S 0741 (2) OPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPF.RTINO - BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MCCIIANICAL' (N o 7 A Z
NW LDINf:PR(IJ t:CT IDwrillICATION J 14F
BUILDING ADDRESS: SANITARY NO. APPLICATION SUIIMI ITAL DATE
y2 Fi1P c/'ee �E v�. 2__ Q9
OW ER'S NAM PIIONF.: CO AC OR:S N �•F% LIC NO:
I LAl NIC CONTItOLp
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\ ARCHITECI'/HNGINEER: I.IC NO: ADDRF,. ✓n '❑
CONTACT:
PHONE:
'y BUILDING'PERMITINFO
. - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME/ MECW1
LICENSED CONTRACTORS DI CLARATION QIY.«.' 1 FLIiCTRIL PERMIT I ls'� e' '.FEE JOB DESCRIPTION
hereby affr n that I um licensed Ile p f Chep r,9(cn un n t b
DMZ with Section l(g111DIMiAman 3 ofthe Business Pr omwas 1 O aodmyhcerw v RESIDFNTIAI'
WO, s PI RMI]ISSUANCE
CLL- in f II forte end cILyy�1 .. - - ]SFDWL ❑KITCHEN REMODEL
QUzU License-j7:` � Lic.p AI'1'LIANCIS-RESIDENTIAL - ❑ADDITION Ll PLUMBING RGI'll'Ii
so Qu] Dnla F iP Commemr
tL AHCHI'IIiCT'S DEC[ ON ❑MUhTI-UNIT ❑STRUCTURAL
ZFpnZ I understand my plans shall he used as public record% IANLLS MODIFICATION
CZ-O Ul'TO 200 AMPS ❑INTERIOR E3 CHIMNEY REPAIR
W Licensed Prom,,ional 201-1000AMPS DOPROVEMI?NT ElSWIMMING POOLS
�
OWNER-BUILDHR DECLARATION OVIiRI(NOAMPS ❑BATH RIMODEURFPAIR ❑DEMOLITION
C CW Q I hereby affirm that I am exempt from the Contractor's License Law for the
O L U following reason.(Section 7031.5.Business and 1'mfe.sinnn Code:Any city or cotumY SIGNS CI,Y.CfItICAL ❑OTIILR
LLOy
which ermines,aIK t wrimorumidur,improve,dannoliO.Or mIedirm,scou,min,
P,i 11. :. Lwm,mm,mc...E If 'u M1pemon to hill a 111cedsmmmenl SPECIAL CIRCUITIMISC. - -
Wa'
9ap0 list he licensed mation,t the prosixico,oftim Contractor,Laen,u Le (Chapter9 - COMMERCIAL: -
wnand - -
momriencmg h Section]IXOpdDvtsion 3 oldie Bueness andl f 'ns Cartel or TEMP.METER OR POLE INST.
dew he is exempt brafrnnl end the bests for the Merged exemption.Any Anlmion of ❑NEW BLDGIADDITION ❑DEMOLITION
Section 1131.5 by any applicant for a permit subjects the upplicanlm a eir it penalty of IMIWF.R DCVICIS ❑TENANT E:1 FOOD SHRVICE
H.ZC not more than five hundred dollars($500). IMPROVF!`j
fL0 (] I,os owner of the property,or my cmpinyws wide wngen ax their sole cmnpemminn, SWIMMING POOL ELECTRIC
F will do the work,and the structure is not intended oroBered lr isale(Sec 0(114,Businwx ❑U1IIEli
W and Professions Cale:The Contact.",Licensa Law does ern apply at an owner of OUTLETS-SWI'I CUES-FIXTURES
property who mi Id or intpmvcs]hereon,and who does xnch work hbmell'nr Ihnnlgh
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR SQ FI!
sale.IL how rot,the building or i ntpmvemcm is sold withinone year of cnlnpI tion,the 5 .I t REA VSQ.14.
mer-builder will have the burden of proving thr he did not build of intprovc for par- L//
pose f. Ie). TOTAL:
Ll I ecoicarr Of the p pent..excimikel,cortmenin,with licensed conte t to
�.mmml he project(S7f Bums d P I n:Code)IIIc C ah.eI r:[i-
'
clove Law does not apply toanowner ofpruamywho builds orimproves thereon. d QTY PLUM BING PERMIT FEF.
who contract"For"0,projects wall a comnmlmto licensed pamm:m to the Contractore
License I., PERMIT ISSUANCE
❑I am exempt under Sec. ,B k P C for this reason
-' - ALTER-DRAIN k VENT-WAI1!R 07A) VALl1AI]ON
Owncr Data
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby olTnu under penally of penury one of the following declnmlions.
