S 0195 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECBING- T
RCIWIFIC Q 0
BUILDING PRfIJEC'T IDLNTIF'ICATION J
BE�NG�ORESS: /1 � SARI('ANY NO, AI'I'LIaCAT10N SUBMI�L DATE
OWNER'S NA �: rL ^ �O�'E�� � CO T ACI' R'S NPME: � LIC NO: ' ^/�^
41` 3 NM. CON'1'ROI,N
RCHD EC1UPNGINFBR; LIC NO: ADORE ❑
g qisi(23
CONTACT: PHONE: BUILDING PERMIT INFO
�6,-p�s,O ❑ Consultant Fees Paid 6y Applicant(Initial) BL❑IK ELECT iPLUMH/ MP❑CH
�yJ LICENSED CONTRACfORR''S DECLARATION7 QTY_ ELECTRIC PERMIT FEE llrny/
I hereby affirm that 1 am licensed ander provisions or chapter 9(commencing JOB DESCRIPTION
C�M0Z with Section 7")of Division 3 ofthe Business and Professions Code.and my license is RESIDENTIAL:
WOOPERMITISSUANCE {'
WF, in full force end ellcct. /.C 1 T-5. J Q ❑SFDWL ❑KITCHIiN R1:NODE.
Licens Cxih ! gpPLIANCFS-RFSIDF:NTIAL ❑ADDITION ❑PLUMBING R6PIPC
L.Z Iy Dam- TS Drmr
m6a ❑MUCfI-UNIT []STRUCTURAL
ARCHITECTS DIICLARA'r10N
z0ioi I undeatand my piens shall he used as public records IANLIS MODIFICATION
0Z4O UPT0200AMPS L1 INTERIOR ❑CHIMNEY REPAIR
I. Fqq"W Licensed Professional 201-10011 IMPROVEMENT 0SWIMMING POOLS
a�R OWNER-BUILDER DECLARATION
R W C 6 I perch (firm that I am exempt from the Cammnnr's License Law for the OVER Inch AMPS ❑BATH REMODEUREPAIR DEMOLITION
e p
n'0 a V whichfollowing motor. rotor t 703 S.Business and improve,
don i Curie:Any cin or county SIGNS ELECTRICAL, ❑OTHER
which requires a permit m rnnstnm6 atmq improve,demolish,or repair any swmorc � �[ U '
F'�OJ prionmt
o its issuance.also requires applicant for such pcino file a signed Indialnt SPECIAL CIRCUITIMISC. qJ xOC - Xti ZJ5-A��_
W�} that he is licensed pursuant m the provisions of the Contractor's License Lar,(Chapter 9
QO (commencing an Sermon 70000 of Division 3 of the Business and Professions Cale)or 'IAMB METER OR POLI?INST. COMMERCIAL '
S y m E that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC 4. Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
FZ> not more than rive hundred dollars($50% IMPROVEMENT
fZC ❑1,as owner of the property.army employcex with wages ns theirsnto compensation, SWIMMING POOL ELECTRIC []OTHER will do the work,and the structure is not intended oroffered farsalc(Sm.](146.Business O
W,�'� and Professions Code:The Carbonate,License Law lows net apply it an vainer of OUTLETS-SWITCHES-FIXTURES `�
a property who builds or ina drome thereon add who docs such work himself or nmugh
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELFCTR SQ IT.
sale.IL however.the building or improvement is sold within one year of compldion.Jhe SQ.fT.Fl.00R AREA FU
pSQ.
town
,r-builder will have the barren of proving that he did not buil)or impmvc for pupar.'reof suleJ. lD
Fl 1,as owner rf the property,am exclusively contracting with licensed contractors to q'
mnswet the project(STs.AEN,Business and Professions Coda)The Contractors L,- FF
most,Law doors not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who commas for such projects with a ea ntmnoa(O licensed pursuant o the Contractor's
License taw. PERMIT ISSUANCE Q �/
1 vat exempt under Sm. ,13&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VAI.(ATI
Owner Date
WORKER'S COMPENSATION DECLARATIONBACK FLOW PROTECT.DEVICE.
