S 0458 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUDAING-ELECTRICAL I'ERMI'I'NO_
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 0458
BUILDING PROJECT IDEN'TIF'ICATION V
BUILDING ADDRESS: SANHARYNO. APPLICATION SUBMITTAI.DATE
10 66 G%)a t Sh 1
OWNER'_ N1,,( � "tHONL_��� CONT@A()hCTOR —5 51pM5 UO L11.3E)O
N C LV1nl L N/C CO TROL
ARCHITECT/ENGINEER: LIC NO: ADDRESS: I U� � V I C ` t fI (Z ❑
CONTACT: PHONE: !V/_ V •Y 1•'b ;INTERIOR
UILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) F� PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEENa I am liecined under provisions of Chapter 9(commencing JOB DESCRIPTION
ZwithSection OIXg1 of Division 3ofte 9usinesoml Professions Cule.and my license is AL:OO PERMIT ISSUANCE
� Fin fall(.me arta effect '-� O ❑KITCHEN REMODEL
aUU Lair Cha`�Lic.a Tau 1 i APPLIANCES-RESIDENTIAL ❑PLUMBING RE-PIPE
anQd Date Li 'CS DEmrANCIIITF.CTS OF,CLARATION T ❑STRUCTURAL
ZOyZ I understand my plonszhall be ued.,Public records PANELS MODIFICATION'UPT0200AMP5OZ—s ❑SWI.MMINGPOOL
NEY REPAIR
LL Licensed Pmfessinnal 201-I000AMPS IMPROVEMENT SWIMMING POOLS
OWNERHUIhDIiR DIiCIARATION
cL 0W< OVER 1000 AMPS ❑BATH RIiMO F ❑ -MOLT
IY C Q 1 hereby affirm that I oro exempt from the Co tore,C s License law for the X 6 V fallowing requires
mance.Gretton Nld I.S. t,alms and eVe.demolish,
Cute:Any city ascountyicam, SIGNS ELECTRICAL ❑QTf{IiR `�-
1+13 LL y which its issuance,
n eealso re construct,aper,i applicant for su demtion t fi repair nny tamusere
ththeisl cense ponce rtyuires lhe roviotfor mchpennilmfiln,signed itsmtemcnt SPECIAL CINCUIT/h11SC.
net
that he is licensed Pursuum it) provisiom of the Cnmranols License Law(Chapterl
W aC (commencing with Section7000)al Division)nldt9 liminuaand Professions Cade)Or TEMP.METER OR POLE INST. COMMERCIAL:
c.d e ae tbar he is exempt parefmm and he basis for me alleged cxemp(ion Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y
Section 70315 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
rn more than five hundred dollars($SqO. ❑THNAN'I' FOOD SERVICE
IMPROVEMHN'I'
StC ❑ I,as Owner Of the propcny,or my anploycas with wages ax their mate mntpcnsatio9, SWIMMING POOL F EL
d will du the work.and the shocsum is nal intended or offered Rrsale[Se,7044,Buxlness. ECT I . ❑olFrit
W m and property
who
ob Code o The oyesCuouractor,License Law dues nal apply s h(owner of OUTLETS-SWITCHES-F 1'
pmperty who builds or Inlpnrvd(bvrcnn.Iced who rites such walA binaxulfm(hrtnlyM1
his own employees,pnnl led(bat such impnncmenu are not(mended n"ofrerud for NEW RESIDENTIAL ELF,CTR
sale.If.however,IM1e building or improvement ixanld wthin one yearof completion,the SV.PT.FLOOR AREA SISQ.Irl'.
cr-builder will have the burden of proving that he did not build nr improve for pur-
pose of sale.). pp p
Fl 1,a%owner or tire P Ae propcny,am exclusively contracting with licensed contractors to
construct the protect(Sec.](H4.Business and Professions Code:)The Contractor's Li-
curse Law does not apply na an owner or propcny who builds or improve%thereon,and QTY PLUMBING PERMIT FEE IIIf��.
