S0029 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY CUPBUILDING-ELRCT'RICAL L•
PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MED1
9
n
p I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SURMICTAL
DAI'F
� + of I-A Mh ^ h.
6 eeflno C , V/44
OWNER9N ME: �� I'll NE: CONTRACTOR'S NAME: LIC NO:
NIC CONrNOL#
`VICT/ENGINBLk: I.CNOF. ADDR[SS. ❑
r
Co/�jrpAc'I`t I'IIO`N}' L BUILDING PERMIT INFO
Ki/fi�11D
pl �/2�� Consultant Fees Paid by'Applicant(Initial) BLDG ELECT PLUNII AILCH
N' M1 QTY. ELECTRIC PERMiT FF.E
I Earthy affirm them I am bcensed ander provisions of chapter 9(commencing JOB DESCRIPTION
Z with Soction 9000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W O p PERMIT ISSUANCE:
��.. in lull farce and ellen. ❑SFDWI. [-I KIT REMODEL
, Ut License Class LEC.# APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE PIPE
9ZW Duro Contactor
m¢a - ❑h1ULTl-UNIT' ❑STRUCTURAL.
FCm ARCHITECTS DECLARATION PANELS MODIFICATION
Z C m Z I understand my phim,hall he used as public record,
CZO UP TO 200 AMPS ❑INTERIOR CHIMNEY REPAIR
W Licensed professional 201-1000AMPS [14PROVEME1,1T SWEMMING POOLS
C
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEfJREPAIR ❑DEMOLITION
5 x Q L hereby affirm that 1 am exempt from the Contractor's License haw for the
KCLU followingnamon.(Sectinn"1031.5,Business and Prufcromns Cede:Any city.,county SIGNS ELECTRICAL ❑OTHER
00'3 W N which requires a Fifork to cnnsWcl,aIle,improve,demolish,or repair any vW<Wre
prior to its issuance,also requires no applicant for such permit to file a signed statement SPECIAL CIRCUILMISC.
'bu(heislicensed pursuant totile Provisions IIthe Counselor's LicanseLaw(Chapter 9
eg (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METI3R ORIOLE NST. COMMERCIAL;
y 6 0 M that he in exempt therefrom and the basis for One alleged exemption.Any violation of 71 NEW BLDG/ADDITION' ❑DEMOLITION
.=m Section 90315 by any applorm I.,a permit subjects the applicant m a civil penalty or POWER DEVICES ❑'TENANT ❑FOODSERVICE
not more than five hundred dollam(S500). I PROVEMENT
C=QE3 I..%owncrnf the pinquir nr my umployms with wages ax lheirsole cout,r niout SWIMMING POOL ELECTRIC
will do the work.and thcstrucuum is not intended oroffemd for sale(St .11114.Business OI HER
W63 m and Professions Coda The Contractor's License Law does not apply m an owner of O11T1.ET5-SWITCHLS-PI%TURFS
pmpeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ PI'.
sale LL however.the handingor improvement is sold withinom yearnf completion.the
SQ.FT 11 AREA SISQ.IT.
_r-Iwilder rill have the burden of proving that Lc did not build or improve for pur- N�
pose of safe).
❑1,ne owner of no pmpeny,am exclusively contracting wilt licensed commons to fA
construct the projet(Se.90W,Business and Professions Cade:)The Comment's Li- ��1
nse Law dont,a,,,applym an owtrerof impart who baud,or imp..us thereon.and QTY, PLUMBING PERMIT FEE '�W7
who commc,s fm such projects with a mmarec o-E)licensed yulsion,,o the Crinmcmrs
License Law. PERMIT ISSUANCE
1 am exempt muter Sec. .B&P C lin this reason
DRAINS d VE ER BEA) VALUATION
Mour ae
ALTAR—D
I KE 'S C I'Et 1'1'ION DECLARATION DE
BACK FLOW PROTEC V {t •��
I hereby affimt under penalty of perjury one of the following declarations: G � 4I
4mve and will maintain a Certificate mf Csmsent to cell-insure for Worker's Conlan- DRAINS—FLOOR.ROOF.AREA, ) srokihof "1'YEE CONSTRUCTION
I ion us provided for by Section 37M of the Lebtr Csdc,for me performance of the
work faF which obis panni,is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section gk
3900 of the Labor Code.fomhe performance of the work for which this pertain is issued. GAS—EA.SYSTENU I INC.4 OUTLETS „ OCC GkOU AEN
My Worker's Cumpensai.n Insuranec eerier and Noy number are:
Gorier: Policyy Na: GAS—PA.SYSTEM-0V OVER 4(17A)
CERA'IPICAI'E OF EXEMPT ION FROM WORKERSGRHASEANDUSTRL WASTE:IN'I ERCIii'rOk
COMPENSATION INSURANCE 1 INC DIVISION PEES
(Th,ortmnnccdno lw completed ifthe Permit is formic hundred!dulled D 000) GR17ASETRAP
or less.) I 9`10 &I .0�
I certify that in the performance of the work for Is hich this pemen is issued,I shaft SEWER—SANITARY—STURMFA.'_00 R.
