S 1007 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY - BUILDING.ELECFRICAL
TTY OF CUPPr: nuT No.
J BUILDING DIVISION APPLICATION/PFRMI-P PLUMBING puniRciiCIlANIFIC 1007
' /" , ItUILMNG I'ItWRCI'IIIBNI'IF'ICATION'•'d•,• "
HI11LIlING ADDRESS �� SANITARY N(l. APPLICATION(ISUBMI07 DATIi
WN-1 N M.. r I'IfDQryG /-p CON1 RACFOR:S NAME: LIC No: ��
1 G c� ' -3��.J a NIC CON'I'RUI.X
AR'1IITIiCf/ENGINIiER: 1,IC NO: ADDlt Ii55: ❑
• CONTACT: PHONE: BUILDING PERMITINFO
_❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUME Mesal
LICENSED CONI RAGTOR S DECIARAI ION QTY. 1 CLE(TRIC PERMIT FEE
I herel,y alrra B-(1 amr I d p rchapter9Hamm s +. t ,:• + I. /. TOB DESCRIPTION
W0Z w,in Seefrva700B)ol'Di arn3onhe Bmeante soma Prnfi,' nacadaf,nnmy lccm+e'a PERMIT ISSUANCE! RNSIDEN I'IAI
F � full force and effect. � , ❑SI•DWL ❑KI'I CIIEN REMODELCSF In
aVp Date Class Com APPLIANCES-RBSIUF.NTIAh ❑ADDITION E3 PLUMBING kIi-PIPE
W Date Cnnhneor
;_DV
_ V ARCHII'I!CTS DECLARATION ❑MULTI-UNIT ❑MODIFTAIIO
` ~�Z Irnderstandm ball he uscla public record. PANELS MOI3IPICA'TION
Oz-- ypenss P - UPTOHNIAMPS [I INTERIOR ❑CHIMNEY REPAIR
r-4 t:W or,cred Paime,imad 201-1000AMPS IM ROVEMEN'I' SWIMMING POOLS
CaCCC_' OWNER-BUILDER DIiCLARAI ION ��H RI:MODELIREPAI It AiMOLIOON
9-�j OVER IfXX]AMPS
Q I M1ereb IEmm Thal I am exam t from the Comrennr's Ciccone Law for mite
iq5 6 U (allowing reuaon (Section]fIJ1.5,Huimess anA I'mfessinns C,de:AnY city or anmty SIGNS ELECTRICAL A el
l"fHF:R t
which mpom,a tenon am oi....1.:ala,improve,denadish,or mpair:my slrecurne
f"�� prior In ilsis+uance.el.+n rcquirev the applicant l inmeb permit lnlileun'ignedlomment SPECIALCIRCUI'[MISC.- � X
� > that he is licensed amormal 1.he provismnsof lire Contomo/s License Law(Chapter 9 COMMERCIAL
W��Q (commencing with Section 7")of Division 3 of the Business and Professions Coca)or TEMP.MBI ER OR POLE INS'i'.
d e that he Is oxnnp(thereM
from and Thu basis for the alleged cacmpn.Any violation of ❑NEW BLI]OIADDITION El DEMOLITION
%^_+anSection 7031.5 by any applicant far v permit subjects the opplicanrm a civil Penalty of POWER DEVICES ❑'TI'NANT ❑FOOD SERVICH
y (m arc than five hundred dollars(5500).
IAIPROVEMEI T
pzQ (]1,an owner ofthe property,or my employees with rages as their sole compensation. SWIMMING PDGI,IiLECfRIC ❑OTHER
C, will dthe k.mul lieshoolliall is 11,11clnJI ff If (Sea 7W4 I{ r
aim mJ Professions Cal The Contract,,,,Lim,roc Law does am p,iy or a own,,or OUTLE IS SWITCHES PIX'IURE
property who builds r npm :there d h does such workit If 0...x,gh
his own employees.providead that such improvements are not intended or offered for NEW RGSIDENINAL ELFCTR SQ FT. Q FF 1 O1LA VSQ.FT.
