner fp pony h blit: p c thereon, d QTY.' PI,UMBING'IPERMIT FEE 494 too
who contracts for.such f 1 t. th a emvctm(s)Iimm,ed pursuant theC rut � - t �"+> 'm /� e
License law. PERMIT IS, ^ �t bl�•s�
❑I am esempt under Sec. ,B&P C fonh s reason o_ b \\ j u
ALTER-D - �g1llATE N
Owner Dam �r77
WORKER'S COMPENSATION DECLARATION BACK F'LO CM#ffGVC s \ tpletlOn iN
I hereby affirm under penalty of perjury one of the following decl.rations: MCI Mice rnmt
❑IM1avcund willtwinminuCenitimmof Canscnurself-insorcfor Worker's Qnnpem DRAINS- ' ):• C lass Ir, e.TO '1'VPE CONSTRUCTION
satins,as hick this
for ai Section 3JW of the IaMsr Code.lin the perhsrnance of the s G Rion),
w rk far which this permit is issued 11 OR P I
❑ I have and will maintain Workers Compensation Insurance,asrequired by Sed.
3700.1 the laMnh
nCoJe,far pn'o
en .nce
nof me work for whichh this permit is issued. OAS-EA. ' - CA •T- ---^"� OCC.CROUP AI'N
My W.. o bar In m carrier and Policy r.
Cartier: s Policy No.: GAS-EA. S"fE 1. F: ( 1
CEiRTIFICA ?OFE%EMPUON PROM WORKERS'
COMPENSATION INSURANCE GRHAS EffND S TW M Ew:I i
This section need not becomplemJ tithe permit is forone hundred dollars($100) ` BUILDING DI VIS ION PEES
nr less.) GREASE `,
PLANA EF,Ii
I cenify mal in the performance mf the work for which this permit is issued,l shall sA
not employ SEWER-SANITAR
p yany person in any manner as subject Workers'Cnmpen- Y-SI s s1iNERGY PF.F.
s..ime Laws of California.Dam
Z 'z' WATER I 'LIiCT -
7O NOTICEAppift-
;PA
NGpCP.
G uj become i TO APPLhe Work es Compensi ti this Cenifimre of Exemption.you should WATER SYSTEM?RFATIN.
h' become subject m the Workers Compensation pmvisions of the Lahr Code,you most IFC
Lail `mss forthwith comply with such provisions or this perma,hal R deemed revoked WATERS : \2,• CONSTRUCTION LENDINGAGENCY NCWRFSIDpJVTIALPLMB. SQ.FT. -
L7 !hereby xffinn mat mere is aconamdion lending agency Gsnhe perfnrmwce of `SrDate ReceipI4
the work lin which this permit is issued(Sec.3119J.Clv.C.1
Leader's Name ��
W TOTAL
Lemdern AJJmsv 'TOTAL: \�
y 1 certify that I have read this application and state that the above information is - BUILDING PEE �\
V) model.I agree hs comply with all city and county ordinances and state haws relating tr QTY. MECHANICAL PERMIT FELE
U mildmilemawnion,and herebyinthvirecrepirmeunvesafthls city mentor upon the 1 SEISMIC FEE \�\
alcove-mentioned property for inspection purposes. PERMIT ISSUANCE s`,
(WO)agree to save,Indemnify and keep harmless the City at Cowman madman ELECTRIC FEE \\
- liabilities,judgmems,casts and expenses which may inany way decrueagaima,.id City AI:1'F.R OR ADO TO MECH. \\
in conamparse of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI-I'(TO 10S. .00)CFM) MLCHANICAh FIili �\
SQQ�BhRRP� /2, X17
AIR HANDLING UNIT(OVER 10,11!10GI'Af) CONS1MECHRUCALFEH % ` \
Signature of ApplicuH ARD rr - Date EXHAUST HOOD(WIUULT) HOUSING'MITIGAI"ION FEB?
HAZARDOUS MATERIALS DISCLOSURE \
Will by the CmIcator futurebuildingCarlo,
Chaptnomor handle I koldr
and Salty HEATING UNIT(TO Itp.Opp HT11) •�
m delitieJ by the Cupeninn Municipal Cmde,Chap¢r 9.12,and the fleahh unit Safety
Code,Section 25532(x)? 1 III?ATINC UNIT(OVHlt 100,000 BTU) s s
C]Yes ❑No VHWILATION FAN(SINGLE RESIDE PAID 1
N
Will the applicant itnntfuture building occupant use equipment(it Receipt
r devices which \\
emit hazardous air eonmmins as refined by me Bvy Area Air Quality Mnnugemvt eHOILL'R-cUMP(3HI'OR 100,1X11)BTU) \
cosit
TOTAL:
❑Yes F1 No BOILER-COMP(OVIiR IW.gl1)BTU)
I have read the himadous materials hapdomenls under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
form.Health&Safety Cale,Sections 25505,25533 and 255 W.I unJcrsmmd that Tom NEW RESIDENTIAL MECH. SQ.FT,
building Jaw not currently have a tenant,that it is my responsibility to notify alc occapam
of the requirements which must he met prior to issuance of a Cenificale of Occupancy.
s Owamor authorad.,car Date TOTAL: ISSUED BY:
OFRCE