S 1029 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDINC.-ELECTRICAL PERMIT NO.
BUILDING DIVISIOYROJN APPLICATION/PERMIT YLU]I - :C11ANIEDF_\llFlCICATIII\ J Q 1029 O29
BUILDING W F.CT
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
Yo �Q4 leA Z-" • 161-is 97
OW NER'SN ME: ` PHONE COOp7RACTORS Nyp1!: LIC NO: NIC CONTROL
Keel 6 �S1 1� r..w 53-0848 11n o -1 905
A7RCA TIECUENOINEER: LIC NO: AD)R''S: ❑
/&A 47 S. aren2•+—
CONTACT. PHONE BUILDING PERMIT INFO
❑ Coosdlunt Fees Paid by Applicant(Initial) RI.IK ELECT PLUMB MECH
❑ ❑ ZT�- ❑
I.ICIiNSLD CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
MWZ1 hcrcM1y eiffrm fhn I sin berrom em,r Inmisiom cf Cba ge 9 fcommcrstag -
WOO hb Secdoa 7(MMBnn)ivixirn 3of dr Bush,,.erd Pmfwionx Coll. oil my lieemr i. RESIDENTIAL'
WOO PIiRMIT ISSUANCP,
FSO ' full fsxcc aril cRm. ❑SFDWL ❑KI LEN REMODEL
ce EE Liamc Clw Id-.N APPLIANCES-RESIDENTIAL. []ADDITION PLUMBING RIi-PIPE
ZIa1 Dale mnnr
Com
Cj¢L ❑MULTI-UNIT ❑STRUCTURAL
ARCIIOECIS DECLARATION
F-7 rn PA NF.IS MODIFICATION
Z O Z umlurvarr my plvns.hWl h u.al u.public records
OZ--'O 201 UWAMPS E]INTERIOR ❑SWCHIMNEY
MING I'AIR
OU
Q�t� Lteemed Prols,hmvl 201-0)110 AMPS IMPROVEMENT [I SWIMMING['0015
< OWNER-BUILDER DECLARATION OVER IOW AMTS P0BATHRFMODELfRUAIR ❑DEMOL.ITION
W eecc1M1CIcY eff rmr,1 em c.acmlx from Uc Cnmrecmr'a Ixcnsc law fur theO1 O following mvrs,n.(Saina 7(DI 5,Businceand 1lofcadaa Core:Anycilym amply SIGNS ELECTRICAL IJIKish RGuim,pt,rrml to cA .l.ell[f,irnpool,deruliF .lr 1-1111 a Y Y—aaa2Oe pranto int smre.W,o myuims lac upplieem lot such pconitto file a xignal smmmenl SPECIAL CIRCUILMISC.is Been,i•uwv nOlbe pmviawm�t the CnnnxlNs Lorene Law(Ch,sal9
aag7000).fa,kion 3ofde Raudrr.rand PnecssitnrC'uc)- TIME,METER OR PoIY.INSf.a that It is exempt Therefrom vrd lh-buts for om alkged csernplion.Any vWaaiun of BLDGIADDI'I'[ON ❑DEMOLITION
Sa'dma 70315 by any ipplicard fora pcmdT,ahjcns dr applicant lBvcivlI l emshy of POWER DEVICES ❑FOOD SF,RVICIS
more Nvn Gve hundrd doll.,(5100). O E HENT
O I.as oxorr a the ploprny,or my-mpltrym xian xv6-sas ami,sok mmprnsatun. SWIMMING POOL ELECTRICwill d,the work,end Pr snucmm is not warmed!(rnRa-d for sale fSm.701 ,Br,iners ER
W 3 and Profnsiom CMc:The Comransr's U.1<W d an apply 10 w owrrr of OL TLHIS-SWDCHLS-FIXTURES
pn"a,whs,mold,or amprves nn,,r,and who&a ,,O h wank himself or lhrvugh
his own errakr n,pnwidm But.such imprmeram.am nil iratm 1 or offered for NEW RESIDENT AL ELECTR SQ ET.
su-.If,hwever.the building or impmvemem is sur within ser Yc.fcorpini pec SQ.ELTOOK-EA 1 VSQ.FT
oxmcr-huilder will have dhe burden of proving thin he did not build 9r or,oe fm,.,
persa
mpar-
pose of salt.).
TOTAL:
O 1,a rwo,of the fr,,,a,,mn m esdtoivdy aammeting wilicen,ml annnanm,l0
con ndel the project(Sec.7014.Busivass and Pmfecriom,Ce 11F Cmgmo(s Lo-
wLaw docmgupMY to un owaerof lmq,any wino buil K or impmva,Amon.mW QTY. PLUMBING PERMIT FEE
whocommsla wch projms with acu Wtd liamad puna,mthe ConusclMs
Lkcnec Lew. PERMIT ISSUANCE A p
L]1 am ucmle wafer Sec. .B k I'C for this,pain
Dan
ALTER WATER(EA) VALUATION
WORKER'S COMPINSATON DITCLARAl ION
ow in, BACK FLOW PROTECT.DI!VICF.
