S0505 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT TING R OJEC7IDENTIFIC O O
BUILDING YROJIiCT IDENTIFICATION
BUILDING ADDRESS: /,� ^^ w 57;-`7� c SANITARY NO. All PLICATION SUBMITITL DATE
/03 �f� a!/L tI� _J
OWNF. 'S M PHOSIF„ `��cs YI' CIOR'S NAME: /p LIC NO:
A J 7 //OLS NIC C( '1' OL N
�NCHI'TECf/ENGINEER: I,IC NO: ,Jif `.C ��•[Z ❑
605
CONTACT: PHONE: Sfjjr (v �C(MS�>•C. (Y J l BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) vI-D, fd.ECl' PLUMB
MEC
N} ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY I:LECTRIC PERMIT FHE '¢ JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
M=Z with Section of Division 3ofda,Businasand Professions Code.andmy license is RF. II_5 )FNTIAL.
W p O PERMIT ISSUANCE.
F-,2 in full loose and effects 7� �S• e'7 ❑SFUWh ❑KITCHEN REMODEL.
¢,UU Licmtsc Cf�9��g L, Lir'p APPLIANCES-RFSIDEN'1'IAI. ❑ADDD']ON ❑PLUMBING RETIFF
F Z w Dote X 77 Contractor
y¢y ❑MULTI-UNIT ❑STRUCNRAI.
'D,,, PANELS DECLARATI PANELS
OZV,Z 1 understand my plans shall be used as public mvoMs - h1
UP TO 200 AMPS MODIFICATION
❑CHIMNEY REPAIR
H`4t:1 Licuiwd Poav,,ioml 201-10(KAMPS IMPROVEMENT 0SWIMMING POOLS
stoN
OWNER-BUILDER DECLARATION OVER 10(01AMPS QBATII REMOD' 11 :P R ODE 01;ITION
C C¢ I hereby affimt that 1 am exempt Bom the Contractors License Law lin the ❑OTHHR`�\ )
LLX13 lL I"'
following nicam.(Section 7031.5.B.,inc nd Prof.,ion'C d 'Any cily or c...ly SIGNS ELECTRICAL
y
which requires Permit t c t t Its top demolish. p any structure
prion t eat. y the applicant such Pe filesigned. emanSPECIAL CIRCUIT/MISC. —\�\/+�'�r.��{�I' v✓ c1
' s
'
E'�y thath dp x II th pi,ofIM1 Cammi 1,111ile Law(C1:1I.9
apo (sato nun F with Section 7000) fD " 3 of he B sinus dP fel6mv,Code).1 TEMP.ME1'IN OR POLE INST. COMMP,RCIAL:
a 6 p K that he is exempt therefr()m and me base:for thealleged exemption.Any violation of ❑NEW BLDG/ADDITION [3DEMOLITION
X^_+u• Section 003 L5 by any applicant for a permit able.,the.,plicad to a civil penalty of POWER DEVICES �TInNAN7 ❑FOODSERVICE
rn not more than five hundred doll.,($500)
I, eopmerof the n IMPROVEMENT
0 () t n y my employees IM1 ed then' I .1 :I s5' SWIMMING POOL ELECTRIC ?s
�
oil do the k.and(h -( lata: lint 1 I 1[ If I (S ]044 B QGTIIHR
W mdI f Cod Th C mi( :1 n L de nt pplyt an of OUTLETS SWITCHES-FIXTURES
a3- foppcny,who builds or imparewevBoreal, d who does such workhimself through NEWRESIDENTIAL ELECT SQ '
his Am employ.,,provided that such imprevencents..old intended or olltecil for
sale 11 h e
the h I i g improvement Id lh rtey f mpl t m the SQ.FT FLWR AREA SISQ.14.
