S 0137 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0137
BUILDING PROJECT IDENTIF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
a/W�i9o� 'rn�J.,� y3111"15121 6Y3- q 7
OI:Q 141 � Pi/ /e�I'H0�9G—�0�� CONTRACf()R:S AME:— LIC NO:
/W./� NIC I CON FR/UI-0
�RCHITE "NGINEER: LIC NO: ADDRESS: ❑ / �(
,Dv g&6N/Terr C-av69/ ,7140 �U 1 L o
C)NTACI': PHO BUILDING PERMIT INFO
.Vkr v NauYE.v &VIr1) 4Via-//G y/
❑ Coneulfnnt Fees Paid by Applicant(Initial) ItL.DG ELIiC'1' PLUMB M1:cu
AgA/ NEE sov eA/(,IQ. �I06 a y-aa 4 V &- � �
LICENSED CONTRACTORS DECLARA1ION QTY. ELECTRIC PERMIT FEE
1 hereby anion flm 1 am licensed under pro.idons arehapter 9)nmmancing JOB DESCRIPTION
O�Z with Section of Division 3 of the lbomess and Professions Ctde.and my liccmwis RESIDENTIAL
WOO in PERMIT ISSUANCE
CSF full hose, nd effect. ❑ ❑KITC1117N REMODEL
aUU Liccnsc Cluas Lica APPLIANCES-RESIDIiNT1AL ITION ❑1'hUMBING KIi-PIPE.
F'Z W Date Commenu
tnQy MULTI-UNIT ❑S'fNI1Cl'URAL
ANCHITELTS DECLARATION
F-D m PANELS MODIFICATION
ZOyZ IunJernanJ my plans shall he usN as public nenN.s UP TO 2101AMI'ti
OZ—O ❑INTER( ❑CHIN(NEY REPAIR
L-iccnaal erofesxional 20I-100AMPS IMPROVENIFEN1 ❑SWIMMING POOLS
�.��; OWNER-BUILDER DECLARATION OVER IIOMIAMI'S ❑BATH REM ODE F:P, I3 ISo r1ON
C C Q 1 hereby affirm mat 1 am exempt from the Contractor's License Law for the
�•O a U following reason ec
(Stion 7031.5,Eymone.5s and Professions e CodAny city or county SIGNS ELECTRICAL ❑(TTHER
which requires a turmoil t t alter, p thamiloh,or repair ny structure
prion t ': al. requirestheapplicantf uchp min fl signedstatement SPECIAL Cl RCLIIT/MISC. -
yhat he licensed pmsu a hetp fd C t sort I La tChime,9
X00 (mmmcncing win Sis 7000)of Disision 3 of Husinms and Prole—on, TEM I'.M E I'ItIt 0R POIX INST. COMMERCIAL:
d a c C that he is exempt therefrom and the hais for the alleged exmnption.Any vmlmion of ❑NEW ILIO/ADD11'I0N ❑DY.MOhtl'IUN
—y Sceinar/O31S by any applicant for a permit subjects the applicant to a civil penalty of MWI7R DEVICES ❑'IENAN'T ❑POODSIiRVICH
not more than fisc handred dollars H50% 0 IMPROVEMENT
SD
F1 Las owner of the property,or my employees with wages as their sole compensation. SWIMMING ptIDh ELECTRIC
F, will do me work,and the swaum is not intended mothered for sale(Sec.NHS.Business OTHE
m amp Professions Cork The Contractor's License law does tont apply It,an owner of OUTLETS-SWI'T'CHES-FIXTURES
0 3 propcny who builds or improves thereon,and who usual such work himself or through
his own employees.provided that such improvetttcros am not imnrried or offered for NEW RESIDENTIAL.ELECfR SQ Fe.
sale.IL however.the building or improvement is sold within one yea of completion.the SQ.FL FLOOR AREA ASV.I'1'.
orworica,builder will have the burden of proving that he did not build or improve for pur-
wIEIIdsale,L TOTAL:
.W.onowner of the progeny am excessively aomeactino who licensed commao�to
construct the project(Sec.0014,Business and Pmfcxsion>CedeO The Commaors Li-
cerise does not apply to an owner of property whit builds or improves thereon,and Q Y, PLUMBING PERMIT FEE
whocommels forsuch projects with acantmcmr(s)licensed pursuant tone Coiaaetors �
License Low. ,11ffi I'Clirthis reaum PERMIT ISSUANCE J ��
❑ I mit cxanpt under Sec.
