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99110013 (2)not ICANTTO F! I IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPE RTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT D GFIRNC-fsIF.C1IANICAI. BUILD G PHOJE(T IDEN'TIFIGII'ION PERMIT NO. BUILI)INC AUURILS'ti: ��� /', n ID O / /�( "11 N1 JLIC Ta-OW2ER$M(/E:/`-1{(� SANITARY HO. APPLICATION SUBMITTAL DATE �^ PHONE: !/ 'rAYAk CO. R f0 NAME: NO: O NIC ❑ CONTROL) ARCHITECI'/ENGINEER: LIC NO: AU F S V CONTACT: PHONE: BUILDING PERMIT INFO >A F PFLf� !>G �eyl_©71.7 VTC (7rL` J ("7 `C ❑ Consultant Fees Paid by Applicant (Initial) BLDG IiLEC'I' PLUMB SH CH ❑ ❑ ❑ IBX LICENSED CONTRACTOR'S DECLARATION I hereby antrm mm 1 am licensed under prov,mns of Chapter 9 (commencing QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION PERMIT ISSUANCE is ith Section ]00)of Fevislon J of the Business and Professions Code. and any, licence is i in full limc:md cRcc ' yi RESIDENTIAL: ❑SPDWL ❑ KITCHEN REMODEL APPLIANCES - RESIDENTIAL License CP: _ LiaM Dia Ljc Conti for ❑ADDITION [I PLUMBING RE -PIPE ❑MULTI -UNIT [3 STRUCTURAL MODIFICATION [I INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT El SWIMMING POOLS ❑ BATH REMODEL/REPAIR [I DEMOLITION El OTHER ARCHITECTS DECLARATION 1 understand my plane shall be used in. public records PANELS UPT02MAMN 1 Llrcnned Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 an exempt beatific Cmdammr's License Law for the following reason. (Section 911.11.5,13mimess and Professions Gate: Any City or coumy 20I-1000AMPS GIVE IOOOAMPS SIGNS ELECTRICAL to cons er.altr. improve,sh, or mash any tweent jwhich requires permit re construe, alter, improve, whichoi¢fiesadcmti%to (xprior -. issuance, also h priz filen signed statement I (Chaer 9 thin nc k liecnsed pumuan, m the ao,iiom' d the Comm"or's Liconcc Use pt (commencing with Section 700) of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of SVECIALCIRCUITIMISC. TEMBMETER OR POLE S COMMERCIAL ❑ NEW BLDGIADDITION ❑ DEMOLITION Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of j not mote than five hundred dollars ($500). CC]1, as owner of the property, or my employees with wages as their sole compensation. 1 will the work. and the structure is not intended or offered for_sole(Sec. 701W. Business POW17R DEVICES ❑TF,NA NT ❑ FOOD SERVICE Ih1PROVEMENI' ❑OTHHR SWIMMING POOL ELEC'IWC o and Professions Calc: The Contractors Licence Law does nen apply to an owner of OUTLETS- SWITCIIES- TURES FIX NEW RESIDENTIAL ELECTR SQ FT. property who milds or improves thorcon, and who does svch;wark himself or lh')a his awn employees, pn.. sled that inch improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of comp1,lian,the SQ, FT. FLOOR AREA S/SQ. FT. er-bmlder will have the harden of moving chat he did not build nr Improve for pun Pascal sale.). Fl 1, a owner of the ma sorry, am exclusively connecting with licensed contractors to l'OTAL: coast rvet the pmjael (Sea 71,14, Business nod Pfole,ase, C-., Hh. Comroeors — cerise Law does net apply to an owner odpax,ort-ty who builds or improves therear, and QTY. PLUMBING PERMIT FEE who cowers for such projects with a contractions) licensed pursuant m the Commeson's PERMIT ISSUANCE License Law. III I am exempt under Sec. ,B&PCfor Nismtons J ALTER -DRAIN & VENT -WATER (EA) Owner Date WORKER'S COMPENSATION DECLARATION VALUATION /6" <J O BACK FLOW PROTECT. DEVICE 1 hereby affirm under molly of perjury one of the following declumtions: DRAINS- FLOOR, ROOF, AREA. COND. ❑ I have and will maintain a