24494 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'fINORUILDING-KLECI RICA I. PERMIT NO. ^ I w
APPLICATION/PERMIT I'LUMBINU-MECHANICAL. L 4�JJ
BUILDING DIVISION BUILDING PROJECT IDENT1F'IC'AI'GN'
BUILDING ADDRESS: �(�I, �n l(7/' �! r SANITARY NO. APPLICATION SUBMITTAL DATE
. 0(053 1VWL Q, 9xi—e ��t/f41TN LOT n It I� 1 % •t—
OWNERS NAME: PHONE: CONTRACT'OR'S NAME: LIC NO:
- O -76 /L �/ N/C CONIROLN
• ARCHITECIENGINEER: LIC NO: V ADDSS L� 1A) El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELIECf PgMECIi
PERMIT ISSUANCE ISS
LICEND3
SEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDEN
AL
p�Z I hereby affirm that l am licensed underpmvisions of Ch:m¢r9(commencing with �+ JOB DESCRIPTION
P010I- Sector 7W(B of Division 3 of the Bosluess it Pfom,xio Code.and my liceow',in PANELS �/� �Q� S�
QFZUj Liclenose Clad effzct. „x U1�ic g }�.Y/�A/7 1
+K'r.-L-'c'f_b"._1 452& 4Z UPI'02WAMPS ♦h �.
v.Qa Date Canaria, 201.1010 AMT'S Vim/♦
FyZ ARCHITECTS DECLARATION SQ.Irl'.FLOOR AREA !E/SQ.FT'
20H Iunderstoodm I hll be used as blit raoNs. OVER 1000 AMPS
OZ_p YPanss a Pu
F ad F W SIGNS ELF.CTIi1CA1.
LiwnuJ Professional
wwwOWNIER-BUILDER DECLARATION
' SPECIAL CIRCUIT/MISC.
KOat-. 1 hereby affirm that 1 am exempt from the Comruanh License Law for the
u1�+I+-tet following reason.(Section 70315,Badness and Pofessionc Code:Any city or county TEMP.METER OR POLE INST.
1_�-O� which rcyuircs a permit to cnnsnua,alcor,improve,demolish,or repair m
ir may wclme
S'E} prim to its icmance.at.requimthc applicant for such pcnniuo file.signed sutcmrni POWER DEVICES I 1
as<0 that he is licensed pursuant to provision,of the Contractor's Liccow Law(Chapter SWIMMING POOL ELECTRIC
04 9(commencing with Section 7UUo)of Division3ofthe Bu%ine,sand Professions Code) VALIIAr10N
W=h of Ron he isaxempnherefrom.nd the basis fortheallcgedeecmption.Any violation of OUTLETS-SWITCHES-PIXY E
t K Q Section 7031.5 by any applicant Emit permit subjects the applicaum m.civil penalty of t
5=p not mom than five hvndrcddallam(S500). NEW RESIDENTIAf.Iil. CTR _SQ.EI'. 'T IIiS TYPECONSTRUCTION
CFo urpm
❑ I.asownerofthe Mro rty.ormyemployeuwithwac.%atheirsolecompensafion.
a3=° will do the work,sad thaswwma is not imenmilm.ffemd buxom(Set.7044.Business U I /J, '
and Profeasino,Gds:The Commerce,License Law Jas not apply Io an owner of v
property who bu dds or improve%Ihemon,and who discs such work himscl f or through his
ownemployecs,provided that auchimprnvememssrtnol itnerakalmoffed fimode.If, OCC.G P RES.UNITS
however,the buildingor improvement is sold within one year ofcompletion.the owner- I
hander will have the harden of proving that he did not build or improve(or purpmc of
.It). PLUMBING PLUMBING PERMIT FEE FLOOD ZONL APN
[:II,asowoeraftheprmpeny.amecclusivelyconr tingwithlicrnsdcontr tonin Q
ns imer the project(Sec.7044.Business and Profealom Cosim)'Me Commerce,
License Lawdoes not apply it)ano,ferofpropcny who builds nrimoo,v,thereon.and PERMIT ISSUANCE
w1m,mmrews rorsuchpuselswifhaeommemrts)Imened,.moot to the Contractor's ACIPA-DRAIN&VIN,-WAI ER EA) FEESUMMARY
License Lew.
