S 0075 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF RTINO BUILDING-ELECTMECHANICAL
RICALICA PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBROJECTeDENTIFIC.
BUILDING YR(IJY:CI'IDENTIFICATION
BUIIDINGADDRFSS1. SANITARY NO. APPLICATION SUBMITTAL DArF
al yly Follo //07-07
( R:S AMB:a Pf UNI): CONfRACIOR'S N LIC NO:11!4 90 Call NIC C(TsTROL P
Ad 49
A I11 C Il. tR: LIC NO: A µ El
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CONTACT. NIONE: BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Inillal) BLDG ELECT Fl.l' IB AIE
LICENSED CONTRACTOR'S DECIARA'IION QTY ELECTRIC PERMIT PBG
I baeny si irm Na i am liceowd noder pnwuinm m Chapter 9(cnmmeremg JOB DESCR ION
O=Z mEslinn"/OIXBMOivu:m3nrme euvircx and mofen.iaa cade..rtd mrha�eie RESIDENTIAL
mop °' PERMIT ISSUANCE
Fu- to full and ❑SFl)WL ❑PLUMBING RE- H19.
�U IJcemc Clus lic.a
6 APPLIANCF_S-kl S%H)MIAL []ADDITION ❑PLUNiRING kE PIPIi
W Dom Comuxar aw
F.Dm A CHrm- DFCIARATI)N PANIiiS ❑MUhTI-UNIT ❑STRUCTURAL,
ZZ I uMttvard my plus shstl be u.1 e public rcrnds MODIFICATION
O -O UPTO fi0AMP5 El INTERIOR ❑CHININEYREPAIR
90W Liccnml Pmfessitmal 201-I11(XrAMPS IMPROVEMENT
EjSWIMMING PIX)IS
Oat I min IUILDER Htithe C-1:OH OVER I(XX)AMPS ❑13AfH HF�GJN
1 Ermby eflimr that 1 R-camps(mm me CaATIONr'e License Law for me
fixx'O a U fOlVaimg rvwu(.Seedaa 10313.Businea aril Pmfee iau taste:Any city or county SIGNS ELECTRICAL OTHER i
W LL p. which rtquim a perm m rnao..alter,impm)e,demolish,or n,Pair any sVucuee
prim In is iwarce,also require,,he appiicamftxaocb perroll to Ekaeigmed Nalenort SPECIALCIRCUITAIISC.
m
that he it liunvcd uulM1e pttt
human pmviBinnn ofthc Csutrecnd.Licenm WwlOa v
fyap0 oe.mcmcm,.M Seniors 9gl(gnf Dlvision 3oOtr Hmimmi and Professmmi Code)., TEMP.MBIERO I. NST.
a a C y Nat he u exemptmcrtfmm and the lasia fa I)n stkged ezemptiort.Aoy violation of ❑NEW BI DGIADDITION ❑DEMOLITION
-vLLi
Seed.70313 by arty applicant man ram,wbjms the applicmb,,civil penalty of POWER DEVICES ❑TEblANT ❑FOODSERVICE
as nXxe sten five hmidred dollars(Sft f11.
Z,P 01HER IMPROVEMENT
�O � I,mnewtok,then prwroemrie,not employees with wages unNeUSocC1)mp:Ovntm, SWIMMING PIX) ;LIiCI'
soill Mthesions endo he Ccso isminrmkde Law
cl fsralepply to an owner s Q'1'l1ER
W s4 ro entry who
Calc:The over be res Licata Law aces nm apply p If othergh OOIL L-fS-SWITC IIFS Fl
a 3� property who buiWa a improves Menem,and who tM)¢ouch soak himrlf a through
his tram employee,provimd that Hach irm ovemenu arc not intended a oReml for NEW RFSIDPAL 1.
salc.If.o-ee,NclviREngoriinprcrvmrcnfksold withinatc ycorof uxnpludun.Bu SQ.h1'.Fl.(�RARPA $SQ.FT
mwrcr-luiltkr will hove the burden of proving Nat he did rW build or impruse:m par- w
El I o ssilo-)- /V
❑ 1,ru other i e, prtrymy,ammnt,,any e0sopmPemfi,c�ag Coth d:)cert 1cnowmorsto
a- L:
mnurua ar prnjeel Wry to
ownLi,er
(vs red rly who halre, h or on b Ctmtrvetors Li-
w1c ve law dna ax apply n.an owner of properly who buildr or lmpmvv.lhemm,and Q9'Y. PLUMBING PERMIT' FEE C�J�
hocontmcu forsuch pmiect+wiN awotrxtty Uicemcl ptuwamno the Commeetters G^.
