S 1395 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY k(M�
CITY OF CUPER'1'INO BUILDING-ELECTRICS. I I.RMITNO 1395
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECBANICAI.
BUILDING PROJE.C'1IURN'I'IFICAPION
BUILDING ADDRESS: SANITARY NO. API'LICAI'ION SUBMITTAL DAT
773 ►� K Yv o w GT n
OWNERS NA PHONIi:� CON'1'kACfOR'S NAM L�� Vies'C NOgoj�
22 L'U N/C CONfROhb
ARCI IITECIVICINCEK LIC NO: ADDRESS: ❑
1 _
CONTACT: PHONE: BUILDINGP1312MITINFO-
❑ CDnSubanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB hi
❑ ❑ ❑
LICENSED CONTRACT ORIS DECIARATION QTY ELECPRICPERMII' FEE
1 hereby affirm that 1 am licensed under provision.or Chapter 9(commencing JOB DESCRIPTION
DWZwilM1 SemiontMxp of Division hf the Business and Professions Cale.and my license is RESIDENTIAL:
in 11.11 fear mal rIf,,f PERMIT ISSUANCE
in ❑SFDWI, ❑KITCHIiN REMODEL
QUU License Class Lie'X APPLIANCES-RESIDENTIAL ❑ADUI'I'ION El PLUMBING RE-PIPC
FF Z.ad Date Commas
tnQ c. ❑MUI..1 FUNIT OSI'RUCfURAL
ARCHITECTS DECLARATION
F y Z I makr,lanJ my na.,hall be used as p.hlie rca+nt, PANELS MOD119CA N
-.
Up,021H)AMPS
ZOZ�� ❑IN'fl?RIOR -Y P
1-�f u1 Licef,ell Professional 201-IIXX)AMPS IMPROVEMEN'P Ih NG 'OOIti
G -) OWNER-BUILDER DECLARATION
(�Y OVER 1000AMPS [I HAITI RIiMODE1BEP y2 DEA 1'1"ION
C Q 1 hereby affirm that I ren exempt from the Canlractnr's License law for the kAq14 R.
n O Y U n Mowing reason.(Section 70315,Bm'ire,,and V la,simt,Cade:Any city m county SIGNS ELECTRICAL ❑(YfIIEk
311.(Awhich requirecon
,man,a .mit I,c ,man,amec improve.denndlsh,nr repo,,any'mutt...
OQ prior m it,issuance,alw requires the T,i mrwch Pe.a,, file a signed Aalotoon SPECIAL CIRCIA I'IM1SC.
0; that he r Ip pursuant Ih p of the Contractor'1 (Chaplin COMMERCIAL:
ad (....a arria, fit C I 7000) f DLvl,on 3 ofth limi nessand ProfessionsCalc)or TEM 11 MIU ER OR POLE I NS'T.
a S c 0 C door he i'eunnpl mamfn+n and the ha:,fin the alleged e t I I Any i dation of ❑NEW BLDG/ADDITION ❑DEMOI.1'1'[ON
Section]031.5 by any applicant for a permit subjects the applicant n a civil penally of POWER DEVICES [I TENANT FOOD S17RVICE
W m not more than five hundred dollar($501
�=6 ].;is owner or the n Io with wages their side compensation. SWIMMING POOL ELECTRIC OTHER E.MENI'
{ C dept llof is employees ed u, Penes El OTHER
C E.m will du lhcwork,and e:The Cum is tur v lJ emw Lawcdo fof of apply town owner If
W 3- and Profusions carie:The comtthenco Lind w laws such
not work
l r la if owner of OU'I'1.1!'I'S-SWI'ILIICS-Ilx'rukes
his o ny who bails,or improves t t such i and who J.c,such work deed a,fi Ihmubh
his own employee,.Provided Ihul such improvements art not.maraca or affemJ for NEW kISIDENTInI.ELF.CZR SV I.T.
sale lLhoc...the budding..impmvonan.h so It within one yeartl a( a,1vlinq the SQ.14.EL(Kjp(dun EISQ.PI'.
w
owner-builder will have the harden of proving that he did not build or improve for purr, Q 3 11111�kY��yySW��,���
ry+w of sale.). "IYYTAL ��A {J
I,as owner of the Pmpeny,am exclusively contracting with licenwd rnmrunnn to T%'i
.,moa the project(Sae.70a 1.Rearms and P.fusinn,Crude)U.Comntnnr',Li- r r.
cause Law dors not apply In an owner of properly who b.11J,or in,pracc,Ncmon,and QTY. SIDING PERMIT FEE
whoeontrscts f+rsuch limiters with acontracmt(H licen.wd pursuanuothe Contremor's
License Lit.. PERMIT' SS NCI
Iumexmumander Sec. ,R&PChathi,reaam
ALTER-D VE AT 1: ;A) VA LUA PION
Owner Dan,
• WORKER;S COMPENSATION DECLARATION BACK PLOW PR DE 13
1 hereby affirm under penalty no perjury one of the following declaration,:
IM1.ve and wilLnuinwin scan.❑nnr.of Cnmentmxelf-ireurc for Worku'x Camper- DRAINS-FLOOR.R 'A.COND. STORIES TYPI!CONSTRUCrI(if
xnliou,as provided I I,Seefion 3]1x)of fie Laho.Code,for Ne peraanvIncc of the
work tor,Into this permit is issued. FIX IT RLS-PER I RAP
❑I have and will maintain Worker's Compemmion Inwrsome,as required by Section
3]1x)ol he Luber Code.tn ,w pe lnnfare ofihc work ft,ytli Itl+t���s�� GAti-ErA.SY5'rum-OVERiVIP�1�1 OCC.GROUP APN
M WoM1ar,( nmJ I'ollcy n
rncr �I�� xO"se v"rmic Pulley Nn.:
CERTIFICATE OI'E%EMPIION FROM WORKERS. GREASIANDUSTRL WASTE INTERCEPIT)R
COMPENSATION INSURANCE BUILDING DIVISION FERC
(This mlion need bol he completed iflhe lariat i,for one hundred dollars IS I IIB) GREASE THAI'
nr PLANCI IECK PIiH
fees.)
I ccnilY Nat in the perpoimantoof the work ler which wPL Nis Permit i.ised.I shall SEWIiR-SANITARY-STORM EA.21N)
not empiny any Person in any....cost,as to ben+me subject m the Workers Co.,.- ENERGY PER
.Z ,anon Laws of California.Data WATER HEA'ITR W/VENTAHLECTR GRADING FEB
Z O APPlicam )
NUI ICE APPLICANT:If,after making Ibis Ccnlficme el Iixemption,your shoorM WAI ER SYSTEMG REATING
SOILS FRI.:F-' beunrc h.hjea to the Wicker's Coons or this prevision,of the Labor C.Je.You must
Wti forthwith comply with such provisions or penniuhallMJeemeJ revnkeJ. WAI'IiN SERVICE
PAID
CONS'TRUC'TION LLNDINGAGENCY NEWRINIDENI'IALPI.MB. SQ.19'' Uac Rccc'
V O Inerenr l8rm mat marc isarutr,wan+n mttditts agency R,r me l+•dnrmana.r
W the worA for which Ni,permit n.ssueJ(See.3119].Ci¢C)
O Leader' TOTAL:
,Name OITA :
L) lenders Adkins,
1 certiNat I have mad this applicalon.,,it state routine above InFranima ix BUILDING FEE
fto correct.I agree lommply with all air)and county ordinances andstic laws reining to QTY MECIIANICALPERMIT FEF SEISMIC FEE
Q building construction,and hereby authorize representatives nDhis city to enter upon the
ahovo-.nanfiofal poart,Em imareion Purpmc°. PHRMI'I'ISSUANCE ELECTRIC FCL!
(We)agree to save,inJemnily and keep handt,,the Cily a1 Cupcnino ng.insl
Iiabifiliesjudgmena.cast,and expenses which may in any way accrue against said City ALTERORADUTOMECH. PLUMB1NGPC17
in mcquenae omit
f the granting of this per .
APPI.ICANI'UNDERSTANDS DWILL COSIyyyttl WIT11 ALL NON-POINT AIR HANDLING UNIT(TO I0.0(X)CFM) MECHANICAL PTI!
SOURCE kf:GUhAUON."
AIR HANDLING UNIT(OVHR 11400()CPM) CONS'I'kUCf1ON'1'A%
Signorina of Appllcant'Contmtlor Datc E%IIAUST HOOD(WITI HOUSING MITIGATION ITS.
HAZARDOUS MArl;RIALS DISCLOSURE _
Will thcapplicmn or l'ulurchuilAing occupantvoremiandl.hemoba,mmcrial BEAT ING UNI'1'(10100.00)11'TU)
a,Jefined by the Captain,,M.nlei,d Colic.Chaptar 9.12.and the Health and Safety
Code,Section 25532(x)'! - HEATING UNIT(OVER I00,000 WITH
E)Ye, EJ No VI!N'II I.ATION FA N IS I1,41I.17 it F.SiD) PAID
Date Reccipt X
c ... the air somalmfurore IdamagrccupuBuseequipmentordevice,which BOILI!R-COMI'(3H1'ORIIX),IXUBTU)
mit hazardous air ummm.nam,m def bed by the ItaY Arca Air Quality Managemcm TOTAL:
ITetnetfI1011,ICN-COSI-OVER 100,000 BTU)
❑Yes El No
I have read the komdou....an.[,"areuscnu under Chapter 6,95 if he Cali- AIR CONDITIONER ISSUANCI.DATIi
fornix Health h Safety C+Je.Sea to 25505,25533 and 25534.1 anderstaml Lha if the NEW RESIDENTIAL MSCI I. SQ.FT.
Indidagdoe,not cuncnlly hawstenon,shat it i,mym,poo,dvlit,to faulty throcepallt -
oflherequim.nuns,which lnml he dna Prior o issuance of a Cenlficaeol"OoCuemcy. -
Owner or authorized agent Data TOTAL] ISSUED BY:
OFFICE