29773 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION A P.ICATION/PERMIT PLUMBING.MECHANICAL.• O `�
BUILDING PROJECT IDENTIFICATION J .J
BUILDING ADDRP' /N SANITARY NO. APPLLIICAI'[ON
NSSUBMITTAL DATE
Ir
1'IIONF.:
w OLS+ Erg 4 N/C CONTROLp
4RCI31TEC1'IENGIN iER: LIC NO: DRESS: ❑
IoM 1 a c 1+ 1 AI2Poon-'T R zo3 on
CONTACT: //�� C. PHONE: w`r RI-'�$r)6a i BUILDING PERMIT INFO
J s m Sr I k C406 728 ``/v� � Consul lln[Foes Pail by AppBCanl(Initial) 4?'
LD E PLL/ ECH
LICHNSEDCONTRACTOWSDRCLARATION QTY GI,ECTRIC PERMIT PEE
I hereby affirm that 1 am licensed undn provisions of Clar 9(commencing OB DESRIPTION
qaZ th Section orTivision3 of the Businessane Prdossions C.de,anamy license is RESIDENTIAL,
�00 wt R itki ISSUANCE
full force and effect.
��H to ❑SF'DWI. ❑KITCHIiN REMODEL
U License Cla s Lin,p
F.
Ume Contractor APPLIANCES-RESIDENTIAL ❑ADDITION Fy�` l`.a ❑PLUMBING RE-PIPE
Veia4iARCHITECT'S DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL '
ZOyZ PANUS
lundctstend my plans shallhuud as public recoNs Is
OZ—O UPTO 200 AMPS
❑INTERI '1 19WHIMNEY REPAIR
Liccnscd Prolcssional - - 2U1-I(IIN)AMPS IMP�ENT
J OWNER-BUILDER DECLARATION OVER 10,`00PS S
y C Q I hereby affirm that I am exempt from the Contractors License Low for the ❑BAT ODfiUREPAGIRt P DEMOLITION
X O L U following reason.(Section 703 1.1,Business and Prnfa,dom Cade:Any chy or county SIGNS ELECTRICAL ❑OTHHRf
1z7 O X0
which rcquirts o permit to conxtmn,alcor,improve.demolish,or repair any swctum �
�n poor to its issuance,also requires the applicant forsuch permit to rile a signed statement ECIAL CIRCUITIMISC. r�
that he is licensed pmau,nt to the provisions of the Contractor,License Law(Chapmr1)
�g p. (commencing with Section.—'afDivision 3ofthe Busineaand Professions Calcine TEMP.MET POLE INST. COMMERCIAL'
0.�e T that he is exempt therefrom and the basis far Ne alleged ucmption.Any violation,of ❑ EW BLDG/AUDITION ❑DEMOLITION
^'y Section 70315 by it,applicant fora pennit sabjema the applicant m a civil penahy of POWIIR D S � W BL ❑FOOD LITIONSERVICE
Z} ind mare Nan rive hundred dollars(5500).
E C 01.as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL IC IMPROVF.MF.NT
will do the week,and the,duemre i...t intended or offered Ibr sole(See.7044,Iltrsineas 1 ❑OTHER
LL�1 mend Ihofessions Code:The Contmnols License Law does not apply to an owner of LOTS- WIES- RES �
l� r
property who builds or improves thereon,and who does such work himself or through T Hhis awn employees,provided thin such Intpmvcinents are not intended or uttered for NRW RRSID t 1 Rh CTR SQ FT.'
sale.IL however the building or improvement is 6nld within oneyear of completion, e S .IT. l.t PA YSQ.FI'.
caner-builder will have the burden of proving Chet he did not build nr improve for pu OZ.
