S 1169 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERT•INO - BUILDING-ELECTRICAL PENMITNO.
BUILDING DIVISION AI'PLICATION/PERMIT PLUMBING-MECUANICAI. S 1169
BUILDING PROJECT IDEMI'IFICATION
BUILDING ADDNF.SSt SANITARY NO. APPLICATION SUHNUI"I'AI.DAto
�75U0 ) Trwik V•. l -21�R�2
OW iR:S NAME: PHONE: COM'ftACI(iR'S yyAM LIC NO,
a Cay 633048 NIC CONTROL#
P LIC NO: ADDRESS: ❑
da ARCHITIFCI'll? EIiR: -
1o58 Sl�n vwrock ']jr.
CONTACT: PHONE: - BUILDING PERSHT INFO
1l_ ` Z42-q ❑ Consultant Fees Paid by Applicant(Initial) PLUG_ ELECT PLUMB MECj
Vie— (a L ttl 37 7- r{i
LICENSED CONTRACTOR'S DECLARA'T'ION QTY. IiLECTRIC PERMIT 1rL•i? JOB DESCRIPTION
I hereby affirm that I um licensed under provisions of Chapter 9(commencing
Matz with5ecticat70n)nToO,imi 3ofthe E9.ciness and Professions Code,and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE
FSC in full force and eRecl. aa // ❑SFDWI. ❑KITCHEN REMODEL.
MUF License Cl.ss L- ` Lie.# &3l(,Y15
< U _ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMPING RE-PIPE
Za Dote f Comruc r �- ❑MULTI-UNIT ❑STRUCTURAL.
F.Dm ARCH(I'ECT'S DECI.ARA'TION - PANPI.S MODIFICATION
OZn
UP TO 21XAMPS
❑INT?PLOP ❑CIIMNGY REPAIR
—M
F-v4 F-W Licensed Pndeniomal 2DI-I000AMPS IMPROVEMENT E]SWIMMING POOLS
12.5 - OWNER-HUILDER DECLARATION OVER IIg111AMPS Tfi REMODEVREPAIR El DEMOLITION
1 hereby affirm that I am exempt from the Comment's License Law for the
ca, fallowing reason.(Section 7031.5,Business and Prnfessiore Codd Any Or,or 1 ily SIGNS ELECTRICAL D (YI'HI?R
3 W ' which inquires a permit to connate,#her,Impmse demolish.on repair troy amrtuva
prior to its issuance,also requires the applicant lot uch perininu file a signed statement SPECIAL CIRCUITIMISC.
SSS99�y that he is licensed pursuant o the provisions of the Contractor's License Law(Chapmr9
WE C (commencing with Section 7000)of Division 3 of the Nosiness and professions Ctx4)Or TEMP.METER OR POU?I COMMERCIAL
L G cy� that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BCUG/ADDITION ❑Df:MOLI'1'ION
DCm4,
Section by any uppllcan,fo apeimit snhjensthe applicant macivil penalty of POWER DEVICES
fn ❑TENANT ❑IY)OD SERVICE
ty^pa
actuator then five hundred dollars($500),
H. Q Lasow,v,cfde n SWIMMING POOL ELECT RIC OTHER� ❑ (] pinta Y,nr my employees with wagOs as theinnle ttwmpen.xmiom' _ ❑OTHER
wJl do the work,and she nructum is not imm�JN m n0errd fonale(Sec.](W4,Rosiness
W 3 m and Professions Cade:The Conuactors License Use arcs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who holds.,improvea thersam,and who does such work himself ar through
his own employers,provided that such Improvements arc not intended or offered for NEW RESIDENTIAL ELECER SQ ET.
ealeFLhu,evc,,the building Or improcdmenl is wild within one yearufcnmpletion,(he _ SQ.FT FLOOR AREA $/SQ.Er.
owner builder will have the burden of proving that he did not build or innplove for pm- A
poseofsam), TOTAL: /'� 1 D
L as owner of the pmpeny,am exclusively contracting with licensed contractors to
oemmt the project(gee.7614,Business and Professions Code:)The Contrmmrs Li- r q 1
cense law does not apply to an Owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FF,F; A•Vp,6il gryS
who contracts for such project.,with a comations)licensed personale the Contrumnr's
License 1.uw. - I'IiRMI'I'ISSUANCE:
F7 I um exempt under Sec. ,li&PCfor this reu.,nn
ALTER-DRAIN&VENT-WATER(FA) 170N�u
caner Dine
5i—CRKHR�S
under Penalty
COMof wriuq on DECLARATION HACK FLOW PROTIiCI'.DEVICE
.• IhcrchY affirm under pcnuhy of perjury one of she following declarations: V✓
❑ I Have and will malmain aCenificate of Conscnfeself-insure for Workers Compen- DRAINS-FLOOR,ROOR AREA,CONE).
