S 0609 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPID RTINO BUILDING-ELECI'RICA I. I'IiRMI I'No,
BUILDING DIVISION APPLICATION/PERMIT TNC.�MRCHANIG:
RUILDING S 0609
Nf:PfoROJECT'IDENI'It'IL'A'TION
BUILDING ADDRESS: SANITARY NO, AI'1'hIGIION SUBMITTAL DATE
OWNERS NAME: wt PHONE: CONTRACTORS NAME: LIC NO,
Elf 0
NIC CDNTROL9
IZW —a
.ARCH]"rECTIIiNGI EER: LIC NO: ADDRESS: ❑
1345 S 418+c sir, ooli✓-41,110f G.
CONTACT: PHONE. BUILDING PGRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT 11PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION TY. ELEcrRIC PERMIT' FEE
E ben'hy tmmmm Ihm I ant licensed Imdcr,owilio.s of Chapter )(<tumaen.mg Q JOB DESCRIPTION
F.2 in lot]<Clus. y-T iness nnJ Pmfcx.inns Gulu,anJ niy ll<cnnc it ' �O El DWI1NTIAL:
aZ 'th Sorion]1k)),,I In,kiun 3ofthe Nuc PBRMI'1'ISSUANCIi
og i' tame Clcan<I Ice , 6e<Ty Zwo ig ❑SPDWI, ❑KI'TCIiIiNµL'MODF7,
6_u Lie'� APPLIANCES-RESIDENI'IAh ❑ADDITION ❑I'LUMIHNG RF,-PIPE,
Contractor
vi4a, ❑MUI.TI-UNIT ❑STRUCTURAL
15o ARCHITECTS DECLARATION PANELS
m',L I undmtand my,lues shall he used as public mcnrdv MODIFICATIONOZZNG UPT02MAMPS ❑IM1TERIOR ❑CHIMNEY REPAIR
t-h Fp] Licensed Prnfasinnal IDI-I"AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODFLIREPA1R 0DEMOLITION
C lY Q I hereby affirm that I am exempt from Continuous Contcmrn License Law for the
X 3 EL F following reason.(Section 7031.5.Basimexs and Professions Cooke:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to conxtmed.i llc.improve,demolish or amid,any stralum
F��.al peer to its issuance.also myuima the applicant forsuch permit m file.signed xtuement SPECIAL CIRCUHUMISC. ry
any that he is licenxed pursuant m the provisions of the Contmnors License law(Chapter9 OMM R "TAI'
1=,1 MM (commencing with Section 7")of Division 3 of the Business and Professions Gxfel or TEMP.METER OR POLE INS
W%o y the he is exempt thcrtfrom and the basis for the alleged exemption.Any°Wolin.of NEW BLDG/ADDITI + ❑DEMOLI'110N
a.
Section 7031.5 by any applicant for a perrusubjects the applicant to a civil penalty of POWER DEVICES NTENANT ❑I'DOD SERVICE
no,mem than live hvndrcd dollars($51)0). IMPROVEMENT
Sp ❑ L as owner of the property,or my employees with wages as their sale conmpen.salioa, SWIMMING POOL ELECTRIC
will Jothe work,oadthextru ame,,nalmendednroffcrcdl invale]Sec.](Flq,Hu.ainca ❑OTH13R
.tole
and I '.. Code Il C t t L L J : ,ply t ser of OUTLETS SWIICf{HS I'IX'1'11RE5
Ipre,crly who 6 "IE. p :thereon, d whittles: h vork hunwil through
1's toso cimpleyces, provididl that I h improvements are RA latended or"Ibed for N12W RESIDENTIAL I I.LCI'R SQ Irl'.
scale lLh u,0clu'IJ ynia,mvcment \xJdwltin+ ywrtlt ntplU'an tM1e SU PI'. //��OfL(it�l]/rk� bISV.I'I'.