_ not unploY any person in any manncrwas to hecnmesubjectmtha Workers'Coomm- ENERGY IEIt
S
Z lotion Laws of California.Date WA'rLk HI'ATEk WIVENTIELFCI'R
z Q i GRADING FEL
Applicant
.N. NOTICG TO APPLICANT:11,after making this Cenlfimtc of Exemption,you should WATER SYS'TEMITREAI'INC, SOILS PFI:
become subject to the Workers Compensation provision,of the Irbrr Cale,you mus,
corm th comply with tach pramsinns or this penna,hmll be devoted remtkcd. WATER SERVICE
a �
1 vO CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
I hereby affinitIhanhum is o constmction lending agency fur the Exaf r:mmof Date RaciptN
F the work for which this permit is issued(Sec.3099,Civ.C.)
C U I<ndcrs Name TOTAL:
Lender's Add as AL
F 0. 1 verify ohm 1 have read this application and Stam that the abm
above infotaion is - BUILDING F19i
0 c.re,.l agrmmcomplywhhall(city and county ordinera,atd.am laws miming to QT'Y MECHANICAL PERMIT FEE SEISMIC IEE
V ,Z, builiingcons,mction,and hereby amhorim represenunvesofmbis city manner uponthe
di anentinned prolan,for animalism purposes.. PERMIT ISSUANCEO,
(We)agree to stave,indencr y and Amp harmless the City of Cuponino ngainal ELC;CFRIC FT.'L
1 Iiahilities.judgmcnts,msts and expenn is Eich may in any wayocerueagalnnmid City ALTER OR ADD TO MECH. PLUMBING FEE
ugaen a of the gninfrg or this lama,.
AmPPLICANT UNDERSTANDS AND WILL COMPLY WE'If At.[.NON-VOIN'F AIR HANDLING UNIT(TO 10.000 CIM) MECHANICAL IEE
SOURCE RHOULA1'IONS,
AIR HANDLING ON]'I'(OVER 10.000 CFM) CONSTRUCTION TAX
Slgnmureol'Apple nUCo rra,1 Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE?
Will the applicant or future building occupam„ure or handle haxamous material HEATING UNIT(TO 101.000 RTD)
as assrderrmal Sectiby he C.O 7p Municipal Code,Chapter 9.12,and,hu Health and Safety
yHEATING UNI,'(OVE1t 100,(XNl B1 U)
Cl YO. ❑NoPAID
VHN'FILAr10N I-ANI SINGLE RTSID) Daus Receipt#
Will the applicant or future budding occupant use equipment or devices which BOILER—COMP CHP OR 100.0001 BTU)
lax mmum'air comvndnmns a,defn,d by aha Buy Area Air Quality MumNgemen, TOTAL: • J
,,, ❑No BOILER—COME(OVER 100.000 BTU)
I Ease read IM1e hazardous mmerials requirements under Chapter 6.95 of me,Cali- AIR CONDITIONER ISSUANCE DATE
m fmmia Health&Sufm Ode.Section,25905,25533 and 25534.I understand(hu,O Ibe
y NEW kF51DENl'IAI.Mf!GIf. SQ.FT.
of
srecurmndy have.inerptont o ismy res ponsibilitytom many heorcript
or the reytdremeu which rattan be mm rriono lawaae ora cenifieme oracapanq.
Owner,tar authorized agent Date ISSUED Ry:
OFFICE