28417 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPPSION -' G- EC .I`IiNMII'"°. 28417
APPLICATION/PERMIT I'LUMIIING-M1IECIIANICAI.
BUILDING DIVISION _71M PROJECT IDENTIFICATION
BUILDINO ADDRESS: SANI I ANY No, APPLICAI ION SURMI I"I AL UA I I:
7571 o RnlnwR. IINITN LOTN �
-�9WNERS NAMI3: a PIIONHi C TtAC'Ir)INa IAC NO: (/
NIC CONI NOTA
Pv-T ALLI xAME: n1 — >7� 63
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<CI it IYCIn;NOINEHR: LIC NO: ADDRIi,SS: ❑
L] v� e ✓ yes 91 o
CONI ACI: PHONE: Ql'Y. ELECTRIC PF,RMIT ) hCfi BUILDING PERMIF INFO
�y I \,'
GA Cf sf—� /' C�C) PERMITISSUANCE BLDG CLECT PLUMB MECH
❑ ❑
LICENSED CON'TRACTOR'S DECLARATION APM.IANCIi9-RESIDIiNT1AL )OR D13CR11• ION
POO IhetebYafftmkion3offire ednnderpruvioomnf@epmr9l I ny Ird"gwilh 6'��� CZr
�DOW❑O Seni^o]IN0)af Divixiun]n(Ihe❑n,inen.,nnA Pmfcaiem Cac,and my lirenxe is in PANELS
�Z, full icrove and ellen.
' Iag..ZW Liur^'e Class Lic.N UP'IO2m AMPS
In<% Dam Cnntmaor 2111-Has)AMPS
z0f0nz ARCHII'f:CTSDECLARA']'ION OVER IfXXIAMPS SQ.ID'.FLUOR AREA S/SQ,IsI'.
Oz—qqqq l lot...land.y Plamshall he nada,public reel
F vst� SIGNS RLGCIRTCM.
�sdd5 Lmcnad['.ifcalnt nl
K�jV OWNFR.III ILDER DT,CLARA I'ION SPECIAL CIRCUIT I'/MISC.
On ,hereby AID mt that I am csanla frau lite Cnmmcmrl License Law,for the
1Q. fnllowin,ade n.lSeninn]BJL$,❑uainesa anA Profession Cde:Any cirymrnunty TEMP.MI9'I7R OR POLE INS'T.
VNOa which myuires a pemnit In ronalmn.alter,imPtnve,der^^fah,ar rcralr ally structure
YJM Prim m ata issuance,also rctrvirt,lire applicant for such permit to file a signed statement POWEROIiVICES
yip that he is]accused pummin ceche pmvisioa of the Coalmen',Licrnse law]Chapter
Qj 9(conumming with Section 7000)of Division l ofthe Business and Professions,Clark) SWIMMINGPOOLF:LECIRIC VALUATION
y'j'-4'q mlhm he
i
rtthnea^a dm haxi,farina anegrnerrn�pfmt.nny val
hrmt car (�
�'.tba Seninn]B➢SUIShYenyxpupltuir.mfOU
nrapctmitathjaDthreppliannnnrivilpeaveyof 'ILEI'S-SWUCIIES-FIX'I'lTRCS
zp
nor than Five hundred dJlina RIs). NIiW RESIDIiNTIAI.IiLIiCIR 5 .PI.
I ce ❑ I,amwmrofuhepmpemY•amy cmploy ec,wilh wa rand lit!( lecan,odcation, U STORIES '1'YI'li(:ONSI It CIIDN
will do lite walk.still theimnnure I Ainend rcofcle for e.]ID4,nnsinaa
and 14^fec,irm,Cola The Cold, ,,Iia w dorrt 1 p ,to an t w ud of '
ptopeaywbohuild,orimpmvesther send. . aAuchlsURklt Ifomhmughhia
emplayeen.provided lh.t such lm ta nmidedorafferedfo...le.If, OCC GROIII' Ii9 UNITS
hnweva,lhnyn
ehuildingor impmvemm�ti er WWp,,, nfernmpletion.Inowner-
budder will bovetheburdennfpow.,I ail nfit Ni]d m imperve,for purpose of TOTAL:
side.).
\/
❑ Ta, fit proper a imively conosdngwth licensed cotnruaory m QTY r PLUMOING hERMIT "r; .`, EEE I'IAOII Z.ONI: nPN
c m t tit pie 1 e .n .m �ofev als Cdr) the Contractors PERMIT ISSUANCI.
