24871 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,R'rINO BUu,DL11:.1,I,?T I Ric' PERMIT NO.
APPLICATION/PERMIT rl.ummuc->D:cxnrvlcu, n ^ O
BtJ IL DI NC DIVISION BUILDING PROJECT'IDENTIFICATION L 4 O
BUILDING ADDRESS: SANITARY NO. APPLICA'r10N SUBMITTAL URI'
��.F„��� 3 ll�—qc3
_75- LC UNI'fx LOT is
OWNE AME: PRONE: Q N'FIR R'S NAME: LIC NO:
�i s !mac' /�X /��L r� 7g� N/c cONTIOL.
4A
RCHITECIE-e GINEER: _�LIC NO: ODDRESS
N /O 3'r
/ �l� iozrn+n prcf
NTACT: PHONE:
QTY. ,., ELECTRIC PERMIT •. FEE ' BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE, Ohl
TJ
LICENSED CONTRACTOR'S DECI.ARVpION APPLIANCES-RESIDENTIAL
Cm'Z Iherebyaffirntnatlamiicenwdundefpmvtslonsuf Chapmr9(commennngwim JOB DESCRIPTION
taCO SectiunJ(N101 of Division Jof the Business and PmPossiuns Cale,and my li<emeia in PANELS
milforceandeffecl.
NZ License Claw Lic.# UP TO 200 AMPS � 0
6d Dam Contractor 201-1000 AMPS ��SS(y■
F,7 ARCH1TECrS DECLARATION N YFT.DOOR AREA 5/SQ.FT.
>_Cy— OVER IUfiO AhIPS 1
�Z-_14O I understand my plans shall he used as public records. Y.
_y SIGNS ELECTRIPLL'
<—<_ Licensed Pralessionul II11
xW W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. A
�
tC�U I hembv affirm that 1 am exanpt trot he Contracmr's License Law far the
y a y following reason.(Section]OJ 1.5,Busineu and Professions Code:Any city or county T1iMP.NEI'GR OR POLH(NST.
which requires a permit to construct.alter.improve.demolish.or repair env nroame Is:
�y Y� to its issuance.also then applicant for such tto file a signed statement POWER DEVICES
prior requires pp perm, 6n
y_Cp 9(can Hlicensed itpursuant Scen .7")of Divisions ion
me C.mrdctors License Law(CImpter
sion,Cde) SWIMMING POOL ELECTRIC
LL 9(mmmerming witM1 Section JBODI of Division 3.fthe Buainea afro Pm(essions Coda VAWAT�N
,mN nr thin he is Isefnpuherefrom and the hauls fordarilleged exempd.n.Any violation of OUTLETS SWITCHES�FlXTURES Q O
F Z¢ Section 7031.5 by any applicant for a permit subjects the applicant m a civil peod y of
not more than live hundred dollars SM. NEW RESIDENTIAL CLEM —SQ.PT. V
pe ❑ Luowner.fthepropertv,ormyempl.yeexwim wages as theirsmlecompensation. Q STORIES TYPE CONSTRUCTION
p. will done wmk.and thenrmemre is a.,intended.,offered fm,,d,(Sec.7W Bus
and Professionde,Th
Professions Coe Commuterm's License Taw does not apply on owner of
property who builds or improves rhercon,and who does such work himselfor tnrough his
own employees providedthosuch improvemmre
esunot ineadedoroffctsd forsale.Ir, OCC GROUP RES.UNITS
however,the building or impmvcmcm is sold within one yearofcompktion,the owner- TOTAL:
builder will nave the buNen of proving that he did not build or improve for pufpuse.f
mle.). QTy,; PLUMBINGPERMIT'--- ”,FEE `2 FLOOD ZONE APN
Cl hmo ref thePmpenY.amendmivdy<ontraaing with licensed c.ntranorsm ,:vsv •,'? r�,z:;
rote,theproject(Sec.]Data,Business and Professions CodcO The C.n,—.,. r,_M - -
LicenseLawdoeanmapplymvtownerofPropcnywnoboild,mina,morslhercnn,and PERMIT ISSUANCEa
whocontrapsfa,such Projects with.emmmcuars)licensedpufsuar,ado,Cmassemr'a ALTER-BRAIN&VENT-WATER HEA) _ ,;FEESUMMARY
Law.
