S 3905 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-RLRLTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3905
BUILDING PROJECT IDENTIFICATION
BUIIDINGADDRPSS: - SANITARY NO. APPLICATION SUBMITTAL DATE
1 K E D 9,VE I*
OWNER'S NAME
--:(I ^` n^ /PHONE; / �/.� CONTRACTOR'S NAME LIC N'O'. ^
TfVV J Ar 40 6 1W NIC CO. LM
ARCH1'IECUENGINEER, LIC NO ADDR ISS: 11
CONTACT: PHONE HUILDING PERMIT INFO
❑ Consultant I m Paid by Applicant(Initial) HU)G BLECIPLUMB MECH
❑ ❑ LJ ❑
LICIiNSI[D CIINTRACTOR:S DECLARATION t
1 Epr affirm that 1 em licen.ed uemder roomrm of Clump 9(commwcin QT ELECTRIC PERMIT FF.E
r• - JOB DESCRIPTION
{O�Z nim sK�nxn TlMnl mr Divi.iun3 rf0e Hneiee,a.,oral PrRe4irn,c«1e.uw my liana ma, RFCIDENTIAL
FOO ' full force and dfwl PERMIT ISSUANCE
W— e" ElSFDwL E]KITCHEN REMODEL<U�j L' Class Lic.M
eF�a TAR,a Cmtruera APPLIANCES-RISIDENTIAL ❑ADDITION El PLUMBING REPIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT QSTRUCURAL
S O�2 Z I uralk ed my,one salt be used oa public mceods MODIFICATION
Oz.—a UFTO200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
L,ecneeal pi.lasiaal 20140I10AMPS IMPROVEMENT
❑SWIMMING POOLS
�y W<
OWNER-BUILDER exempt
ER m the ION OVER I00)AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
i O eeLL Cy I hereby;them Nat 1 am aroio from the Comparator n, a Littera Lew for the
>(3 d U following minas,.fSm'mn 7031.5.Hnsitev,oM Pndceiom Citric:Any city or cmmnlY SIGNS ELECIRICAI. 0 OTHER
lliilt IL wlli[h n�YlRs•ISrrNI to[fIM1S W[L e11R,impNK,demnliiL,m rf{aLr apY{1N[IUR f7
prioxmiois,Onca.r1,00,,i RS SPECIALCIRCINUMISC.
f 1yT cm
ter, li[rnaM pussuenm was rovisira,ufthe Cnnnrclni;liana law(CTaP1erY
I�i1=00 nnsncing withSmiun91M10)m DivisinnJnftK Huaima.oral Pmfwiom Crdc)m TEMP.AIFTER OR TOIL(NST. COMMERCIAL
n rL e 5 tar a is exempt ileRfrom and the hard, a
is Eo Js ellepcerep. .Any vicls ims of ElNEW BLDGIADDITION C1 DEMOLITION
y Secllra TIH L.'by any applicant for a Permit subjcers he a gA"nl to a aril penalty of PON'PR DEVICE$ (]TENANT' [I FOOD SERVICE
nor mom than fi,hunthW duller;(S.HNp.
1-�< C 1,as uwmer cat the pnpeny,or my eeoPkrcai with;;'ages to their sok conspemisomn, SWIMMING POOL ELECTRIC IMPROVEMENT
0 will dothe work,unl the arocmmk wx i nlendedor"Mesal for sale(Sec.TIl14.Busuees El OTHER
W 3 erd Pmfwaimw Code:,IM Conaecter'e License law does nor apply to an owner of OUTLETS-SWITCHES-FlXTURP
pe,o ty wlw Ivilda or tmrrvw dertorm,and wits,dors such wort,himself or thmugh,
his own employees,pmvided thin inch imprmmmenu ere not intended or effered for NEW RESIDENTIAL F.LECTR SQ
-1c.If,M,the building rr impmvemnt is told withinme Y.,ifcompkaice-Joe SQ,PL FLOOR AREA SISQ.ET.
ter-huildcr will have the burden of roving Nal he did not build no improve fm Pur-
L ue ) ' '
TOTAL:of trpeny,oto clmvdy unrvcnmg wm Iisnmrvcwn m
enoacrai chic
(Sc.](ILL.Hi einas and Prfessions Code:)Tbe Contrecturs U.