on U C7r \ [ ]owe ofrtaacome, th omercbre6an the project(See 761,1.Hunn, nd Pmfenims Cash:)The Commerce's Li- `AkIdLutc
conson Law does not apply nt an owter(if property who builds or improves thereon,and QTY. .UMBING PERMIT FEE
who contracts for such projects with a controcmt(9 licensed pursuant o the Contractor'e
License law. PERMIT ISS 5
❑Iain esemt under Sec. ,B h P C for this reason _
Ow D �� ALTER-D N& RA)
A7 A VVAI/,B"ON—�
WOR R'SCOMPENSATIONUECI.ARATION BACK TEC't DB ICE Llo CO (^
ereby affirm under penalty of perjury one of the following declarations:
FI I have and will maintain a Certificate of Cunsenuo self-insure for Worker's Campem -FL OOR AREA,CONI) STORIES TYPE CONSTRUCTION
sntion,as provided for by Serious 37W of the Labor Code,for the performance of the
wort for which Nis pennit is issued s FI 'DRGs-PETR
1 have and will maintain Worker's Compensation Insurance,as required by Section
3]fNJ of the lahm Cale.fonhe perfommnce of the work for which this permit ixissued. GAS-EA.S 'bf-I INC. IITLEfS OCC.GROUP APN
My Wnrket's Cumpenentin.Insurance canon and Policy number ore:
/ Comer. Policy No.: GAS-F.A.SYS' M rvF.R4(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPJI S ,WASTLi INTERCEI'fOR ��
('Ibis section oecd na bewmpinM i[Nepemdt is for ane hundreJdollars(51 W) BI111.DIN0 DIVISION FEES
of less.) GREASE TRAP PLANCHF,CK FEE
I certify that in the performance ofthe work forwhich thispannit is issued,l shall SEW EN- 'AN - EA.2011 �all�a
not employ any person in any manner so as to become subjeet to fine WorlaCompete ENERGY FEE
O 7. satin.laws of California.Data WATER HEA NENT/ELECTR
Z Applicant GRADING FEE
.N. NOTICE TO APILJCAbU,Baffin making this Crafcum of Exemi you should WATER SYS9EM/T ' G
f~ � become subject the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
fonhwithcnmpdy with such prrtvisionsnr this pennit shad l be deemed revoked. WATERSERVICG 456
U0 CONSTRUCTION
teloor LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,PI'. PAID
L) 0Thereby affirm that there is aconurunion lending npcncy for the performance of _ Date ReceiptN
the work for which this p t is issued Scc.3 Civ.C.1
0 U Lender's Name w NF_ P'IJ Nt�O 150 TOTAL:
Lender's Addfcss
yI certify that l have read this application and state that the above information is BUILDING FEE
Z1 correct.l agrtem comply with all city and county imitimpes andsmm I.,"clatingm QTY. MECHANICAL PERMIT FEE
U bmldiugermorecti.n,and hereby uuthorim represcntntivea ofthis city to entetuponthe SEISMIC FRC •
above-mentioned propcny for inspection purposes. n=01GII 16
(We)agree to save,indemnify and keep harmless the City of Coleman against PERMIT ISSUANCE ELECTRICFEE
Iiabila es.judgments,costs and axpen.ee which may i a any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE .w
APPLICANTUD WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 1(1,1100 CTM) MECHANICAL"FF.E
SOURC CGULATIONLATIONS.
AIR I IANDLING UNIT(OVER I R(10O CFM) CONSTRUCTION TAX
tgt mmufAppdic inductor Dine EXHAUST HOOD W/DUCT) HOUSING MErif;KTREN PHI? '
AZARDOUS MATERIALS DISCLOSURE
Willtheapplicnnt or furore buildingoceupamuurenr handle Economics,mamriel HEATING UNIT(TO Half,"BTU)
us defined by the Cupertino Municipal Cale,Chapter 9.12,and the Heahh and Safezy
Code,Section 25532m)7 HEATING UNIT(OVER I00,00ad BTU)
[I Yea [:J No VENTILATION FAN(SINGLE RESID) PAID
Will the applicem of fumrc building occupant use eyuipmem nr devices which - Date Receipt M
emit hrmdous it contaminants as defined by the Bay Am.Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
TOTAL:
District?
Yes CJ No BOILER-COMP(OVER 100,00013TU)
I;have rand the hazardous materials mr,iremcrou under Chapter 6.95 of the Cali IR CONDITIONER
Room HISSUANCE DATE
ealth k Safety Code,Sections 25505,25533 and 25534,1 undetsmed that if the NEW RESIDENTIAL MGCH. SQ,FT.
buildinrr
gdocsnilcuently haveatentr that it u mymsponsibidityutnotifytheoccupant
of the requirements which must Is,met prior m issuance of a Certificate of Occupancy, r
Owner or authorized agent Data _ I / ISSUED BY:
OFFICE