AhTEH-UNAIN h VI3NT-WATER(EA) VALUATION
Dwner Date —
WORKER'S COMPENSATION U13CLARAtIUN 1{ACK II.OW IBOI'HC'r.DEVICE to
1 hereby ulRrm under penllty of perjury one of Ne lidlowing Jedamtionc
❑ I have and will maintain a Cmificam of Consent nr scii-insure for Workers Compen- DRAINS-FLOOR,EGO,
COND. STORIES '1't'I'IiCUNSTRUC'I'ION
sation,as provide)for by Section 37M of the LeMrr Cade,fir the perfr mmove of the
work for which this pc.it is issued. FIXTURES-PIER TRAP
❑1 have and will maintain workers Compensation]as umnce,as on cooed by Section
U0it of the Ladner Code,(onbe performance of the work for whieh,hi,permit is issued. GAS-ISA.SYSTBM-I Iso 40UTLETS OCC.GROUP AIN
My Wmkefs Compensation lnstmnce carrier and Policy number am:
Carrier: Policy No.: GAS-PA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION MO."WORKERS GRFASI%INDUS I'B.WASTE INEIRCEFTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
TThissaaion meednmaccumplecd ifthe pormnit is for one hundaddollars(SIO)) GR17ASL TRAP
nr
less) PLANCIiIiCK FEE
certify that in the carformmaccofthe work lirwhichthi.v till issued.l shill SIiWER-SANI'T'ARY-ST0RM EA.NO)FI'. ln
not employ any reason inuny mtimun,oaa m bav cnobject topic Wnrtons'Compen- 13NBROY FEE / to
V�
Z union hxwx of Culifimnia.Umc WATER MINE 17R WIVENTELGCTH
z Q Applicunp
GRADING ItiE
NOTICI?'TG APPLICANT 11:after making this Ccnilicure at lisoomplion.you should WATER SYS'I'FloREATING
h SOILS FEE
F` bee a subject m the Workers Cnmpensatian provisions of the Lobo Chale,you..in
forthwith comply with.such provisions orchis ryrmitshall be deemed revoked. WATER SERVICE I
0PAID
CONSTRUCTION LENDING AG17 ICY NEW RESIDENTIAL PLMB. SQ.FT. Dae Rcccipt a
U OI hamby affirm mat mem i a construction leading ag am,for the performrnce of
the wnrklorwhkptia��c ntsi.5s.al lScc. flao Civ-c
�s U I<ndcrs Name IA lot MCN/ /7 -F/�C.S?ETTEZ. TOTAL:
U 1<nder.Addrex joreyY / - TtxAL:
I ccnify th t 1 have read this applicainn aha Stam olio the above information t BUILOING
C11.F y c nccL lagree mcomply with all city and county ordinances and stem rows relating to TY A1F:CHANICAI-PERMIT PF,B SEISMIC
V Z building construction.and hereby authorim representatives of this city m enter upon the
aMmc-mentioned progeny for inspection pacT v. PERMIT ISSUANCE ELECTRIC 2E
(We)agree to.vase,indemnify and keep hemdess the City of Cupcnino against
Iluhilities,judgments,costs and expenses which may in any way wane against said City ALTHR OR ADD TO MECH, PLUMBING FEF.
in can
.cqucnce of the granting of this pemnii.
APPLICANT UNDIIRSTANDS AND WILL COMPLY W 111 ALL NON-POINT AIR I]AN ULINC HNI'1'(TG I003)CFM) MIiC1]AN ICAL PEfI
SOURCE.RITGULA VIONS, /
AIR HANDLING 11Nfr(0Vh;H 11L00O LTM( CON STRUM ION TA
Signator!of Appleant/Contracmr Dau EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HA3ARD0U AMRIALS DISCLOSURE
Will the applicant nr future building occupant so car hrndleM1vardous material HEATING UNIT(TO 110).10O BTU) D
as okrm,by the Cameroun Municipal Gde,Chapter 9.12,and the Health and Safety
Cede.Section 25532aU. RELATING UNIT IOVI!R 100.030 BTU)
❑Yes VEbH ILATION FAN(SING LE RFSID) ) pate Rcccipta
1 Will the applicam m umre huilding occupant use equipment art devices which 9O1LF-R-COMP(BHP OR If10,(O0 BTU)
'emit heotrdous air contaminants qs defined by the Buy Arca Air Quality Management - 'TOTAL,:
DirtdcR �T'd(/v BOILER-C0MP(0VER 100,010BTU)
❑Yes
I have read the huzudouxmateriu6 rcquiranemx under Chapter 6.95 of the Cali- AIR CON DI'HONER ISSUANCE DAT
Broin Health&Safety Code,Sections 25505,25539 and 25534.1 underhand the,if the NEW RESIDENTIAL MI!CIL SQ.IT.
building docs not cnrently have a mnanL that it is my rc.sponsibllhy Ito notify the rc1amill
ruyuirepm:ms whish must ctp'rn loiseuunc ofnCcniticup•ol'(kcu un
Owner or nufhnriee agent Doc TOTAL: ISSUED BY:
so OFFICE ,