99120019 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING ELECTRICAL reRMlr NG.f /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGJECTFCDANICAI. Y�qy
nuu.Omc rnOdecr u)d:NTIFIcgTIUN
BUILDING ADDRESS: x SANITARY NO. APPLICATION SNIT MIlTAL DATE
z S. eIIIX� — Z - - ,
(IWNER' NAME: P DNF;: CONTRALTO SNAMIi: / LIC N6.
,y eSL I[oYN/C CON'I'RULq
Ze
CHITECT/ENGINEL : .( L O: ADUk ❑
0. (oy4fYSS•S CA 9�6 .o
CONTACT: PHONE: BUILDING PERMIT INTO
ClTests Te is Paid by Applicant(Initial) BLDG It PLUMB MECH
1:1 1:1 -LSF [:1LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FIT,
I hereby wfirm that I am becomd under provisions of Chapter9(commencing .1013 DESCRIPTION
IyQyI 00 with Section 700(pofuivision 3 ofthe Bucthessand Professions Ccale,audmy license is PERMIT ISSUANCE RESIDENTIAL
�WZ in full fame and en'ca. "'I(�(/�2 ❑SFOWI. Ll KITCHEN REMODEL
"UtQU(j Lirenu Clus Lich - APPLIANCES-RFSIDENTIAI. []ADDITION [I PLUMBING RC-PIPE
Daae Z Contras '✓t ZY
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCI'URAI,
,=to PANEL ti
Z O-,35 I understand my pans Khali be used as public records MODIFICATION
OZ—, UI'To 2W AMPs ❑INTERIOR El CHIMNEY REPAIR
[:Pj 1"'W LiccmeJ Professinnw 201-111ERAMPS IMPROVEMHN'1' I]SWIMMING POOLS
OWNER-BUILDP.R DFCIARAI]ON
N OVER IIXXIAMPS EI 121?MODEL/Rlil'AIR EI
AIR
4q Q I hmeby elfinn Wm 1 am exempt from the Comnmmr's Liwnsc Law(nr tear
xOatU following reason.(Sertion 7031.5,Business and Professions Code:Any city or county SIGNS Ii1.13CIRICAL ❑OTHER
1 3 W which requires a pemat to construct,alma improve,demolish,or repair any xuueum
f"�yg prior to it,issuance,also requires the applicant forsuch Permit o file a signed mwancat SPECIAL CIRCUIT/MISC. �,C
fyW} Mct he is licenud pursuem nuhe provisions of the Cmm�mnrs Liccme Law(Chapter9 �A
�C4p0 (rommencingwith Sectinn70(10lof I]h,sioa3arfthe Businessend Professions Csale)m 'TEMP.MCI'IiR OR POLE INST. COMMERCIAL:
6 y o y that he is exempt therefrom and the basis for the alleged exemption.Any vinlutiun of ❑NEW BLDG/ADDITION ❑DEMOLI'HON
iC ro0. Section 7031.5 by any uppliwat for a permit sub,lecis the applicant to a civil penalty of POWER DEVICES
Or, El TENANT C1 FOOD SERVICEurn mora than five hundred dollars($500),
C [DI.aaowner ofthe pmpeny,or my employees with wages as their sole unapcnsalion, SWIMMING POOL ELECTRIC IMPROVI?MIiN'I'
will do the work,and the swctue,is not intended or ufietcd fm rale(Sec.9M4,Resilts, ❑OTHER
W m and Professions Code The Contractors License Law dons not apply to all owner of OUTLETS-SWITCHES-FIX I URFS
6 3 pmpeny who builds or improves thereon,and who dose such work himself m through r-�—
his own employees,provided that such improvements nm not intended or offered for NEW RESIDENTIAL ELECIR SQ FF 1
sale.If,harvest,the lonldivgnrimpmvemetn ismld within one ycarofcompladon,the Q.FLFLOOICA EA
builder will have the burden of proving that he did not build or improve for par- D� D
Of
poo"fault.).