,ole.If hnwcvantha IF Winger improvement iii,okl wiffmare y.,allomplei n the A ro
will have the burden at proving ilial he did not build or improve for po'-
f']a) TOTAL, �['(1�II
owner-bolder OCT 2 1 RL{/{�
w h nth project IS ]Rii I{ II f Com:)Tb C t t :1 -- - - ; } -'
cc . 1 Iws t only to ftp ty h h'I I: I :tit � 1 QTY" � ,PLUMEINC IIa2MIT,�•, FEIi
who c t ofor.such Jec(.s with acon(mcln(s)Icarmad pursuant the Contractors ` t /s f� CfIT'L�/�
License Law. PERMIT ISSUANCE CITY OF CUPEHTINC
❑ lam ext tun Sec. ,B&P C for this reason
AL'IHt-DRAIN&VENT-WATER WA) VALUATION
Owner Data — — ��
ORK R'S C( PENSATION DECLARATION _ BACK PLOW PROI ECT.DEVICE /11/�/f
• 1 hereby ME or under penally of perjury one of the following decimations: S 11
❑ I have mid will muntain'n Cenililum nfcnnseramself-inomito Worker's Connno- DRAINS-FLOOR,BOOR ARBA.CONS). STORIES 'I'YEE CONSTRUCTION
s tion,os provided for by Section 3700 of lite labor Calc,for the pertnnaancc aI the ,
work for which this permit is ixiueL FIXTURES-PER TRAP,
Cj 1 have and will maintain Workerx CmaPensmion Insurance,as required by Section
7/00of the Labor Cn]a,far the pml'onaanee of the work ha which this permit is issanni GAS-I?A.SYS'1'HM-I INCA(IUTLP,'1'ti OCC.OR AI'N
My Worker's Compensm inn Insurance tamer and Pot icy mmrbar arc:
Comm,: policy Na: GAS-HA.SYSTEM OVER 41EA)
CERTIFICATE OF EXEMITION FROM WORKERS' CRRASPJINDUSTRh WASTIi INTERCEPTORCOMPENSATION INSURANCElU D G DMS ON F'
1'ILissectinnneed notbeunnpleted it the Pemmil is lin onehunJmJ dnllfm(MINI) GREASETRAP
� or less.) PLAN E '13G
I certify thin in the performance oflhe work for which this permit is issued,l shall SEWER-SANITARY-STORMEA.20OFI'.
not employ any Peron in anymmnner so I's m h,comosnhird ,,the Workers'Cnnmpctr IiNle ;Y Pule
,Z sauna Laws of Callfnmia.Date WAS ER HEATER W/VENT/ELECI'k GRADIN IS
Z Applicant I
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREYrTNG
F '�^
become ecoe supca n the Workers tensadon Com f the Lahor Code,you area, SOUS PIT!
trout droll
Bmhwilh comply with tamvi.v
ch pinns onhis permit bnll be JeemeA revoked. WATER SLRVICI?
Q
CONS'1'RUCTION LENDING AGENCY NEW RIiSIDFNTIAL PLMI1. SQ.Pr. PAID
hereby uflirtntnat themkacanstmcdn i lending ugenoy for the Perforator.of Data ReceiPlX
LULF the work for which this permit is issued(Sec.3W7,Cie.US HUAI:
Q U Lander's Name TGTAI.
Led .AddX.ress I
ycel ny11 lin r 10 : ppl i d rt tittm h for BUILDI ICE �•
Er. rn co 1 g l ply thug city J N t county and I +reloadingat, QTY. MECHANICAL PERMIT' �PIiIi -(
U Z building construction.and by tit u p n tivs ffri city to mer upnmthe -.
S
EISMICFE
above mens oned property for inspection purposes FERMI ISSUANCIi I
(We).,me nm'ave,in lanv,ify and keep harndess the City of Cupetion against
babili(ies,judgmems,casts and expenses which nary in any way accmc against said City Alll'ER OR ADDTO MECI I. HF
in conequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) L FEE
SOURCE REGULATIONS.
Alit ANDLING UNIT(OVER 10,00)CFM) ION TAXSignaturcofApplica marwmr Da¢ EXHAUST HUGE)(WMUCI) 'IGATIONF i
IIAZARDOUSMATIiRIAL DISCI,OSURE
Will the vptlicam or fuwrc building neuupam save or handle bnxurdoux mmerial HEATING ON[fit 0100.010 BTU)
or defined by the Cepamon Municipal Cale,Chapter 9.12,and the Health fail Safely tlliAl'ING UNIT(OVER IINLIXNI BTU)
Code,Section 255J2(a)1
�Yas ❑No V17N'TILAOoN PAN(SINGLII RESID) PAID
Dam Receipt p
Will he applicant or From building occupant use e,uipmmll or devices which gplLHk—cUMP(ANP(lk 1(X1.000 BTUI
coil haeardous air contaminants as defined by the Bay Arca Air Quality Management 'IDEAL:
District 1 BOILER—COMP(OVER 100,(NN)BTU)
❑Yes ❑No
I love mail the hauWons materialscgaintreers under Chapmr695 of III,Cali- AIR CONDITIONERISSUANCE DATE
fornix goes&Sufmy Cuda,,cions 255115,2553):red 25534.I understand that if the NEW RESIDIiNTIAL MECfI. SQ.FT.
s - office
answhichu cumarall have She met prim
ismy umrwc morvinilllymnmifythemecutom -
oftherequirtmenowhichmusthemmpriormissuvnmofie Cenihcam of[kculmncy. '
Owner or au(hmRed agent DumTOTAL: ISSUED BY:
OFFICE