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE; SANITARY
FEES
SANITARY YN
Owner Date DRAINS-ROOR,ROOF.ARFA,GOND. RECIEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IMrcbyaffirnnhailhaveacertifcateofcortiwntmsclf-insnre,oracertifcutcof FIXTURES-PIER TRAP RECEIPT#
Worked Compensation Insurance or a certified ropy thereof(Sa.3800.Lab C.)which PARK FETE Y N
Poll
aIle p �uc{ GAS-EA.SYSTF-M-I INC.40lJi'LETS r• RECHIPTa
Policyk v4 109 / BUILDING DIVISION FEES
Pd
Comnl '1 �1 L GAS-FA.SYSTEM-OVER4 U:A) PLANCHECK FEE
❑ Ccrtifid copy is hereby famished.
❑ Certified copy is fled with Ne city inspection division. GRPASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CFRI'IFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILSFEIE
COMPENSATION INSURANCE
(Thisxacuion need not he completed i(tim permit is formic hundred dollars(SIW) SEWER-SANITARY-STORM EA.20KAPr. ENERGY PEE
loss.)
I ccnifylha in the perfmmanceofthe work for which this .it is issuuh l shall WATER HEA'1'Fit W/VIEs T/ELIECTR
nm employ any person in any manner as to become subject to the Workers PAID
Compensmion Laws of California. Dart—so WATER SYSTEMITREATING Dam Receipt#
Z Applicant
NOTICE.TO APPLICANT:If.after making this Certificate of Exemption.you should NEWRESIDENIIALPLMB. SQ.FT. TOTAL:
(~ fq fccomexubject to the Worker's Compensation provisionsofthe Labor Cede,you must
fndbwim comply with such provisions ormis permit shall be deemed revoked. BUILDING FEE
c ZD
[5 CONSTRUCTION LENDING AGENCY SEISMIC FEE O
z
I hereby affirm that is a construction lending agency for the performance of /
ELECTRIC FEE
:7 �
U O Ur'work for which this pcnnid is issued(Sec.3097,Civ.CJ
Lender's Name PLUMBING FEE
Lender's Address QTY. MECHANICAL PERMIT FEEh
C U 1 cerin,Jut I have .if this application and sure that the above iofnnnminn is MECHANICAL THE
s1' D.l corcn.l agree to comply with all city and county ordinances and state laws relating u PERMIT ISSUANCE h �
building construction,and hereby amhmies reptesenutives ofthis city Insider upon the CONSTRUCTION TAX
1..) z aboveanclnns ioned property fori tion purposes. ALTERORADDTOMECH.
(We)agree Ins a Inde y and kcc rmlcsx it Ity of C rtinm.gmnst
liabilitics,judgmc reds enpenses hm'm way reem tsaid City AIR HANDLING UNIT(TO IB,(MMI CFM)
in conuyuence t to ng mfdis it. /
/// AIR HANDLING UNIT(OVER 10.000 CPM)
goal App teanVCon tar am EXIIAUSTHOOD(W/DUCO PAID
HA9.ARDOUS MATERIALS DISCLOSURE HEA-1'ING UNIT(TO IW.WOBTU) Data Receipt#
Will the applicant or(mare building«cupvn score tar handle hisesel material IWATING UNIT(OVER I W.00)BTU)
as defined by the Cupcninu Municipal Cmdc,Chapter 9.12,and the Health and Safety ) 1
Code.Section 255321.)1 VENTILATION FAN(SINGLE,RESIDE t
❑Yea ❑No
Will OeapplicanmrfuwrcbuilJing«.pant u¢equipmenmrdeviceswhich emit
BOILER-COMP(JIiP OR I W,000 BTU) ISSUANCE DATE
• hmurdnus air contaminants as defined by Elm Bay Arco Air Quality Management BOILER UE000 BTU)
District! PAID
❑Yes El No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hazardous materials rcyuircmems under Chapter 6.95 of the 19 1992
California Health&Safety Civil,Section,25505.25533 and 25534. I understand dial
if the building does not currently have a tenant,that it is my responsibility to notify the NOV�#YY
occupant of the requirements which must be nel prior to issuance urn cempcac or1
Occupancy. CITY G k a°�
Owner nr amhnriacd.gear Dae T ISSUED BY:
OFFICE