❑nl mn es mpt mde,Sec. ,B&P C for this rcss.n BACK FLOW PROTECT.DEVICE OU'rSIDL FE S
SANITARY YN
Owner Date DRAhNS-FLOORROOFAREACOND. RECEIPT#
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
1 hereby affmuha 1 have a wni0eme of comm m ulGinsurc,or a ceni0cam of
FIXTURES
XTURES-PER TRAP RECEIPT is
_wa penaotionleorceniEN coPY thereof(nee.JBW,Lab C.7 which PARK FEE Y :V
�
a117,apIoYc2s undererthis lhia permit. GAS-EA.SYSTEM-I INC.aOIITLETS RECE1PON =__
�slicy p BUILDING DIVISION FEES
_ompany GAS.EA.SYSTEM-OVER#(EA) PL NCHECK FEE
❑ Certified copy is hereby famished.
❑ Coifed ropy is filed with Ne city inspcnion division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFlCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not to completed ifthe permit is for one hundred ill S INF SEWER-SANITARY-STORM EA.2001T. ENERGY FEE
.,less.)
Icertify that in the perf.rname.of the work far whichthis permit is issued,Ishan WATER HEATER W/VENT/ELECR
not employ any poral in any manner so as to become subject to the Workers' PAID
Z Compcnsatiun Lawn of Calimm.. Dae WATER SYSTEM,TREATING Date Receipt#
Applicant
zU NOTICE TO APPLICAN'r:If.after making this Cenilicate of Exemption.you should NEW RESIDENTIAL Ill SQ.FT. TOTAL:
- fes become subject undeWorker's Compensmm.pmvisi.nsathe Ltbor Code.you most
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE �•
_N
s(. O CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that hem is a construction lending agency for the performance of
TOTAL ELECTRIC FEE
U O
the work far which lh',permit is JIS c.JW]Cty C.7 aq�
O F-
Lenders
-old QTY }.4;• MECRANICALPERMITr,% h I ,a,FEE r? ; PLUMBING FEE
U I emify that I have d this ppl t o and nate that the above abominations
LL correct.Iagreemvomplyw th all oyand coumy nNmances and. claws relining to PERMIT ISSUANCE MECHANICALFEE
C.
Ln Z buildingw
conscllon,and screw amnou
n ¢ppeasonivesof Nis city to enter upon the CONSTRUCTION TAX
above-mentioned pmpeny for inspcmon purpmes. ALTER OR ADD TO MECIL
(We)agree re save,indemnify and keep harmless the City of Cuperdn.against
Iiubili0es,judgmcnts.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO W.D00 CFM)
in conse;qr oftbe grarria (this permit.
AIR HANDLING UNIT(OVER 10.00)CFM7
- -9
gnamre of ApplicumsCnmmen, Date EXHAUST HOOD(WMUCD
PAID
thV\RDOUS,WATERIALS DISCLOSURE HEATING UNIT(TO HNI,(100 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material TOTAL:
as Joined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety fIFATING UND'(OVER I W.OW BTU)
Cade.Section 25532(a)° VENTILATION PAN(SINGLE RESID)
❑Yes ❑N.
ISSUANCE DATE
Will the applicant or future building occupantuweyuipmemordevices whichmat BOILER
COMP OR I(NI INN(9TU) A
M1a J I t ddlneJ by the Btry Arca Air Quality Managemem BOILER COMP(OVER IIN).al(1#TUI 0
Cs e_
-+��s ❑Ycsan ran❑.No NEW RESIDENTIAL MECII. SQ.FT. A
RIs
\
have mud the h,arSafe,,
de,Secants,5505,25533 under Chapter understand
.(me C
ria lleghh&nafca Code,have to?St,that it is y responsind 255�4.bility
I ity to pasty
that C1/� 993
pre of g does nm menta w ich must
be, et prior my rmarap oil'ny to nficat rhe V(-
.ecopam.1 the requirements which mea be inn pour w ixauanv'e nl a Certificate aOeupa \�\ �)
0,per,ncy,
owner,n anmed.ed.,gem Dam TOTAL:J 1ssulsD BY
OFFICE