cr-hu ider will have the burden nfm
, ing thal he did not huJJ or inmmvc lir,ury r 11��
pwe W NIaE. TOTAL:ee3,�,
I,enc owner of the properY,ala exclusively corouslong with licensed aoromwer,Ra YEP 18 �J'�
onlNet the,rojeor(S .7114.4,Baxlne�[and Prnfexxamt Couc:l The Corar- QC /�[�1
nr'x I.t-
nmlawdexnolapplymanownerofprogenywhobuild.or improves thereon,wd QTY. PLUMBING PERMIT FEE
who commas hasuch projectswall acontr.ctor(s)licensed punuunl or the Cnnhationr's /�
License law. PERMIT ISSUANCE CITY I I Ur I��JrLH �NQ
O 1 am exempt under Sec. .B&P C for this.-.a
- ALTER-DRAIN&VGNT-WATER(IiA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
Yaffinn under penalty of perjury one of the folkawing Jedarutinns:'
[] ]have an 'DnaimainxCenilicate of Conxnl In self-insure far Worker'.Camper §GRHAS
FLOOR.µ00P,AREA,CON4 STORIES TYPIi CONSTRUCTIO)
ration,a provide ,Ter by Section J]ql of the Labor Code,for the performance of the
work for which this lemait is issued
-PER TRAP
I have and will inuinmin Wnrker'x Com,enxatinn Insurance,as required by Sermon
37k)(if the Labor Code,for punurmuncc at work for which this fermit'ry issued. 1-I INC AOU'I'hE'TS (ICC,GROUP AI'N
My Worker'C/am,,�enyy�..hu,mance e d Palley n lwr nN:
Carrior. }a�"'tf+ot:--✓�s�`"'is,Na: $� OZ,102Y0% S S h :RJ EPA)
C 4R IFICAl'13 OF EXEMPTION FROM WORKERS L AS'117 IN'IlEdOCEIJOEt
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thiowcdnn need nm he complcteddthe,e.it is farad hundred dahmn($HXB GREASETRAI
I'LANCIIIiCK ITili
nr less.)
Io,any that inlb.parfnrmanccofrbc workuse hhjhthx the W is ke,o' ..open- SEWER-SANITARY-STORM HA.2fN11T.
nm employ any person in xnY manner so ax m become subject m the Wnrkcrd Cnmpcn- ENIiµGY FEE;
Q Z saliou laws til Culih+ria.Date WATER HEATER W/VEIST/CLECTR GRADING ITE:
Z p Appiwcml
NOTICE TO APPLICANT:IL afmr making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
bcmme subject sea the Worker a Compendium pmvisians of the LaMa Cade,you run
Emhsith comply with such provisions or this permil zhall he deemed mocked. WATER SERVICE
yPAID
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. DoleReeciptM
V Q I hereby afina than there is a construction[ending agency for the performance of
CS. the work for which his vocit is issued(Sec.3097,Civ.C.) 'TOPAZ.:
C) F" larders Name TOTAL:
r Lender's Address BUILDING FEE
y I certify that I have tend this application and nate that the above information is
F rn cancel.I agree to comply with all city and county ordinances andante Taws mirdagm QTY. MECHANICAL PERMIT FEE SEISMIC RB
Z') Z bailAingpmartetion,and hereby vulhorive representatives ollhixcitym cntcrupm the
ahovo-muntloned pmpeny liar inspection p r,,)wx. PERMIT ISSUANCE ELECTRIC]71311 3
(We)agree Io save,Indcnmify and keep m,ndO,,c the cty of Capenlno n,ana,
h.hilaiex,jmlglacoll co ax send cxpcmcs wh�ay iu any way 1...umagain.axnid City ALTER OR ADD TO MECH. PLUMBING FEE
in sequeaccI cgrnlin into,
man
APPI"CA I' )ERSTANDS \' L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(XXICFM) MECHANICN,ITHE
SOURC' h .A'1'IONti
AIR HANDLING UNI'P(OVER Ip,IX10C1'M) CONSTRUC'DONTAX
Si arrcofAMfic C sur ])are EXHAUST HOOD(W/DUCT) HOUSING MITIGATION THE
IiA' NOUS MATERIALS DISCLOSURE.
Will the applies or future banding occupant store or handle hcidd..material HEATING UNIT(TO 100,00 H'1'UE
as defined by the Cu no Municipal Code.Chapter 9.12,ani the Health and Safely
Code.Section 25532(x)" HEATING UNIT(OVER 100,001 BTU)
❑Yes ❑NoVENTILATION FAN(SINGLE RESIDE PAID Dae good Ja
1,11 Will the applicant or future building occupant use equipment or devices which BOILER-COMP QHPOR Bidding)13 1 U)
t hamrdous air contaminants as defined by the Bay Arca Air Quality Management 'TOTAL:
Clone1Y BOILER-COMP(OVER 100.0IOµTUE
❑Yes El No
I have mail the hwarJeus moteriol.a rryuiremcnls under Cham"695 ill Cali- AIR CONDITIONER ISSUANCE DATE
temin Health&Saley Axle.See no 25505.25593 and 255311 m der,d I thw it he NEW RES]DEI AL MECH. SQ.FI'.
haHmngdrxanal immudy huveotenem,that nisnmyms,x,n.ibiLrym....lily the axeu,anl / 97
0 the¢gaimmenta whoh train w met prim to issuance aro n Cenilicntc til Occupancy.
Owner or anduai.i agent Dale 'I'O'TAI.: ISSUED Ely:
OFFICE