Cenilicate of Consent to self -insure for Worker's Camper- ration, as pmvided for by Section 3701 of the Easier Code, foil the pefmmam se of the STORIES 'TYPE CONSTRUCf1UN work for whicnthis permit is issued. FIXTURES -PER TRAP ❑ 1 have and will maintain Warker'a Compensation Inmmncd, as myuired by Section 3700ofthe Lber Ced,rot the pr(urnortce mine wmk for which tbox permit is issued. My Work r penx:mon Inw a CO Came . d Policy nu Cher are t�In 4. GAS - EA. SYSTEM -1 INC. J OUTLETS OCC. GROUT' , Curiuc _Policy No GAS- EA.SYSTEM-OVLRJIIIA) R0 WO/r1��17 rlF AI'' WORKERS' COMPENSATION INSURANCE ENSAFI.XIION INSURANCE (This section need not he completed tithe permit is forone (SIM) hundred dollars (SI or less) GREASEIINUUSTRI. WAS IH INTERCEPTOR GIVE FEES GRIiASF. TRAP PLANCHECK FEE SEWER -SANITARY -STORM EA. 200 FT. I coNfy that name prabot ossoffficIs kor which lhis'niont is ironed. (shall not employ any person in any remotions as to become subject to the Workers' Compry ENERGY IEE WATER HEA'TFR WIVENTIFLECTR ' satins Lows of Conforms. pace Applicant ) GRADING FEE j NOTICE TO APPLICANT: If, after making this Cerubeate of Exemption. you shoulJ ' Face re subject m the Workers Compnsati er provisions of the Labor Code, you must WATER SYSTEM/TREATENG SOILS FEE WATER SERVICE forthwith comply with such provisions or this permit shall be deemed revoked. • CONSTRUCTION LENDING AGENCY jIrewYaffirm that there isaconstruction [ending agency for the Performance of NEW RESIDIiNT1Al. ('LMB. SQ. FT PAID Dare Recciptp tae work ffor which this Permit is iuueJ (Sec. JfM)]. Civ. C.1 Lcndx,,y Nanta "1 (YfA V I hndvR Address TOTAL: BUILDING IgiF 1 certify that I have rtaA this application and xtxm that the above information is QTY. MECHANICAL PERMIT FEE I cancel. Ia8rcuom,nrply with all city and comdyoreinaoac, and swat law srelating ,, building combination, and hereby authorize repmsematives of this city to enter upon the SEISMIC PEE uMvcmemimad prnprty for inspection purposes. (We) agree m xuvc, indenmify and keep harndees the City of Cuprino YBmml PERMIT ISSUANCE ELECTRIC FIRE - liabilitics.judgmen¢ costs and expenses winch may many way acme ogams said City in asequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING FEE AIR HANDLING UNIT (TO 10.(0(0 CFM) MECHooiLAICAL FEE APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE RF. ULATIONS. AIR HANDLING UNIT(OVER 10.000CPM) � /� , / 7 Erb //—Dat�� CONS' 1'ION'IA Srgnamre ofA piano CmaracP HAZARDOUS MATERIALS DIS .OSUk13 EXHAUST HOOD DODUC) HOU (TIG i HEATING UNIT 100.000 BTU) Will the applicant or future building occupant.uore or handle hazmdous material as defined by the Cupnioo Municipal Code. Cbepmr 9.12, and the Health and Safety Codc, Section 25532(x)? HEATING UNIT (OVER 10(),0101 BTU) Cl Yes Will the applicant or name building t use equipment or devices which pp dbythenn Arco mit ha menus air contaminants as defined by the Bay Area Air Quality Management Dutricl" E] Yes P U One Reecipt VENTILATION FAN (SINGLE RFSID) BOILER-COMP(3HP OR 1(0,000 BTU) TRIAL: BOILER - CUM P(OV IIR III(I,INIO BTI]) AIR CONDITIONER I have read the haeardn I, maletiaL arts under Chapter 6.95 of the Cali- ymmmen p ISSUANCE DATE •" NEW RESIDENTIAL h1ECH. SQ. FT. matin gdoes & Safety Coda. Sections 25505. i 25533 and 2ribil 11. adify th that if the building does not currently nate a mrunt, that it is my responsibility to notify tae rKcupam art mewIt hattest t pairtoissa ace ora andieat•oro'am Z / �` Z _r ISSUED BY: Owner or authonmd agent Dae TOTAL: OFFICE