S 2391 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO BUILDING.ELECTRICAL PERMTr NO.
BUILDING DIVISION APPIACATION/PERMIT rINGpRgGicr1DEArEHFIC S 2391
BUILDING 1'ROJI!CI'IDFN'I'L4'IC.ITIUN
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL
D�/AI
o ER. NA E: PHONE: C RACfOR'S A E' LIC NO:
NIC COME'HOLp
iialAle
ARCI if IECT/EIRA EBR: LIC NO: ADDRI 'S: ❑
^z
CONTACT PHONE: L BUILDING PERMIT INFO
❑ Conb'ullast FINS Paid by Applicant(Initial) 11I.DG 1?LECI' PLUMB MECII
�- El 'D Z�i' ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
CMZ l hereby affirm here l am here.w miner v evidnns of Ch:lmer 9 to, r,ndng JOB DESCRIPTION
wiih Section 7(XX0^rDivi_dm.3 cobs ntt,inc,.and Pocia,vic.,Coda,and my license, RESIDENTIAL
W OO PERMIT ISSUANCE
CSF intahmnecandettect �, I ❑S17DWL ❑KITCHEN REMODF1
aUU Dole. Class Lie.x 5 APPLIANCES-RESIDENTIAL. ❑AEDITION ❑PLUMBING RF.I'IPE
y a a Dala CnmrJCl Lkti
ABCHITGCI'S DECLABN'1 N 0MI11:1'I-UNIT ❑S'IRUC'TURAL
4+0'�
PANELS
C h Z 1 undine,.)my plans shall be used us public rtes.), MODIFICATION
C
OLS UP T02W AMPS
O ❑PAPP VE ❑CHIMNEY REPAIR
OL
Q�F'W4 Licensed Pm&ssinn:J 201-101MAMPS IMI'ROVF.MIiNT SWIMMING I'OOhS
OWNI?R BUILIIEB DECLARATION OVER 10(10AMPS ❑HATH RP.MODELIREPAIR [I DEMOLITION
C C d I hereby al film Thal I am excmPl rem the Contractors License Law for the
X3 L U following reason.(Section 7031.5,Business and Profession,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL Uri— which re4uims a permit to consumer,alter.Improve,demolish,or repair any,Imcmrt
4"�O< prior its issuance,also maims the applicant for such permit m file a signed statement SPECIAL Cl RCUI'I/MISC.
f,ra y'' that be i,Iiccusal Pumnanl In the provisions of the Contractor,Dean,Law(Chapter.)
(cmuncreng with Section70(X)of Driloon 3 of the Business and Wofic,iom Code)or TEM P.METER OR POLE INSE. ER
it.a ox that he is exempt therefrom and the bassis for dm alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X.nLL Section o 0031.5 by any applicant for a)emit,sroacts the applicata civil penallyof POWER DEVICES
W�.� nt ❑TICNANT F1 FOOD SERVICI?
nm moreman five hundred dallar.s(5500). IMPROVEMENT
SQp ❑ Las evncnnl the proryny.or my employees with wages a,their sole compemali^n. SWIMMINGNl(ILELECTRIC
4. will do the work.and the structure is not intended or offered mr,aloSee,70Jy Business ❑OTHER
L'3 en and professions Cele:The Contractors License Law doe,not apply to an owner of OUTLIifS-SWITCHES_FIXTURES
pmpery who builds or imprwes thereon.and who does such work hireclf m thr rgh
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENT Al,FLECTR SQ FT.
sale.BEhowever.the building or imVmvnneat is sold within one year ofcompletion,the SQ. '.FLOORARfA $/SQ.FE
ovsner-twilder rill have the burden of proving that he did not(wild or improve for par,
"'cof sale.).
F as owarrol Ile p.pru,: es,l:mively vocaruaing will Ihcnsed mn(ramnn m 'IDEAL
in :
: trust,heprujeo(Sec.7194,Business and Professions Coda:)The Contrnctnr's Li-
Lawtls not apply man owner ofproperry who builds or improves thereon.and QTY. PLUMBING P17RMIT FEE
wa «lm rontracts for smch projects with a cantremoq,)licensed pursuanun the Conmmenrs
I.i'crw Law. PERM jr,ISSUANCE
I um cxcngar der See ,li&i'Chu Nismuson
Owner Date AEfER-DRAIN&VENT-WATER(12A) VALUATION
WORKI?R'S COMPENSATION DECLARATION HACK 19AW PRO]ECT.DEVICE.