STORIES 'I'VI'1?CONS'fftI1C'I']ON
sation,as provided for by Section 37M of ane Labor Code,for the performance of the -
work for ubi,,h this permit is issued. FIx ruRES-PER THAI'
❑1 have and will maintain Workers Compensation Insurance,as required by Section
1100 m the Lalam Codd fnnhe pertormance mom work forwhieh mislamen is issued. GAS-I?A.SYST1?M-I INC, PTs OCC.GROUP APE
My Worker's Compensation Insurance carrier and Policy number um:
Cartier. Policy No.: GAS-ITA.SYSTEM-OVI?R 4(EA)
CERTIFICAlH OF EXEMPTION FROM WORKERS GRI:ASI%INDUS'I'kl:WASTE INTERCEPTOR COMPENSATION INSURANCE HOILDING DIVISION IVES
('Thissection need nil be completed it he aund isfor one hundred doll.(1100) GRI?ASETRAP
or less.) PLANCHECK FEE
I ccnify,that in the performance of the work for which this permit is issued.)shall SHWER-SANITARY-STORM EA.200 FI'.
nm employ any person in any mm�ner su as to become suhject to the Workeri CumNn- ENERGY FEE
cation laws of California Date WA I 17 IWATER W/VENT/HLECTR
ZApplicant I- GRADING PEE
.Ni NOTICE TO APPLICANT.It,after making this Ccnificam of Exemption,you should WATER SYSTEMORHATING SOILS FEE i
a7 became subjec,m the Workers Compcmmion provisions of the LM),Cole,you mud
W forthwith comply wirhsuch provisions mthis permit shall be deemed revoked. WATERSERVICE
Q PAID
CONSTRIICTIONLENOING AGENCY NEW RHSIUENT(AI.I'LM11. SQ,Ef. Date eipt#
I hereby nffimuhatthere Is u comnim;iun lending agency Ibr t e performamc of
1.1a 0 Ne work for which this penal,is issued(Sea.3097,Co.C.)
O U Lenders Name TOTAL.
U Lender.Address TOTAL: ccvl
f1. 1 ccnify that 1 have read this application and sem that the above information is BUILDING FE
V) cane.,I agree In comply with all city and county Ordinances and state laws relating n: QTY. MECHANICAL PERMIT ITE.
U z building oonnrumioa and baruhy uuthoriremmv,cmmivesnllb,ehylo cut er..pun 0o SIiISMIC FEE
above-namioned property far inspection pugnsen.
I'1?RMI'('ISSUANCE ELF.C'I RIC FEE
'
(We) save,indemnify and keep homnlexs to Ciry of Cmpenino against
Ii.bilities,judgments,costsund expenses which may in any wuyaccmeagvinstmid City' ALTER OR ADD TO MECH. PLUMING FEE )
in consequence of the gmming of this permit. -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 10,000 CPM) MSCI IANICAL FEE
SOURCP RP ULATIDNS. - -
AIRIIANDLINIONI'I'(OVER 10.031 CFM) GON,S"TRULTION TAX
am of
Dam EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the rNnicantof forum buildlogracuped,state m handle hctrahms materia] HEA'T'ING UNIT TO 100,019 IFFM
as defroal by,he Cupeni no Mnmicipal Cole,Chapter 9.12,and @e health and Safety II I?ATINC,UNIT(OVHR 110,000 B W
Code,Section 255321u)i
[I yes 0 N VENT I LATION FAN SINGLE RES]D) PAID11 Dine Receipt#
Will the epp]Icant n1 future building racupant use equipment or devices which BOILER-COMPOHPOR 10,000 BTU(
temit hamNous air contaminants m defined by the Bay Arca Air Quality Management TOTAL:
('61Districi? Yea i]Na I BOILER-COMP(OVER 100.0001111J)
I have marthc hvnrdous mccrial,requirements antler Chalon 6.95 of the Cali- Alit CONDITIONER ISSUANCE DATE
amnia Health&Safety Cole,genions 25505,23533 and 25534.1 unlemand that if the NEW RESIDENTIAL MECIL SQ.FT.
luddeingdoo,macctend,haven tenant that it ism,nesponsibilisy to notify lheoecomed _
of the raquinemen¢which must ba met prior m issuance of a Certilicam of Occupancy.
O emer-or authorized.,cut Dam 'TOTAL-: ISSUED RY:
OFFICE