S 1846 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPP:RTINO BUILDING-RLEC'I'RICAL PEtlTND. 1846
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECDANICAL \V
BUILDING 1s1RYJticr IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICA'I'[ON SUBMITTAL DATE
9r
OWN iIfS NAME: ,PHONE: CON'TRACTOR'S NAME: LIC NO:
NIC CONTROL
N
ARCIETECDENGINIFIL LIC NO: ADDRESS: ❑
COMPACT: PHGNC�O q BUILDING PERMFF INFO
I ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECf I'LIMliCll
U C F - 76? ❑ ❑ 1MP ❑
LICIiNSED CONTRACTOR'S DIiCI. RATION QTY. EL.EC'fRIC PERMIT FEE
I hereby affirm that I oto licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O0Z withticaon Section Divisi3 of the Puniness and Pmfessran,Code.and my liccae is RESIDENTIAL:
41 0 PERMITISSUANCE El KITCHEN REMODEL.
I- toruli lbrcennd eHcyx 79L�/, ❑SPDWh
�UU Lie Class �Y Lic.N .- APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRIiPIPE
F¢'W Date Contractor
F,SH ARCIITT17CF-S UECLARA'1'ION PANELS ❑MULTI-UNIT ❑STRUCfURAL
ZOVfz l understand my plans shall be used as public records MODIFICATION
OZ4-a UPT0300AMPS ❑INT'ERIOR ❑CHIMN17Y REPAIR
a4,l"JS Liccoed Prul'c,ounl 201-I100IAMPS IMPROVEMENT ❑SWIMMING POOLS
gs1F, OWNER-BUILDER DECLARATION OVER IIXIf1AMP5 El BATH REMODEUREPAIR C1 DEMOLITION
W, I hereby affirm that I i exempt front the Come mm's Limme Law for the
U following rowan.(Section]1131.5,Business and Professions Code:Any city at county SIGNS ELECTRICAL ❑OTHER
'- r
Rtt m which require,a permit to congtun,alter,improve,demolish,or repair any,enure LAJ
c� prior itsiss..auae,aBor,mar,the applicanlia such lxrmiuulileasigned smncment SPECIAL CIItCU1T/MISC, A/�/lIPeQ T/o
2�'r that he is licensed puraminto the previsions of the Contrasanti s license law(Chap,er9
W CpO fcmmmencingwith Seninn]IXXp of Divixinn 3ofthe Business and Professions Code)or 'TEMP.Int OR P01.13 INST. COMMERCIAL:
d y m LLXey that Ire is exempt thvcliom Hand the basis for the alleged exetnptina Any vielatian of ElNIiW BLDG/ADDITION El DEMOLITION
1 LL' Seen 70315 itx
by any applicant fora permdjecal the applicant m a civil penny of POWER DEVICES
y Intoes than the hundred dnllats(3500). ❑TENANT El FOOD SERVICE
Z Y IMPROVEMENT
d [)O SWIMMING IIDOIELECTRIC
❑OTHER' will dollar wn.N,vndthearrumisnm intended oraOiaJnrtole(See.]p44,Itsnes
0.3 and Pmfession.v Code:The Comneors License Law does nut apply to na owner of OUTLETS-37S -FIX'NRF,S
property who builds or improves thereon,and who does such work hin sclf or hourgin
his own employees,provided that such impmvetnems art no,intended or aliened for NEW RESIDENTIAL ELECfR SQ FT.
side hnwcvernhe huiWing arimpmvanem is salt within ane year of cnmpininn,the SQ.IT. (X)R ARBA SSQ.PC
owner-lander will have the harden of proving that he did not h ii1d at improve Iia pur-
pose aLwlel.
711,as owner of the prnpeny,not exclusively contracting with licensed rammCttab to TOTAL:
mother,,he pmjoet(See.71144,Business and Professions Codc:)'fhe Contractor's Li-
mmw Law does not apply to an oumer of properly who builds or improves amnion,and QTY, PLUMBING PERMIT FEE .
whocstmreets liasuch pinjects with.comenct (d licensed pm,uartohhc Cnmmcmr's
License Law, PERMIT ISSUANCE
❑ lain exempt under Ste. ,R&P C far this rcasan f
Owner Date AIBER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
❑Ihtvc vnd will mainein aCenifica¢nf Cmnscnuo hhefollowing
ts,rae ngdeclmmianv:
I hereby affirm under punchy Od duty one of
Code,fords, Worker's Corel the DRAINS-Fl.00R,R(R)R AREA.GOND.
