29961 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAI.
BUILDING PROJECT IDENTIPICAT'ION 29961
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
OWNER' AMB: PHONE: T AC'I'D %NAME: LIC NO: `•�
NIC CONTROL#
ARC I /EFIGNEER. .1 NO:- ADDRESS: ❑
C
CO ACD PUTS: BUILDING PERMIT INFO
/J q/ '1 O\I ❑ Consultant Fees Paid by Applicant(Initial) -BLDG ELECT PIER MECH
(1 Z A7 moo(„p J r ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hemhy atErm dist I am licensed ander rmwi,ians of chapter 9 wommane ng JOB DESCRIPTION
•,O„�'Z with Section 7")of Division 3 ofthe Btfuessand Professions Code,andmylicenu is RESIDENTIAL:
F Oin full force and effect. PERMITISSUANCC
RUU License Class Ue.p ❑SFDWL [I KITCHEN REMODEL
�Z Date Cammmar APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C)STRUCTURAL
>>
zO y❑ 1 understand my plans shall he useJ as puhlic rtcivds � MODIFICATION
OZ�O \ UPT02MAMPS El INTERIOR ❑CHIMNEY REPAIR
f:aw Licensed Professional 201-1(Np AMI•S IMPROVEMENT
C� OWNER-BUILDERraemptDECe Conte ON OVER I000AMPS ❑BATH REMODFVREPAIR DE ION
y C l hereby affirm this 1 1 S tempt from the Contractor's a:Any a Law for Ne r!a) ��/,
>(a C.V following rcuvon.(Section 7031 3,Ilusiness onJ Professions Cale:Any city lir county SIGNS ELECTRICAL 1. ❑OTHER L�IA J
47 LL O which rectums a permit m conswct,alcor,improve.dermdish,or repair any sracture
prior,.if,ism...r.alw unpirtstheapplicam far such permital Elea signal smmment SPECIAL CIRCUI'I'/MISC.
a� that he is licensed pursuant to the provisionsofffie Contractors License Low(Chaptort)
00 (°ommencing with Section tll(XpotDivision3of the Business anJ Professions CMe7or TEMP.MEI'ER OR POLE(NST. COMMERCIAL,
a e e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
{e• Section]831.5 by any a" '
" tinta"if subj¢a Ne applicant ma civil"""of POWER DEVICES
rn} ❑TENANT ❑FOODSERVICE
z not mart than five a ndred!props ty,orrmy em). - IMPROVEMENT
Cp ❑Lathe owner k,and
napery,structure
ycmplended wiNwred for alei(Sao 0o 1,B sinewson. SWIMMING POOL ELECTRIC
tCs will dn.foWmk,Cdeh Th.Cum isnaintended draw does
to
oa,frl or ❑OTHER
a� and erty who
Cade:The Canuherea License law stns not apply s lf owner of OUTL1'f5-SWITCHES-FIXTURES
property who build,or improves thcrem,and who does such work himself cf though
his own employeese provided that.such improvements am not intended or olTered for NEW RESIDI?NTIAL ELECTR SQ FT,
h.wcvcl.will
have me burlding den
issoldhe id noneild or
parvietihh,the SQ.IT.FLOORAREA. S/gQ.FT.
owncnbuilder will have the Furden of proving that he did not build or improve far pan-
pasanfxhl rte JUAI
❑ I,as owner of the property,,B exclusively contracting with:)canoed contractors 1996
nstmn the Project(Sm.]D44,Business and Professions Code)The Contmcmr's Lt.
cense Law docs not apply to on owner of property who builds or improves thereon,and QTY. PLUMBIN /PERMIT FEE
whoconuacts forsuchp Peels with ucm"cia0s)licenud pursmmtothe Contractors C'7y Ur
License,Law. i - LUMCfr IIIY
❑Iamesemptunder Sea ,B&PCfarlhismawn PERMII'ISSUANC. U
Owner - Dam ALTER—DRAIN cNT— (E4 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE .D ICE
1 hereby affirm under penalty of perjury^rte of the following declarations:
❑ I have and will maintain u Cenificte ofComem to selGopme,for Worker's Compen- DRAINS—FLOOR,RO ,A�,C
sation,as provided)for by Section 3700 of the labor Code,for the performance of me STORIES TYPE CONSTRUCTION
work for which dispersal Named. FIXTURES—PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Seetion
37e0o1frhe Labm Cale,far the perRnmanceofthe work far which this permit is issued. GAS-P.A.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No, A)
GAS-EA.SYSTEM-OVER 4 TE
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRI.WASTE INTERCEPTOR
((Tis section accident be completed if the permit is(atone hundred dollars(SIM) BUILDING DIVISIO :ES
or less.) GRGASE TRAP PLANCHECK FEE
I certify that in the performanceif0m workforwhich this permit is isaued,loodl SEWER-SANITARY-STORM EA.20017.
not employ any person in any former mer so as m Wilma subject o the Workcn Compen- ENERGY FEE
O which Law,of California.Dam WATER HEATER W/VENTNLECIR
77 Applicant GRAVING FEE
ah NOTICE TO APPLICANT:ILnflcrould.,this Certificate of F,xcmptim.you should WATER SYSTRM7REATING
become subject m the Workers Ciann d ltim provisions of the Ia1nr Cade,you most SOILS FEE
ti forthwith comply with such pnsisiom or this rermiuhall be,deemed revoked. WATER SERVICE -
Q
7'z CONSem is ac0NLENDING AGENCY NEW RI'SIDENTIAL PLMN. SQ,FL PAID
V Q I for
rte that thereissued(Sec.inn leading agency far the perinrmance of Doe I ci #t#
fix r the work far which this permit is issued(Sec.3097.Civ.CJ
Q F' Lenders Name TOTAL:
L) Isnder'>Addrcss TOTAL:
96 1 certify that I have read this application and nam that the Arose information is BUILDING PEC
tti to comen.l agree to comply with all city and county ordinances and state laws relating to Qty, MECHANICAL PERMIT FEE
V ,`4 buildmilcanswctim.and herebyamhorizemprelmounNes oftlinsity memertpon the SEISMICFER
above-meminned rope ry for impaction purposes,
(We)xgrce to xuve,indemnify and keep hamtlees the City of Cupeninn lignins, I'IiRMI'I'ISSUANCE ELECTRIC FI7E 1Nj
Iiabildies,judgments,costs,and expenses which may inany way access,against said City ALTER OR AUDTO MECH.
in comer aence of the gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To IBM CFM)
SOURCEREGULATION MECHANICAI.
// AIR HANDLING UNIT(OVER IQOIXICFM) CONSTRUCTONTAX
Siem r Di s EXHAUSTHOOD(W/DUCT)
IIAZARDOUS MATERIALS DISCL( 'URE HOUSING MITIGATION FEE
Will dee applicant or forum building occupant score rhandle hazvdnm material ABATING UNI'I'(TO I(XI,UIIII(ITU)
C dcfinN by the 32(. no Municipal Coda Chepmr 413,trod oro Ilcahh and Snlcty
Me,Section 25532(1?
HATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RP.SIU) PAID
Will the applicant or future building occupant use equipment or devices which Dam Raeipt#
emir hazardous air commitments as defined by the Bay Arca Air Quality Management ROLLER-COMP IMP OR IM,11M BTU)
District? TOTAL:
❑Yes ❑No BOILER-COM P(OVER 100,001)BTU)
I have mad the hazardous materials rements under ter 6.95 of the Cali- AIR CONDITIONER
reol2 Chap ISSUANCE DATE
fomia Hades&Safety Cale,Sections 25305,25513 and 25534.I u radify the
that if the NEW RIiSIDENTIAL MECH. SQ.FT.
building does currently haveuunant,that's is yrcaponsibiliry mnotify the occupant
o menu which sr be ma prim van n a C, ificat d po y.
rauthnriu age t m 'TOTAL: ISSUED BY:
OFFICE