me law dote Ml apply to an owner of property who build.mor,ot BeRmt.and QTY. PLUMBING PERMIT FEE fJl LI
wlu conaeco for such PRjeers with a nmeaco ds)licenced pmswnt to ha Contractor',
Liccme Low. rr,�]
PERMIT ISSUANCE, -� JUN 7
❑ tum arra dm See .B&PC fee Rea�n
ALTER-DRAIN&VENT-WATER(DO A O
Oloon
wrx Dom
SfPSL6MPF.NSAIION DECLARATION BACK ITOW PROTECT DEVICE
m an
penally of perjury ore of Jmc following alma Wntims: Y
I ave end will maintain eCmiO[ote of Conan mself-inmrc sur WokeEe Commit- DRAINS-FLOOR.ROOK AREA.GOND. N CONSTRUCTION
radon,v provideal for by Schon 37M of safe,labor Code,for Ne pedrept of the
work for.lord Nis nmol ie i.arN. FIX'I'ORES-PER TRAP
EJ 1 have oral will nuiwio Wonder,Cumpenwion 1muTaace,u required by Section
JTI(Inflhe LaMar Cnle.for the pe,Gwmuoreof the work for which thio Permit k eetied. GAS-P.A.SYSTEM-I INC.A OUTLETS OCC.GROUP APN
My Worker's Compemsetion Inuuaree crrr:er end Policy number are.
Carrier. Policy No.: GAS-EA.SYSTEM-OVER a GDV, v 19
CERTIFICATE OF EXEMPTION FROM WORKERS' if r
COMPENSAI ION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
Curie;emus,need nor he mmplciN if Ne permit Ie for one,hundred dollars(SIM, BUILDING DIVISION FEES
or ld) GRE SE TRAP
I`LANCIIECK FEE
I certify math Ile wyreaumrul the oosk tievahich pect to mammitis i;,t¢dcrpt ll SEWER-SANITARY-STORM E1.200 FT
z �iramphr,any Low,.Celilim i.Dao: ceuto become wbjecl to the worker:Cnmmcn- ENERGY FEB
z2 Applicant WATER HEATER N'NT?NT/IJ,ECTR GRADING FEE
N NOTICE 10 APPLICANT:B,after making fos Ccnibcare of Ememxion,pu should WATER SYSTEMOREATING
abecome wbjecl in the W A'c4 Coni eari""Ixrvisior,rnhe labor Cale.yon mast SOILS FEE
CQ forthwith comply with inch p oi%iwn or Nis permit shall be deemed ovum. WATER SERVICE -
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII, SQ.14. PAID
U p I herthy a0inn tan Kele is a caummcdon lending age,for the prr(omume of Dene xy=v
P IM wad for which this permit is i.emm(.tic,.3091,Civ.C)
U handsets Name TOTAL:
WLender's Adthus AL
D. 1 ccnify tho 1 have rtah thio vpplicemion and case dor the above iofomasim is • BUILDING FEE
rn Lw I,1 agree o comply with all city ad coamy rrdinsti oral sense laws rtlaung to QTY. MECHANICAL PERMIT FEE
U z buildingcen,melion,and herthy amherise reprtxntuivw Mthi;,itymenlCe upon the SEISMIC FEE
pMwomendemed Pr.,ey for no,celirn pmupma.
(We)agree 1.ave,inclemmfy end keep harmli the City of Cupeniod eppirem PERMIT ISSUANCE ELECTRIC FEE
iabilld 'tdgmcnet riammdexperucs whichrnyinarrywryxcrueegiimmsaid CRR ALTP.R OR ADD TO MECH.
n. q ctdsM gs" 7r' c,fthis rmtit PLUMBING FEE
APPIJ cON ERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNH'(TO 10,000 CSIP MECHANICAL
SOUR G 8, 0
1 Pi
AIR HANDLING UNII'(OVER 10.000CFM) CONSTRUCIIONT
Sig re
RIN)US Iter MATERIALS DISCLOSU Doe HXHAUSTHOODWA)LICI') HOUSING MITIGATION FES
f Vs%A
Sillmbeapplicant or Tamm,Mdlding rceupon.taxa ur.sale Lm:Wournwcrial HEATING UNIT(In I OL M)BTU)
ax defml by dare CoPenirw Municipal Cede.Carer 9.13,em IM Health real Site,
Cmc,Solon 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑yer
VENTILATION FAN(SINGLE RESID) PAID
�e Dole Rwcir x
Will the r,licanr or Roue building..,.pair use egolmmett or device,which BOILER-COMP CHPOR
I W,ODU BTU)
mil hacvdeu.air canandnana w Jefmm by Na Bay Arta Air Quality Management
TOTAL:
DielrinP �/ BOILhJt-COF1P(OVER IpI,(100BN)
❑Yes R1.51.
haw nal Joe hmadous reercdds mer 695 of lbs Cali- AIR CONDITIONER ISSUANCE DATE
rtquin mends uNcr Ca /`/~/
fomis h&Sdfety Cak.Secximn 25X15.255JJ ural 25534.1 ummaW not if Ne NEW RESIDENTIAL MECH. SQ.FT.
buildi d ,rwl Cuinndyhave x tenLlhalline my ex,rNeibildy to n4d,,Jr.occupet /J �7
of Jr u epai ;hie outs mes prior to ire .f v of `)' /J
O rinC Doc TOTAL LSSUEDBY:
OFFICE