notion,as pmvWcJ for by Srv'unn 370N3 of Ne lobar Code,for the Mrformance..Rhe STORIES 'I'YPP.CONSTRIICfION
work liar which this Errant is Ixwed. IgXTURES-1'ER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700nfthe Lobar Cale,for rformarmufthe work fiewhlch,hie tixis.-ued. GAS-PA.SYSTEM-1 INC.4 OUTLETS
pa penmt _ OCC GROUP APN
My Wnrker'sllnmpensa,ion lnvur rood Policy a c t tJ� Gp5-EA.SYS'I'P.M-CIVERJIEA)
Cartier: �f-/%ICY(FLF�caMiPPolicy FROM
CERTIhICAHi OF INN PRAM WORKERS'
COMPENSATION INSURANCE. ORIiA51%INUUSTRL WASTE IMfF.HCIifTOR BUILDING DIVISION BEES
(Thisetionnced not becomple¢J ifthpe
e nnilisfaroateradrtddollats13110) GREASHTRAP
ur lasxJ sePLANCfIBCK FEE
immifythat othe performance afthework ftnwhichmis permit i,issued,],hall SEWER-SANITARY-STORM EA.210 FT. ' OO
not employer,person nn
in any maer so cam tamorm object m the Wnrker4 Compere V ENERGY FEE
0 Z satin..Law.,mf California.Dee WATI7R BEATER WHEN IDELECTR FEE 0 Applicant GRADING F
y NOTICE TO APPLICANT.IL after making this Cenifiene mf Exemption,you should WATER SYSTEM/TREATING
abeanne xmose,mahc Worker's Compensminn provisions of the Labor Come.you air, I SOILS 17EE
W fanhwith comply with such provisions or this permit shall be deemed¢yoked. WATI2R SERVICE
Q
UO CONSI isaco[ON LENDINGngAGENCY NEW NIi91UliK1'PAL 1'LMB. SQ.IT. LAID Date
1hereby affimt .cirri issed(Seetinnlending agency for the performance of
the work for which 01s pcnnih is issued(Sas 310,Civ.CJ
0 F Least Name 'fAL:
UULender's Address TOTA
candy than 1 have read Ibis application ttnd rune thin the inose information is BUILDING PEIi
Val corem.l ugrccmmmply with all city and een,y ordinantts nnJ trot laws relining to QTY. MECHANICAL PERMIT FEE
handingennntumion,and hereby authoHi mpmxemativesofthiscirym etnerupon the SEISMIC FEE
ehnvu-memienrd proprny for in,mid at IN....ua,
(Wn
e)agree vt save,indemnify and keep hanler,the City of Culicninu again,, I'IiRMI'I'ISSUANCE ELECTRIC FEE Nein
liabilities,judgmems,costs and expenses which nay in any wayaccomagainst said City ALTER OR ADDTO MECH. r J
PLUMBING FliE
in asequence of the granting or this pennit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI III ALL NON-POINT AIR HANDLING UNIT LTO I0.000CFM)
SOURCE.RR ULATIONS. MECHANICAL FRE
Y; ' wl / 9/-g��r!�y AIRHANDLING UNIT(OVER IQ
g0CFM) CONSTRUCTION TA
Signature OLApplefur(Conarrincon
Dote FXHAl15T HOUD(W/DDCT) 11s
HAZARDOUS MATERIALS DISCLOSUREI HOUSING MI'I'IGATIIIN FEE
Will the applicant or future building occupant stare or handle humtle.,material HEATING UNf1'(T0 100.0Q9 BTU)
rax defined by the Cupeninm Municipal Code,Cbnp¢r 912,and que Health and gaily ��n
Cade.Section 25532m)? ABATING UNI'i'(OVER 100,000 CIII)Y UI- V JCGll1 nYU
❑Yes []No
VCNTIIA'IlON IAN(sING1.B IxIS11J1 PAID
Dane Receipt#
Will the applicantor future building occupant use equipment nrdevfxawhich BOILHR-COMPUHPOR IW,IX)0BITI)
emit hxearJoue air nmtaminmm�os def ncA by the Ray Arca Air Quality Managmnem TO /
Uisairh"
El y,' [3N. BOILER-COMP(OVER 100,0 0 BTU)
Ismereml the hazarx m
Jnuaerial.c rern
quirmnty under Chapter 6.95 ofthe Cali AIR CONDITIONER ISSUANCE DATE
Parma Health&Safety Code,Seelimns 25505,25533 and2553a.1 marrsmndthat ifthe NEW RESIDENTIAL MECH. SQ.IT. / �^ (�
building does not currently haven team,that itis my responsibility m nmifydhmsccupant
of Ne requirements which must he met prior to issuance oft Certificate of Occupancy. •�/1,y�
Uwnca'Har and AmugaN Urate TOTAL: ISSUER IIY: "✓� //� l\
OFFICE