I hereby nllil'nt undar ou alty of perjury one of the following declaration.:
n Ili ..it will craintemitCaftforte.02misear lowiff-muntref Workers,C,,.,eDRAINS FLUOR.BUOY.AREA,CON D. STORIES TYPE CONSTHUCfI(
m p this Idf byS t 3700 of the fab, Cd f The pert eof the
h li .fie t J FIXTURFS PER'IAP R
sunt h' J vvill ine-law W k C p f I d by Section
31X1,1'm,labor Code,for the parmmeamu of the work for which this permit is issued. GAS-PA.SYSTEM-)INC.4 OUTUirS OCC.GR(IDP Ali
MY Worker/�'ml •rwm'nylevurvn artier and Policy,y +�+r�yL�
Carrier �R Policy No.: (j'�fy4-1 GAS-RA.SYSTIiM.OVER 4 EPA)
CR IFLCAI H OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASI%INDUS,BI.WAS1,IN I'F.RCEIvPOR
(Thiswarner,neednmbecompleted ifthepermit is forme hundred dollars(SIM) BUILDING DIVISION FEES
,r less.) GREASETRAP PLANET IECK FEE?
IcenifYIhm in the per mif eriae,f theworkfor whichthis):amenLaer,CtI'on-
nor cntploylalylwnnninan � to hcconm. belmthe Wnrkes'Rmn inn- SFWIiI<-SANITARY-STORM ICA-21111 PI'.
y tnunnc'sn.ts .atJ 1 ENERGY FEE
O Z smimn Laws,I California.Date WATER HEATER W/VENTIELECI'R
Z O Applicant GRADING PER
=
NUI ICE TO APPLICANT.It,after making the,Comficme of Excmmion,you should WATER SYSTF,M(T RHATING
a > Fenn¢ .hja,(In the Workers Compnuminn prevision,of the Labor Cade,yon ma.i SOILS PEE
forthwith comply with such provis..a,or his permit shall he dee ad revoked. WA'I'17R SERVICE
aQ
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMH. SQ.FL PAID
U O Ihertbyarfmuo,a mere is aconpnmmiun lending ugencY fettle perfiannmeoof Dine clpl#
Por work for which this parent h issued(Sea 30)7,Cr,.C.)
O U Lender's Name TOTAL'
} Lenders Address Q L
kkr.� 04I certify that I have read this application and state that he uMne information is BUILDING FFE
F-i h eared I a"re In omnply with all city and county ordinances and state laws mating to QTY. 1A NICAL PER T I E
UZ holding consltuction,and hereby adurrim representatives ofrhis city reenter tips the SEISMICF
abave-mentioned pepeny for inspection purposes.
(We)a,.m save,in larmify and keep hvrmle,the City of Capon,,against PERMIT IS F. O [LGCTRI
labdue,judgne,fl,costs laid aspens,,which may in any way,,eine ugaimsl said City
morn....arecnd The Semirigid this pernfit. AITFR OR TOMECH, PLUMBING Ty(
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLE UNIT(TO I0.(XpC
MECIIANI LEEK
_ AIR HANDLIN' ;R llllho CI'M)
CONS'I'HUCTIN 1AX
Sega re f)vIplifEirourbatreau at,
EXHAUST HOOD(W'/DUCT) HOUSWG MITIG,TION Flit
HAZARDE)US MATERIALS DISCLOSURE
Will theappllcanl nr Bottom Mildin,mati,amelm,m handle ba.ardou.....moat HEATING UNIT(10 IW,P)0 III ED
r dulincxl by the Cupconao MaldaipA Cede.Clopwr 1).12.and the Health a Sammy
Came.Section 255320)^. HEATING UNIT(OVER 100.0110[1TU)
C]Yes nNo
VENTILATION FAN[SINGLE BESIDE PAID
%III he a Beat, fawn bailie,6mnupucgmpmm� or devices which Dame RnnipN
BOILER-COMP(31111 OR I IHI,INXI B'TU
mit M1aaallou..air cnnwminam.m detincd by the Bay Area Air Quality Management BOILER
DinWcR T
]Yes No BOILER-COMP(OVER I00.OlN1 B'IV)
Ihave read the l:munfn a Ina¢rid,reto under Chaaur 6.95 of the Cali- AIR CONDI ISSUANCE DATE P
ymrenen I
fnmia Ilcmtb&Surety CWc.Snnionu 25505.255}3 and 25514.1 understand mm if the NEW RFSIUF.NTIA1.MECH.
SQ.FT /0—(
O^ (a`
building does not currently have a tenanuhat it is my resrymsibility m notify me occupant (P
of The requirement.which must be mer poor m issuance^f a Ceti of Creation,
Owner or authorized agent Date TOTAL:I
IISSUED BY.
OFFICE