'C]I have and will maintain a Cerificate ofConoxaL to m!Ginsure for Workers ComO,m- DRAINS-I4.00R.ROOF,AREA.COND. STORIES 'I'YPECONSTRUCHON
sulion,as provided for by Section 3700 of the Lubar Cadc,for the purformamcc of the
work for which this permit N o,,Oed. IT TO RIS-pl!R'I'RAI'
❑I have and will mamldn Workers Compensation Insurance,as required by Section
3900 orbit Labor Cafe,for the performance ofthe work for which this Femur is issued. OAS-I!A.SYS'1'IiM-I INC.40I1TLEIS OCC.GROUP AEN
My Wor4,"e r'sC it ration ..met caricrand Policy r�b r ra -
CamecC/Policy Na � f CAS-EA.SYS'1'I!M-OVI3R 4(EA)
CE 'FICA . .PE IiMPHONFROMWORKERS' OHP,ASIJINUUS'I'NI.WASTE IN'IEHCI!I'fOR
COMPENSATION INSURANCE. f1U1LOIN(3 DIVISION FF.RS
(Thissection need not be completed ifthe peratil isfnrone hundmddollan(5100) GREASE TRAP or lr,) PLANCHECK FCC
Icenifythatinthe peAomtaaceofthe work for which this permit i%ivaed,I%hall SIiWER-SANITARY-5TORh1 EA.200 17.
nal employ any penton
many m:umer w ns to become subject titm Worker{Conlpen- ENERGY Poli
Z spun Laws of Califnrnin.Date WATER HCA'I'ER WIVRNTIELECIR GRADING FEL!
NOTICE bj APPLICANT:If,Ca making This Certificateuth Exemption,you should WATTµSVSTF.M/rREATING SOILS PEF.
a ; foramit acompy the Workers Comp,or this provisions of de coed Labor Code,you must
(1.1 forthwith comply with such provision.or pemtit shallMdcenmd revoked. WATER SERVICE
Q
n' CONSTRUCTION].ENDING AGENCY NI7W RESIDEN'UAL ELMB, SQ.IT'. PAID Dale Be'[
r7 Z Ihereby air.don there iso construction lendingagercy for the performance of tin
LUL the work for which this permit is issued(Sec TOO,Civ.C.)
n
O U Lader.Name- TOTAL:
Lenders Address TOTAL: 9.
C Jl
I certify]hal I hove lead Ilii.applico .arr,
ion i it m Our the above information i. - v t� BUILDING PEE
to corer.l agreem comply with all city and counly tralmaimes and slate laws relwing m QTY.,' 'I ' MECHANICALPERMIT •rFF.li
U Z building construclimn,and herebyauthorrze representatives ofthi%city to enter upon the SEISMIC FEL?
aMrve-menjionul pmpeny for inspection purposes: PERMIT ISSUANCE
(We)agree 10 save,indemnify and keep harmless the City of Cupmho against Ii1.EC1'ItIC ITiC
liabilities,judgments,casts and expenses which may in anyway uceme against said City ALTER OR ADD TO MECH.
PLUMIIING PER
A APPLICANT
Nthe RSTiN Sthis permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR_HANDLING UNIT(TO IO,INO CIM) MECHANICAL IEEE
S)URCB REOULATION. -,y
1=\� L {�.LZ) AIR HANDLING UNI']'(OVER III,IXN)CFM)
CONS'1'RUCfION TAX
'ig roof pplicauRContacl0 Dam I EXHAUST IIOOD(WIDUC) HOUSING MITIGATION FT:E
HAMRDGUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazmdons material HEATING ON]'I(TO 110.1100 TO 111) -
axdeltoid by Ile Caperllnn Municipal Code.Chapter 9.12,and the Hcult 1 and Safcly -
Code.Section255J2(a)1 HATING UNIT(OVER W,gNIHTU)
[I Yea ' VNo PAID -
- VENI'RADON PAN(SINGLE RESIDI Doe RL'iptA
Will the applicant or furore building occupant use cyuirynenl or devices mm, BOILER-COMP UNP OR 100,0001110)
emit hazardous air cmmaminanl.a as defined by the Pay Area Air Quality Management
TOTAL:
L�� gdovs
tit MOILER-COMP(OVER 100,101)BTU)
❑Yes ❑NO
Ihave read the hazardous materials is under Chapin hos m(lac COi- AIN CON DOIONEIt ISSUANCEDlcahh&Safely GNe,Semions 25505.8533 and 25534.1 unJersmnJ the ifthe NLW NI!SIDEMTIAL MECfI. SQ.Irl'.not cmlrcoly haven tenant,that h is mty resp ,ibiBry trmtily looceapma+Aar,limmenowin h/rfyu�s{t`emelpT)ormissu:mceofmCend"am rf C)cc�cy.� amnh? ��5�1 7--%/ Dam TOTAL: ISSUPLOBYI�CJ��/� — 1 e �
OFFICE