LL have
and anion under ainx Penalty of of Coyencofthefollnd ha devWtolker'sCs:
ulhave ono will far
eCion 37 a of theLaor Code,for the performance
of the DRAINS-Iq.00R,RO01(ARI?A.CORD. STORIF_S 'I'YI'13 CONSTRUC'r10N
sauna, r provided far by Section l9W of the Lahr Cede,for the performance of the
w kfar which this maintain
issued FIXTf1RGS-PIi12 TRAP
I have and will maintain Workers Camp(if the n Insurance,as required by Section
.tfNl of the Labor Cade,for the per(nrmanee of the work for which his punnit is issued. GAS-UA.SYSTCMd INC.40I1T1.1iT5 OCC.GROUP APN
MyW xCompen ti r ec 'erand Policyy ny a+e �0.;.'�9 GAS-EA.SYSTEM-OVER 4(BA)
Cortle Policy do n
CERNFICATI3 OF EX.MPrION(BOM WORKERS' GRLASIJINDUSTRI.WASTE INfI?NCI?I'I'OR
COMPE'NSA'TION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is Imone hundred dollars(SIW) GREASETRAP
YLANCHIiCK FEE
or less)
nomI unify that in the performance eOhe work for which this permit is issiltd.%likliall til?WIiR-SANITARY-S'I'ONM PA.2M Irf.
ploy any person in any manner so as it)become subject the Worker M1 ENLRCY PEE
Q 7.. cation Laws of California Date si WATER HEATER W/VENf/ELECIR GRADING FEL?
Applicant ki
rN.o NOTICE TO APPLICANT:If,ufmr making this Cenificum nl lixentp shon a Wq SYSTF.M/TRI?A'1'INO
(~ , became subjmt to the Workers Compensation provisions of the I ,you must SOUS FEC A
forthwith comply win such pravisinns onbis peaail,holl be deem vokeJ.An WATE iN
O ``•T
CONSTRUCf10N LCNDINO AGENCY n NEW >SID' � d LMB. SQ.IT. PAID
V Q (hereby offred thanberc is a emismodon lending ugen fmtppperfnnnadm,v` Da Receiptp
the work for which this permit is issued(Sec.XN),Cie CJ -i BY
O U
Lenders Name T(l'I'AL:
lender's Name I"
�.S a BUILDING FL
[r I unify that I have red(]this application and state that the shove inform
fA correct lagreemcomply with all city and county ordinances and slate lawsmisti , 'Y. F.CHANICAL PPRMIT FEE
CJ z huilJing ttmstmctien,anJ herchy amhorize rcpresenmtivea of this city to rarer upon the SEISMIC FEE /A
above mentioned property far inspemion purposes. I'i' SSUANCE V
(We)agree to save,indemnify end keep harmless the City of Copula.egaimt 1iLELTRIC FEE X 71
Iiabilities,judgmems,costs andexpen.seswhich may in any way accmeagamil said City ALTER OR ADD'1'O MUCH. O
in comminute of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT ABR HANDLING UNIT GO 10,000 CFM) MECHANICAL FEF.
SOURCE R ULATION- S.
AIR HANDLING ON[['(OVER IO.WI)CPM) CONSI'RULTION TAX
Signature of Applica Contractee Date EXHAUST 11001)EV/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hueurdous material HEATI NO UNIT(TO I II0i BTU)
its defined by the Cont iso Municipal Code,Chapter 9.12,and the Brain'and Safety
Cuda Section 15532od? HEATING UNIT(OVER i00.000bT(9ISSUEDRY.
El Yes ON. VENTILATION FAN(SINGLE RESIDPAID
Date Receipt X
WIII the it commor jufuutre ric making by the Bay
eea Air Quality
tlManawhich
l hamrdous air nmmminams as definNby the Nay Area Air Quality Management BOILER-COMP(3NPDR 108,(X10 B ,)T
istrin? BOILER-COME(OVER IW,000 BT
❑Yes ON.
I have read the haeard.d.mamdals damormems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC.DATE
burns Health&Safety Code,Sections 25505,25533 aid 25511.l understand that if the NEW RESIDENTIAL MEER.
huilJing Ines not currently arm,amnant,thm it ismy responsibility lomidly neoompunt
o(the rtqu is
most he p r to issuance ofa Ccrificmc of ps y.
Owner oiauthorir ge Dau
OFFICE