e-hu Idcr will have IIn,burden of prow ng that he did nm build oronprove for pur
pose el sale t
❑1,as owner of the property,am excluzively contracting with licensed contractors it)
n'nl"'
construct the protect(Sec.20X.Business and Professions Code)The Contractor's Li--
cease Law does not apply to an owner of property who builds or improves thereon and QTY, PLUMBING PERMIT /"4 , 0
who contracts for such projees with a contractor(s)hcenvd pursuom to the Commctors ta
License Law. PERMIT ISSUANCE o/1
❑Iantenumpl under Seo, .B&PC fbnhi,rcusm ((�/
ALTER-DRAIN&VEN I'-WATER(EA) 1r4t 44.TION
Dan, C1
Owner WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ` OF L[✓
• vend yafham under penally me or Coycclin Ihefolm,f Workertions: T N
❑ Ihnvc unJ will mmmm�o Cenificam ul'C.rsemmsclf-inxure fm Worker's Compact- DRAINS-PhOOk.ROOF.AREA.GOND. STpRIjL / V 'I'YI'Ii CONSI'RUCfION
anion,as provided for by Section 370(0 of the Labor Code for me pednmumw of the
work for which this moot is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker,Compemaion Insurance.as required by Section
3700ofthe Labor Code far the performance of the work for rywhhcic�h�this Permit is icaped. GAS-EA.SYSTEM-1 INC.4 OITILF OCC.GROUT' APN
My Works';Com ation to o 'e P'IdYN�ynN WY�'3�O�I� GAS-EA.SYSTEM OVER 4(EA)
Currier: IU U/ /
CERTII'ICATIi FEXIiMPIIONFROMWORKF.RS (ikFA$1%INDUSTRL WAS'IT:INI'ERCEI'IY)R
COMPENSATION INSURANCE BUILDING DIVISION ILL'S
(This section need not be confided ifare Permit is for one hundred dollars(S 100) GREASE.TRAP
orlms.l PL\NCHECK FEE
I certify lhmas he performance elite work for which this permit is ilwad,l shall SEWER-SANITARY-STORM HA 200 FT.
not employ any person in nay manner ao a to bcnmme suh,w m the Worker,'Colo,p ENERGY PEE
Z 'noon low,()f Calihom..Date WATER HEAMR WNEN'I'IFLECIR GRADING FEE
Z O Applicam 1
NOTICE:TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSITUMTREATING
become soh eel to the Wnrkeh Com tion f IM1e Labor Code, SOILS FEE
pen's provisions o you mu't
monolith comply with such provisions or this permit shall MJcemed revmkcJ. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDI?NTIAI,I'LMB. PAID SV FT' Date Re ipla
L) O l hereby affirm that there is a construction lending agency for the performance of
the work for which this Permit is issued Sec.301 Civ.C.)
0 U Lender'Name T( AI.
O :
W TQI'AL:
Lender's Address
I ecnify that I have rout this application and rule that IM1e atswe mimmation is BUILDING FEE
(/) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEL S17ISMIC FEE
V Z building construction,and hereby audou,,reprewconvesofthis city(()enter upon the
above-mentioned pmPeny int rospccdnn Purposes. PERMIT ISSUANCE ELECTRIC FEE
Owe)agree to save,indemnify and keep harmless the City of Cupcninn againv
lidladinc',judgirroO,coxtOmd expense,which may in any way acerve agmeol,aid City ALTER OR ADD TO MECH. PLUMBING FEE
in asequence of IM1e gr,miag of this Ili
APPLICAN NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,10X)CFM) MECHANICAL FEY
SOURCB LA' ONS. //
✓�`J r 1�� �7 n(a HANDLING UNIT(OVER IDfIfMI CPM) CONSTRUCTION .
Sign.ureof plicant/Contrai Doc EXHAUST HOOD(WMUC) HOUSING MITIGATION 'Y,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future wilding occupant store or handle hoefthm'tnmenal HEATING UNIT(TO 100.X01 BT U)
as defined by the Copenino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IIXL(NIU BTU)
Cede.Section 25532(x)'!
q Ye'
ON. VENTILATION FAN(SINGLE ItESID) PAID Dau Receipt#
Will the applicant,future hiiWingnccupum use equipment nr device,which BOILER-COMP(3HPOR❑01,N)OBTID
mil hmuNou,me comaminwt,a,defined by the Buy Arca Air Quality Mmagemom TOTAL
D...net' BOILER-COMP(OVER 100.001 BTU)
❑Yes ❑No
AIR CONDITIONER ISSUANCE DATA
have read the CodNme materials rcyuiremems under Chapter rsta of the Cali-
f()mimIf oes&t curie Code-Sestinas.that.25533and255$4.1 In notify th.lde
thud'he NEW RI?SIUIiN'TIAI.MECII. SQ.FT.
of thbuilde rgdoe'noleurhich have Ix,.11 .imel.is my llo.'If-Certymnmifylhc�ecupvm \e
of the rcyuiremems which must be m.poor m issuame of a Certificate of(Rcupmcy.
Owner or unarmed agent - Dots ISSUI?D BY:
OFFICE