1 MchY ultimo urdcr penally of lcrjury win of the lollowing dmlurvlian,e
❑Ihav-vWwillmumeine,00n 37700 of Cx,LailunCocienfartfm Wiorn Comprn- DRAINS-Fl.WR.ROOF,AREA.-OND. S1 oK I LsCITY Or IVY �"yI&UN.l'rHUCI'IUN
,lion, r prnvidul for by Scdlran 3711f101 the lalwr Coda fm Nc Pcrfmnwcc of IhC
work far which Nis pantois astJ. Fl%"KRIS-POR TRAP
E]I ban err will maintain WuleYs ComprnWim Insuruncc,u myuirml by Section
37(9 of Nye�Dodo�ryCpco�mnea.forlhe p-Hmrt .of Ne work for whieh this lrmin i,iaeum, GAS-EA.SYSTEM-I INC.4 OUITI.Ii s [ICC.GROUPMyWorl, AI'N
Cern',/]LC Mx cardsrl•�y No 2§1&4O/ GAS-IA.SYSTI:M OVER 4(1A)
CERTIFICATE 01' 11-HTION FROM WORKFAS' GREASPIINDUSfRL WA51'E INTERCEPTOR
COMPHNSA'TION INSURANCE BUILDING[)[VISION FEES
(Ttisrenion load stn is,trap t,dNc bort is fa mr hundred ddlas(SI(MI) GREA.M:TRAP
Or less.) PLANCIII!CK EEE
IanifYThn in Ne perfmmvr-n(Nework forwhich dais pt,rml is issoed,l shalT SEWER-SANITARY-SIURM EA.200 FE
rut emploanpeon
y y In any mavmt ann,r,nu IV bsubject In Ne Workne'Cnmrm
fENERGY FEE
OZ nioo Laws of Califonn,Dac WATER HEATER WNENT/ELECTR GRADING FEE
Z O Applic<ol '
y NOTICB TO APPLICAN'I.It,after making[hie Cer ifcvm of liscm%ann,You Mould WATER SYSTEM/TREATING
a lr<ume subject to lir Wnr4 's Cwros nom pnmsirms of th<labor Cu)e,you must _ SOILS FEJT
fort w.N emm,ly ,O,.h provhinnv ur Nls pcnnil,bvll be Jamal rmvkcd. WATER SERVICE
0
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELAM. SQ.IT PAID Dolt Rcecips N
U O I be mby affirm that there Na conUmninn lendingagency Grine perLrmmnce of
IL (•' dr work for which this permR ui.ssad l.Scc.3097.Civ,C.)
U < rs Num:
TOTALTOTALrdc
t<rdcfs Addmis TOTAL
)n d BOATING Ili!
1 cenify Nn I Mvc real Wi.r epplieeliam saint,cote Ww rM uhwe inlitrtnutlm ix
F^ In e.t.It,rce menmN,wilhull city erW manly ordimmnvod same law.Awing or QTY, MECHANICAL PERMIT FEE
U Z huildingemenudion.amd bembyeudrrim mpmsnnuiv-sat this oily m-mer uDulhe SLSh11C FEE
aGmc-mendunci p rr'for bupanion pwP.cs. PERMIT ISSUANCE
(We)41.IV-11 imkmrtifY and trap hums,,use City of Cuperdrw.'sures, I!LECfRIC THE
Iishililies,judgmenls,m,u and expcnscs which may in any way accrue against said Ci ly ALT ER OR ADD TO MECH.
PLUMBING FEC
rnne of dr gmnlin Nis
APPLICANT UNUE ST DS ILL UMPLY WITH ALL NON-POINT ptµHANDLING UNIT(TO iQOfq CFM) MECILWICAI.M.7.
URCB 0.E '
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Si,,nauum OAKPPKsoaCmn� C% J Oats, E%HAUSTHOOD(WIDUC) HOUSING MITIGATION FEF.
HA]ARDOUS MATERIALS DISCLOSURE
Will th apllieenl afwu,building occupant score or hvrk hnzmdea,mv<rinl H EATING UNIT TTQ 100,0(10 BTU)
no&fir,d by N-Cupenino Muniui rd Code,Cm,,9 12,mol Ne Ileallh uM Safety
Code.Salon 8532(ep HEATING UNIT(OVER 1110.00(1 BTU)
❑Yes ❑No PAID
VEJNTILATION FAN(SINGLE RESID) Dam Reseio
WillNe applitenr a tulure budding rrcurynt u.e eyuipmenl sr devitts which
•emit hevrdous ear conn ummars,as defirN by Nt Bey Arta Air Qaality M.amgcmcnl BOILER-COMP 0301 OR 100,000 PIU)
l(YfAI:
Diwicl l BOILER-COME(OVER 110,000 BTU)
❑Yes 0 N
I bavermd thehvasknr majesty re'eemems urdn ChaNer 6.95of We Celt AIR CONDITIONER ISSUANCE DATE
forms 11ea1N A Sefny Cade.Smimn 25505.8533 and 25531.I mldnHmW dol if the NEW RESIDENTIAL MECH. SQ.IT
molding day not comm0y hove a tt6wl,flon it is my Ieynmihillty w notify JTe oavyanl
d Ne reeryimnrm.s which must Is,rrer Paw to i.asuurc of.Ceni'ewc ot(kcupancy.
(Tuner rr nulhartvd vgenr IAm
'r(YIAI: ISSUED BY.
OFFICE