Lee.Im. PERMIT ISSUANCE
I un exempt uakr Sec. .B&P C for mix reascm L
Owner Time
ALTBR-DRAIN&VENT-WATER(EA,) VAI ION
WORKER'SCOMPENSATION DEC1ARKHON BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of pujury one,of Nen following decluuitms: G
�-1 lhavemdwillmeirnaineCrnif kof Co ttaaelf-inzumfawa ec CmM- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
utim.as provided for by Sectitu 37W of Nen Labor Cak.for the performance of the
work fa which his parTU
a is kou,d, FIXRES-PER'L'RAP
m
❑1 have Xl will incemu n W'orker.r Compenawiun Ifuunne<,sic nquifed by Sstion
37W of Nen Labor Code.for de psirh a Mae work fa which this .it is mud, GAS-EA,SYSTEM-1 INC.S OUFTLEfS OCC.GROUP APN
My Wookey C tion ImuT c�!(�- amt Put number
I Cscirn_`1 XT?bT 1'nlicy No.: S-EA.SYSTGLOVPAC(PA)
CIiHCIFl Ti OPB I,ION FBON IffiKBRS'
COMPENSATION INSURANCE GREASFJINDUSTRI,WASTE IMITRCEPTUN BUILDING DIVISION FEF_S
(ibu teimn nttd not he complennJ if d,pewit in facer har�al"Iera lS l Bo) GRFASETRAP
m:evJ PIANCHECK FEE
[certify that in Inc performaoec ofatc work for which this permit is iaued,l shall SEWER-SANITARY-STORM BA.2W FT
mc mploy any P=M any n nersem ha'ome ahjcut to he Worker'Compen- ENERGY FEE
Z ration 1'.of CstiRxma-Dote n
,-
ZO Applicam 1 wAfHR HEATER WNIliT/BLELTR GRADING ME
g, NGnCE TO APPIJCAN-E If,offer making this Cembfule of Eicmplion,you slhoi WATER SYSTEMTREATNG
- F he,m,subject to mer Worker's Compenraium pnwisiom of the Labor Code,you mast SOLI S FEB
W [ (tnbwilh comply with ssM1 provixitxu err[hie pcnnil stall M tlnnrd revokcJ. WATER SERVICE
aQ
U z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PEAR. SQ ET. PAID Date H t
U 0 IhefebY affirm Nm tMmiaarnnsnr.ionkfdie.ageay for the peHtrrmmce of
W F the work for which this permit is iou (Bene.RYJ],civ.CJ TOTAL:
Q U Lender's NamefAw
ATOTAL
LrnkYx dolre.e
f I curdy may 1 base rend Nu appEcabo)e tion fast sate that d,amfammion ie NUILD.Nen FE
y
enrrtel.Iagme mamp:ywim all ciiyardmumyadinarrevnaluuclewam:atmgio QTY. MECHANICAL PERMIT EHE
U beddingeonafmim.,and hetebymrhmla Apresemalie,,411ls coy m ever upon the SUISMICFEE
oMrvmntcr tW imo,ny fm'mspaNm puTxatx.
(We)agree to save,indemnify amt lore,humkse the City of Cupmim againsr PERMIT ISSUANCE ELECTRIC 'F:
habilitie judgmems.cows and espences which may in any way e¢me against said City ALTER OR ADD TO MECH.in cauryueme M tFe granting of Nie pmoit. PLUMBING I
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINIAIR HANDLING UNIT GG I0.(XXI CFM)
SOURCE RF,GUTATIONS. MECHANICAL I E
AIR HANDLING UNIT(OVER:B.(X)BCFM) CONSTRUCTION TA,
Sigretufeof ApplicanvCaureOa Dale EKHAU.ST HOOD UVIDUCD HOUSING MITIGATIO FIE
HA]ARD(NS MATERIA:S DISCLOSURE
Will me.applicum m fume M1uildingtxcupont 9lactx lwmlle hmarmus matenial HEA'T'ING UNIT('IO l 50,000 BTU)
a�cls ind by dr Cupeninn Municipal Code.Lhrpeer 9.12,mal the Healm ora Safety
Code.Smite 2.55324)' HEATING UNIT(OVER IWE"BTU)
❑Tens No VENIH IATION FAN IS I NGLB RI-SID) PAID
W'II mea beano err Ime,buidin l u.¢c t or devices which Date Rmdpt M
pp gby th,n aAir n BOILER COMP QEIP OR H)ENp BTU)
emit hmminus air ctmmminanu v JeErcJ by dr Bay Arm Air Quality MomBemrnt
TOTAL'.
District? BOILER-COMP(OVER 100.000 HN)
❑Yea Chi,
I have mal Nc hafadisoommalsrryoimnunts uakr Chapter 6.95 of the Cal, AIR CONDITIONER ISSUANCE,DATE
fania Health&icamy Code,Sttfiaa 25505.25533 fad 2553,.1 urtdcrvanl that,)fate NEW RESIDENTIAL MECH. SQ.FT.
building docs rot currently have a serer.that it is my msponsibIly m reify the oavNm
Mae a'ucmems which must he ria prior to i..ofe Certificate of Osco y.
Ow miaJ ager e ¢ 'IYTCAL: ISSUED BT:
OFFICE