❑ 1,as at,of lot pmpeny, it,exclusively summating with licaused mnatamotm m T DEC 21999
instruct the prnjcel(Seo.9044.Business anal PmfcA ,Codc:)The Cowmemr's 1,
use Law docs not apply to on owner ofpmpeny who builds or impmves wemrn,und QTY. PLUMBING PERMIT
who contracts for such projects with o eontratmr(s)licensed pursuant to the Cmnmcturs
License La, PERMIT ISSUANCE N00, DD
[D lamexemptundcr Sec. ,B&PCfoehisreawn
ALTER-DRAIN&VENT-WATER(1?A) OF
gTID
cane Date
WORKERS COMPENSA'T'[ON DECLARATION HACK PLOW PROTECT.DEVICE
I hereby affirm under penalty of p am,Dna of the following deelannions,
❑ I have and will mulntab.t Certificate ofConuenuo uelGinsum for Worker's Compmi- DRAINS-FLOOR.ROOF,AREA,C(IND, STORIES TVPIi CONSTRUCTION
,union,as provided for by Suction 37W of the Lausu Coale,once,perfummnce el the
work for which this permit is issued FIXTURES-PER TRAP
[D 1 have and will domain cracker's Compensa0on Insurance,as required by Section
3900 of the Labor Code.for the pefotmance of the work for which this Permit is issued. GAS-13A.SYSTHM-I INC.4 Got LI. OCC,GROUT' AI'N
My Workers Compensation Insurance carrier and Policy number are:
Carrie, Policy Na: GAS-P.A.SYSTEM OVER 4IA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASEIINOUSTRL WASTE INTERCEPTOR
OI111.UIN0 DIVISION PERS
(This sec tion need not he completed it the permit is or one hundred dolrmtsIld) GREASE'I RAI'
nr less.)(This
II?I?
I cenilythut inthe performance,fthewark litrwhiehthapcomit is lxsunt,lslmll SEWER-SANITARY-STORM PA.200 IT.
not employ any pets,,in any manner w as to become subject a the Wake,Cooper- ENERGY THE
OZ xaton Laws of C.1Romi..Date WATER III;At ER T/
VINENGLECTR GRADING PER
Z O Applicant
NOTICE TO APPLICANT.11;after making this Certificate of Exemption,you should WATER SYS'IEM/TREATINC
F u become subject to the Worker's Compensation provision of the Labor Cade,you must SOILS FEE
Wforthwith comply withxuch provisions or this permit shall be deemed revoked. WATER SERVICE
Q JCONSTRUCTION LENDING AGENCY NI?W RESIOHNI'IAL PLMB. SQ,FT PAID Z I hereby a01nt thin them is a construction lcnding agency for the artornumee of Dec Rn,,IIt
U the work for which this permit is issued(Sec.3107.Civ.C.)
1"s Lender's Name TOTAL:
L Lcndcr's Address TOTAL BUILDING FEE
certify that 1 have mad this application and slate that the above information is
FC:) to comet.l nom mattnply withal)city and county ordinances and state laws telnting to QTY, MECHANICAL PERMIT PER
Z building consauaion,anti hereby tomorrow representatives afthis city menter upon the SEISMIC FEE
above-mentioned pmpeny for inspection purposes PERMIT ISSUANCE
(We)agree Insure,indemnify and keep harmless the City of Cupeninn agaiau ELECTRIC FEE
mfialbilitresjudgments,coos andaspemes whlebnuty in any wuyaccmenguinmt,aid City AL'I'Hk 01(At)[)TO MUCH. PLUMBING THEegma, grunting of this permit,
comse of tear
APPLICANT UNDERSTANDS AND WILI`CoudpLY WITH ALL NON-POINT AIR HANDLING UNIT FTU 10,000 CFM)
SOURCE EGIILATIQNS. ��f MECHANICAL FCL'
If ,� U AIR HANDLING UNIT(OVER I0.(XX)CrM) CONSTRUCI'[ON'FAX
Sign rmmf ApplimmrrCnnfh or Date EXHAUtirHOOD(WNUCr) I IOUSING MITIGATION FEE
HAY.ARDOU$MATERIALS DISCLOSURE
Will the applicant nr future building occupant store or handle hazardous notarial HEATING UNIT TO 1110,010 B U)
ata defined byline Cupeninn Municipal Coda,Ornate,9.12,and the Health and Safety
Cada Seelion 25532009 IIEAI'INO IINI'I(OVER I(,,gX)11'1'11)
Yes No
VENTI IA I 10 FAN(SINGLE RCS I D) PAID Date Receipt#
Will the applicant or forum building occupant use equipment or devices which
emit broader,air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR I(It"IITU) TOTAL:
DianctP BOILER-COME(OVER 100,00 ITT())
[Dyes El No
I: hmunlnus materials, to under Chatty 6.95 of the Cul i- AIR CONDI'I'IONER ISSUANCE DATE
requirements p _
fnmio Ilhave read the wlth Or Safety Coale.Sections 2.55115,25593 und 25534.1 understand that if the NEW RESIDEN HAL MECH, SQ.IT. J r (I (S
buildingdoes notcurrewly haveateent.that it ix mytmpo hillty m unify the omcnp /ant ` -L—
of
T /
of the"inven mo which oust be met poor to issuance of a Conificam of Oeca,un,
Owner lir euthnnuJ agent Date TOTAL: ISSUED BY: TXp
OFFICE