26773 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO "oil. Mrs.KLELT TM. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING I-ROO-MEOI N,rivi A 26773
BUILDING 1'ROdla:'I'IUP.N'1'INICA'I'Il3N
BUILDING ADDRESS: SANITARYNO. APPLICA'T'ION SUBMITTAL DATE
5,1A Vw.a/� UNIT# LOTp
OWNERS AMC: I' /� PHONEq /J /�s CO Ac�,fOR'S NAME: LIC NO:
Cl A 00,44 we-W-40'6V JT m(�i NM- COM'ROLp
ARCH]'I'EC'FAINGINEER: LIC NO: ADDRESS: �1 E]Joe BOX 5491I n/7A OS
CONTACT: PHONE:
Q"f Y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
q (a q / BLDG PLUMB MECH
�[ COO (?s`-j 0 / S^b O�� PERMIT ISSUANCE 01 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
Ihereby affirm that lam licensed under pmvixmmofChapmr9(commcncing with
{x100 Section 7000)of Divisions 3,d the Business and Professns word ioCade,womy license is in PANELS
thy-- OF fall force it effect,
F VZ ty License Clan Lic.# UP TO 200 AMPS a
m 6 y Date Conua<mr 201-IOW"I's ``` ssssss 111
ZOr"isz ARCHITECT'S DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA SISQ.FT.
O Z— I understand my plans shall M used as public records.
F�kJW SIGNS ELECTRICAL �k
aJ Licensed Profoselonal I n V .[7 7 0�.
y� 6
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. U �� \ II J Il C7
06 Vs 1 hereby n.(Se that 1 am exempt tram the Contractor's License Lew for the p
3 LL ma following mason.(Section 730 1.5.Business end Profesiom Code:Any city or county TEMP.METER OR POLE INST.
which acquirers permit to constm,t alter,improve,demmiah,or repdv any intoe urt !//q/ u YYY iii
}�
poor its issuance,also requites the applicant farsuch Permit mfile esignWsmtement POWER DEVICES rS 2 y
� p0 that he is licensed pursuant to the provisions ofthe Contractors Licca.Law(Chapter /
a e� 9(commencing with Section 7000 of Division 3 ofthe Business and Profession,Croda) SWIMMING POOL ELECTRIC ON
^m or that he is exempt therefrom and the basis for she alleged exemption.Any vioham.of OVH.ETS-SWITCNFS-FI%TURES
F Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil pemlry of
not more than rive hundred dolhrs($50). NEW RESIDENTIAL ELECTR S .IT.
❑ I.asowneroft Me oy,ormyemployaswiNwagesutheirsole..,..tion, Q STORIES TYPIi CONSTRUCTION
a will do the work,and the structure is not intended oroffered forsale(sco7w.Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsmimpmvestbertoa.uad word.such workhimsidorthro,dild. OCC.GROUP RES.UNITS
own employees,provided that such impmm
novea osanotimendedoroffered foraAe.If,
however,the building or i mpmvemem is sold wi dura a ne year of canpletion,the owner-
builder will have the bund.of proving that Im did am build m improve for purpose of
sale.).
❑ I,as ownerof the propeny,am exclusively contracting with licensed contractors to QTY, PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.70,41,Business and Professions Cade:)The Contractor's
License Lawdoes not apply toanownerofprosm,whobuilds in improvethercon,and PERMIT ISSUANCE
who contracts forsuch projects with a coaaacmrod I icenced puma.t m the Conoma n's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE DO I DE FEES
SANITARY YN_
Owner Date DRAWS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOGLTAX Y_N
❑ Ihereon,senmsbnlhrance acerfi of canunterem'snsu.,ar eardfnmof FIXTURES PER TRAP RECEIPTO
Workeri Cnmpensetionlnsumnceorecmirird copy thea.f(Sec.3g0,labCJ which PARK ME Y_N
covers all cunp.,cox undenhis permit GAS-EA.SYSTI3M-I INC.4 OUTLETS RECEIPT 11
Policy# BUILDING DIVISION F17ILS
Company GAS-EA.SYSTEM-OVER4 EA) PLANCHECK FEE
❑ Certified copy is herby furnished.
❑ Certified copy is filed wird the city impaction division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SDILS PER
COMPENSATION INSURANCE
(This,extummed not be completed ifthe permit is forome hundred dollam SIM) SEWER-SANITARY-STORM FA.20FT. ENERGY FEE
or less.)
I certify that in the perfurrm.of the work far which this Permit is issued,l shall WATER HEATER W/VENT/ELECTR
.or employ any penin in any manner so as m become subject to the Worker' PAID
z Compematinnlawsof Celifomia. Date WATER SYSTEMIMEATING Date Receipt#
Applicant
C Q NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-' (q become object o the Waukee,Cardamom.provisions of the labor Code,you must
forthwith comply with such provisions or this permit shell be decided revoked. BUILDING FEE
z CONSTRUCTION LENDING AGENCY SEISMIC FEE —
I henby affirm that there is a construction lending agency for the performance of
U C) the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC IEE
LL, pLeader's Nome
U Leader's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have rued this application and sore that the above information iv
Ricorrect. l agree to comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL FEE
E,--'-' rte building,msumelion,and henbyauNorie,expre.n.t,on.fthixcity{ismer upon the CONSTRUCTION TAX
U z above-mcmioaed property for inspection purposes. ALTER OR ADD TO MECH.
(We).gne 1.save,irtdemaify and kap hamdess the City of Cupmum against
Iiabilitics,jud mcnts,coste wdexpemuwhich may in any way seems against said City AIR HANDLING UNIT(TO 10.00 CFM)
in consex, - f she granting of Nis permit.
�-/0z AIR HANDLING UNIT(OVER 10.030 CFM)
SignafiuL�npof6'Ap��aplieaduCodiiom acDdle EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10,001)BTU) Dam ReaiptN
Will Ihe.pplicant or future building occupant store or handle hazardous mmiand
.s definW by the Captain.Municipal Cale,Chapter 9.12,end Ibe limit),odd Safely HEATING UNIT(OVER 100,300 BTU)
Code.Section25532(a)7
0 Yes ❑No
VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 10,000 PTU) ISSUANCE DATE
Will theapplicanmrfmurtbuildingoccupam u.eyuipmem ordevice whichemit per,
hamrdnm air contaminants.defined by the Bay Area Air Quality Management ,BOILER-COMP(OVER 100,000 BTU) PA 0 D
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.fR, Jul o
1 have ted the hauaok us materials requirements under Chapter 0.95 of the 19 i99�
C.ifmnia Hcalth&Safety Code,Sections 25505,25533 and 25534.1 ondomm nd that /x'Tye
if the building does not currently have a V tenant,that it is my responsibility to notify the f
cupnm of We regmiremnna which must be met prior to iasmmce of s CeniOcme of r "Ur
I
Occupancy.
Owner or amhoriud agent Dore TOTAL: ISSUED BY: