S005820058 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILTNG-ELECTRICAL ERMITNO. 20058
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT
(DEN I MECHANICAL
ItI111,DING PROJF,CT IDBN'1'IFIL'AI'ION
BUILDIN ADDRESS: SANITARY NO. APPLICATION SUIIMII"B\h llA'fF:
t 0
OWNE:R':NAME: PH NE: CON 'S ,.^ a,_q �IC O�
'IG'IV! NIC CUNTROhp
•\RCHITECOHNGINT:ER: LIC NO: A O s ❑
CON ACI* /PHONE: BUILDING PERMIT INFO
�� ❑❑ Consultant F"S Paid by Applicant(Iailid) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSE[)CONTRACTORS DECLARATION Q'PY ELECTRIC PERMIT FEF.
1 herchy affirm that[;all licensed under provisions of Chapter 9(Commencing JOB DESCRIPTION
OaZ with gcfdnn 7tkgB.n'0ivisionloRne uusineaa and Profesxiom endo.nn0 my liccnw la RESIDENTIAL:` PERMIT ISSUANCE
1-W in fall lincrnd ellecl. - O ] OSFUNh OKI'TCHIiN Rf:M110D131,
aVV Liccnsc Cla Lic.N APPLIANCES-R12SIDENTIAL OADIlIT10N OI'LIIMEING ItIiPIPE
N Zea Date Cnmmct°r ❑MULTI-UNIT OSTRUC'I'URAI.
m ARCIII FIiCT'S DECLAR i'ION PANE(S \
F yZ I undcomnd my plana shall healed m public records M011ll'ICA'I'ION
ZOZ�G UlIT02MAMPS ( s [I INTERIOR 11 CHIMNEY REPAIR
F�tnl Licenced Professional 201-10DJAMPS IMPROVEMENT OSWIMMING I'OOIS
�.t
OWNHR-HUILDER DECLARATION oVERI IAMI'S O BATH REMODEUREPAIR ODEMOLTTION
C w¢ 1 hereby action that I am exempt from the Contractor's License I.aw for the O OTHER
3 F following reason.(Section 7031.5,Business and Professions Cade:Any city or countyT
ELECTRICAL
y which requires a permit to construct,ahec improve,demolish,or repair any structure
6 priorto in issuance.also requires theopplicanl fmsuchpennumfilea sigt¢dsmtememtL CIRCUIT/MISC.
sy (hal he is licensed pursuant In the provisions of the Contractor's License Law(Chapter 9 COMMERC
W C) (mmmcncing with Section 7")of Division J of the Business and Prefessions Calc)orMETER OR POLE INST.
d a e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of O NEW BLDG/ADDITION O DEMOLITION
X^s4 Section 7sll LS by any epplicum forapcmdt subjects the applicam eoacivil pcnalry ofN DEVICES OTENANT ❑F'OOIl51iRVICIiFZn'm..ilia.five hundred dollars(55gq. IMPROVEME�=Q ❑ Ias owner of Ne prupeny,or my employees wile wages as theicsnle compcnvtinn, MING POOL ELECTRIC4. will do the work,and thestmcmm is not intended or offered for side(Sec.0014,BusinessWm and Profesalnns Gds:The Contrai License Law does not apply to an owner ofT$-SWITCHES-PI%TURP_Sproperty who builds or improves thereon,and who doessucn work himself or throughhis own employees,provided that such improvements are not intended mnBered forESIDENTIAL L'LECTR SQ FT.
Vide.If.howmep the building no impnrvanenlov,ld withinone year of completion,the SQ.FT.FLOOR AREA Vs Q.IT.
cr-huilder will have the burden of......ng(hat he did not build or improve for poo-
own
0 I,as raw'n r nl''Improperly,ton uxcluslvaly contraning with he,-rd culnulol,tot T(l'I'A1.:
u,,he pnsjccl(See.7(94,Bmineaa and Plef,"i al Cook:)The Carousal-rn Li- PA
1 D
sc Law does apply to propcny who builds or improvev tbereon,and QTY PLUMBING PERMIT FEE.
he wntrma lin tech projects with a umtmmags)licensed pursuant ao the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this mmnn
jFIXnR
&VENT-WATF.R(EA) VALU.\TION
Owner Dale
WORKER'S COMPENSATION DECLARATION C.DEVICE Cllsf UI; Quvi:Vif INC)
I hereby afw n under penalty of perjury one of the following decti mions:
CI (have and wilhrtainminaCmiticme of Cnmmnuo sdf-insum for Wnrkeh Crimper- OR. .GOND. STORIES TYPO CONSTRUCTION
...into.m provided far by Section 37M of the Labor Code.for the performance of the
work for which this permit is issued. RAP
O I have and will maintain Worker's Compenw.ion Insurance,as required by Section
37M ofthc labor Code.for the performance offee work for which this permit i.issued. GAS-EA.SYS 1'.A OU S ICC.GROUP AI'N
My Nbrkeej��CC�gQQ''�pcsmoral,r m 'rand Policy �n1 GAS*-EA. or
EMPPolicy Nn.: -k-.9s-
C.I PICOMPEN TION INNFROMWORKERS• ___VVV GREASFIINUUSTRLW T. RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FIn3
(thiss,non cardinal be cnntplcmd ifthe permit is Forane hundred dollars.(SHXO GREAIE'IRAP
�
or less.) 1'LANCIIECK FEE
jointly thatolly inthe pedonanow,efthe work no-which this permit in issued.lshall SEWER-SANITARY-STORM EA.210 Fr.
naum
l employ oily person In ally mmer so ns In become subjmuo the Workers'Compum ENERGY IFF.
z, cation Laws of CaliRumia.Dare WATER HEATER WNENT/BI.ECIR GRAVING ME
ZO Applicant
IJ!) NOTICE 10 APPLICANT If alm,narking this Cenifiaec of Rwormem,you should WATER SYSTEM/FREATINO
F^ ; SOILS PBD
beaoare mneo to the Worker'.Cmmpemminn provisions of the Lvbc Gdeyou ntmi
laLl .-t fpnhwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
Q PAID
Z ,' X
CONS'IRIICTION LENDING AGENCY NEW RESIDENTIAL PLM1iB. $Q.il'. Date Receipt a
U p I hereby affirm that there is a construction lending agency for Ne performance of
Cl. . the work fill which this permit is issued(Sec.3097.Civ.C.) TOTAL:
Q Iandcrx Name TOTAL:
r LU Lende/.Address BUILDING FEE �
LI 1(enify that 1 have read this application and state man above information is
F"IZI counter.Iagreealcomplywithallcityandcountyordinancesmadstatelawsrelatingto QTY. MECHANICAL PERMIT FEE SEISMIC FEE (03
U Z building construction.and hereby authndm represemadves ofthm city to enter upon the
aMvomemioned property far impn.ion purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree ill save,indemnify and keep hourr s the City of Cuper ino against
liabilities.judgments,costs and expenses which may in any way accrue agaimusaid City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT ON DE RSTAN US ANI)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000 CFM) MECHANICAL FEE
SOUR !REGULATIONS.
-- oY I AIR HANDLING UNIT(OVER III,gXI CPM) CONSTRUCTION TA%
'ignm plaamVCommetor Date EXHAUST HOOD(W/DUCI) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
W III the applknnt err linme banding occupant mason handle haeanlous manurial IIEAI'ING UNIT'('Ib 100.000 all
sae dafincd by the Copunlno Municipal Code,Chapter 9.12,and the I leallh trod Solely
Cone,Section 2553200'1 HEATING UNI T(OVER IUI,oW BTU) 7�)/sIJ 7
[IYcs [_1 No VENTILATION FAN(SINGLE RESIUI IA _A�/�a•�/--//-
Date Recciptit
Will the applicant or future building by occupant B y A ea Air Qu of detritus which BOILER-COMP(3HP OR IM.IXX)BTU)
� emit hazardous air ftmnminama as defined by Ne Bay Area Air Quality Management TOTAL:
District? Y,,' DiscoBOILER-COME(OVER I(XI.0f0 BTU) /
AIR CONDITIONERISSUANC:D-
1 have read the hacrdous mamdms requirements under Chapter 6.95 of the Cali
TE
foml.Health&Safety Code,Sections 25505.25533 and 25511.1 understand den if be NEW RFSIDF.NTIALMECH. SQ.IT.
noulding docs not currently have' t.ohm it is my responsibility to notify the occupant
of reuirceneld.vo Ibe mel landy lm 1. ofaC fnewc of partcy.
—wccriorircTgcm ami/ TO'fAl.: ISSU[D BY
OFFICE