who contracts for such projects with a amtracum(s)I icensed Pursuant to the CnnlordOr's SEv P O Ecco
License taw. PERMIT ISSUANCE Hb R[{t
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) UI'01,144PU
WORKERS COMPENSATION DG CLARATION HACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one Of the I011uwing declarations:
❑I have and will maintain a Cenificate ofCon.cm toself-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA.CONE. STORIES TYPE CONSTRUCT101
sation,as provided fur by Section 39x(1 of the labor Cale.for the Performance of the
k far which this Permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workds Compensation Insurance,a%required by Section
3IIp of the Labor Code,tBo nn,ypeefffoorrmanceaf the work for which this Permit iiissisued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Caam'.. as tq tl_•at rnr�rrl�fAl oHe,NaY XT`ACf 101 Y'l 9 GAS-EA.SYSTEM-OVER 4OA)
[[H1CF,RTIFIC�'ION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FF.F_S
(This section need not be completed if the permit ix fiaonc hundrtd Jnllum lSIIK1) GREASE TRAP
or less.) PLANCHIiCK IT[
Exert that in the perfamentecoflM work Hrrwhich thispermit Moaned.I shall SEWER-SANITARY-STORM F.A.20014.
not employ any person in any manner ,,az,,become s.hjecun the Worker,'Co.,.- ENERGY FET:
OZ smion laws of Califamia.Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE rN
.�.I NOTICE TO APPLICANT.If,after making this Cenificate of f:xemption,you should WATER SYSTEM/TItEATING
a > become subject tube Worker's Compensation pmviniona of the Labor Code,you must SOIL ir FEE
foMwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O (M
I hereby affirm that them is a ennstmedon lending agency for the Performance or Date " N
F the work for which s permit is issued(Seo.3097,Civ.CJ
p Lender's Name T AL:
V Lender's Address TOTAL:
Hy 1 citify that 1 have read(his application and state that rite above inlimmmi(air is BUILDING FI?I
Z) corer.1 agree in comply with all city and conmy ordlnmmes nnJ s(:ve lows rclming ha QTY. MECHANICAL PERMIT FEE
U Z building conswctioqund hamby amhnri'rn rupmuunmllvc nl'this city(ucnmrupoa he SI 3IS MIC Il31:
above-mentioned property or inspection purposes. PERMIT ISSUANCE
(We,)agree m vavc.indemnify and keep hurmtcss the Cn,of Cul+vino against EI_EC'I'RIC Il?li
Iiabillties.jvdgntcnts.costs and expenses which mnyln z wayammc against said City gLTEN OR ADD TO MECH.
Inco
consequence of the granting of this Pu niii. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10.1X10 CFM)
{Ili
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCItlQ X
Signature of r¢
ApplicanVCon( Inr Date EXHAUST HOOD(W/DUCT) HOUSING ht 1'rIGATN PEE
HAZARDOUS MATF,RIAI S DISCLOSURE
Will the applicant montane building Occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupenimo Municipal Code.Chapter 9.12 .unA the Heahh and Sa4ty
Cade,Section 25532(u)? HEATING UNIT(OVER 10TII00 BTU)
[_1 Yes ON.
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Occupant use equipment or devices which Date R cci g H
earn integral eir ermaminanta as defined by the Bay Arca Air Quality Management BOILER-COMP CHIP OR 10/.000 BTU)
Distriel? VTOTAL:
❑Yes ❑Nn BOILER-COMP(OVER I100.000H'I'U)
I have(cad the hazardous materials(equimmenta unit"Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
figni.Health&Safety Cade.Sections 25505,25533 and 2556.1 utadene nl that if the NEW RESIDENTIAL hfECH. SR F1'.
building does not currently have a tenant,that it is my Ivm
rysibility hoccupant s notify the occupa
of the rryuirernenta which must he Inst prior m issuance of Cenificate,of Occupancy.
Owner or authorizW o"m Date TOTAL ISSUED BY:
OFFICE