I rola da. to s 1 caw ywhohudi,cu nnrfavesihmeoa ad
4o n t 1.f a hp, w11 411 1 r(.sllcen.aedpursuanitol eContracmrs A ITR DRAIN&VENT WAI'LR(EA) FEE SUMMARY
m how
❑ I nm exempt oder Sa. D @ P c for this mase. BACK ROW PROTECT.DEVICE '
SANITARY YN_
yr
r Date RECIANN
WOR K MAN CDRAINS-PLOOR,ROOP,
OM P17NSATION DECLARATION AREA,CONI). SCDOOLIAX Y_N
J Ihereby affirm that l have a renifeme aducanto self-insure.or a certificate of FIXTURES-PER TRAP RECliI1TN
Wnrkerx Conpensaimt Insurance ornrenifed nspytlrcaof(Sec.JRIRI,Lah C.)which PARK Hli Y N
en ull empinyec's under this Penni]' GAS-RA.SYS IIiM�1 INC.4 OU[LMS RECFIIT M
Policy N BUILDING DIVISION ITT.-S
Company GAS-EA.SYSTEM.OVER 4 U:A) PLANcur.CK Pt
❑ CeriBd copy is hereby furnished.
❑ GRCASFIINDUSTRL WAS'IE.ITT 17RCEM'OR GRADING ITE
CERTIFICATE 01;EXEMPTION FROM WORKERS' GREASH I'RAI' SOILS mr,
COMPENSATION INSURANCE
(Iliksemi^nneMnm hecantplmalifthepefrdi,TornnehudmldolleOGDNB SHWER-SANITARY-STORM EA.20017. 1:f4ERGY FEE
or les,.)
I Ordfythm in he perfomtana of the work for whid,@is permit is isrued,l almll WHIRR I IIIA I PIT WNI!NT/IiI.I;CIR
no o^plo, my penan in any manner io tom heau^m ,uhjrcl to the Workers' PAID
Z Cmu,nsminal.awsnf Odif^miw Date WA'I'ERSYS'TIMORVA"I'INO pub, N
Applicant .c
�2 NOIICETOAPPLICAN'T':1L.ltd nmking this Ccnifcnm of lixmnptinn,you should NI!W RESIDENTIAL PLM11. SQ,M. 'TOTAL:
af , bee nnm,ubjecIt,tbe Worker's Canrr'nsation.... isions oft he Latin Cab. Tor timetin se
s ; forthwith rn^rely wish such prmi,imn m this permi,shall he Jeemcd levokel. BIIILDIN
y [] CONSTRUCTION LENUI NO A(BiNCY AIRS
I z I hereby of Firm deal dune is a conduction leading agency for lite performance of
j O the work Inc which this permit is Issued(Sec.MITI.civ.C.) rl.ficwuh.fi
Lendrns Nnnm
lcderx Addmx, QTY. MCCIIANICAL PERMIT kgs - PLUMBING PRF N
I certify stat I have read this it,liatian end sum tba the.Mn.e Information is
Wmrtat.I agree in comply with all city end county ordinances our state laws relining in PERMIT ISSUANCE; MECRANICAI 'EE
adding construction,and hereby vuduolue represontalled nDhis city memcruam the CONSIRUCI' 1NTAX
Mve.mentinned pnVdy[or in,pectian purpsrsca. AIA ER OR ADD 1`0 MSCI I.
._.Q (We)agrte to save,indemnify and kap h.gird,the Cit of Cupcninil again
liabilitie,,judgm 1Rr.a and capemee which e Y cmc.gan. 1 y AIR IIANDLIN(I UNI I'1101p,1110 CPMI
n n,cgne the ing til rids lRr
U AIR DANDLING UNIT(OVER 10,(MCFM)
Si 1�Ib
of App]ican/Conunctor Date— EXIIAUS r I IOOD(WB)UC , PAID
IINd RDOUIS MA'117RIAISDISCLOSppg IIIiA"PING UNIT(TO 100.00011111) Hum Rr iDN
will the applicant In future building occupant sem In handle heuNous material
mf d
deby lite C-upmino Mmticipnl Core,Chapter 9.12,And the I Iddih and Safety BEA']INC,UNI I'(OVER 110,0X01110) (UAL:
Calc,Section 255I2(al]
C1 Ye, ❑No VIiNTILAI'ION FAN ISINGI(SINGLERIiSIDI
:. BUTLER-C(IMPLUIPOR UOdNN)B'I'U) ISSUANCE DAV
' he
'the nppiicunmrTmure huilAingocenpnnlumeyuipnmm ordevicex whichemit I'1
air contaminants As defined by the Buy Area Air Quality Menagctant BOILER-COMP(OVER 10,M)nN) '`
❑Yet ❑No NEW RESIDEN'T'IALMECII. SQ.IT. 21
Q1 have mal Br hmatdnu,memlial,requiremems^^der Chapter 6.95 of the JUL`J
California I Icalth A Said,Craft,Sections 25503,25533 end 25534. 1 mWersmad that (s
if the building dax^nittoodtly haves odnd,ilia it ism,,,,aMbility 1.notify the
mcurymt of tine reyuitemenn which must he met prim to issuance of a Certificate of
Occupancy.
Owner or^mharixed agent Date TOI'A1.: ISSUED nY;
OFFICE