28891 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE.BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUII,DINC.-F.LF.CTRICAI; - -PERMIT NO. 28891,^l8 C8 w
BUIL '2DING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL 9
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
IUB � Leo UCS'
OW ERT NAME: r� - PHONE: Q - -I_ RACT g:S NAI BCNU
• r CI 11 fie&& Z• (0 / RIC NTROLp
ARCHITECUFNGINEER• LIC NO: AD FSS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 7")of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
b•�0 in full force and yl t _ // PERMITISSUANCF. ❑SFDWL ❑KITCHEN REMODEL
g'UU L¢en.ae Cl LiaM APPLIANCES-RESIDENTIAL ❑ADDITION 'E]PLUMBING RE-PIPE
1-7IL Dutc Conmenma
F❑so RCHITELTS DECLA ATION PANELS ❑MULTIUNIT ❑STRUCTURAL
zOyshut z I understand my plans be used as pablic mcwvR, MODIFICATION
Oz-0 UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
F•.~W Licensed Professional 201-1(p11AMP5 IhIPROVF.MENT
•ay+W C Q hereby affirm OWNER-B that I am UILDER DECmpt from `ACRATIONrs License Law for the OVER)"AMPS .� ❑BATTHuu REMODEUREPAIR �DEMOLITION
x3LU folio g S t 70315 B. e, dP f n,CJ Ali, ity or count, SIGNS EUiCI'RICAL C1OTjIR 7,4
fid WoO h which"in., permit t tmn It r p em
dolish t r ep m
'r any mcture
y
prior L issuance,also requires the applicant(f such Wouilt fit"si ncd eamment '
E }.]] B SPECIAL CIRCUIT/MISC
thut he is licensed pursuant m the provisiims of the Contractor's License Law(Chapter 9
WCO� (commencingwiNSecoion7W0)of Division Sof the Business and l'rofex ionz Cude)or TEMP.METER OR POLE INST.
COMMERCIAL:
0.6 c C that he is exempt therefrom;and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X ro LL• Section 7031.5 by any applicant for a perm subject,the applicantto a civil penalty of POWER DEVICES
W^m - [I TENANT ❑FOOD SERVICE
�22 not mom than five hundred dollars($500y ,IMPROVEMENT
a6 Dl;vs owmerofthe propeny,or my empinymxwith wagesmtheinnlen�mpensmion, SWIMMING POOL L'LECIRIC
L=.0 will dothe work,andthe mcmreis not inmadedoroffered forson(Sec.704,L Business
LI OTHER
m
3 m and Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves Nerenn,and who Joes tach work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELEM FT.
sale.If.however.the building orimprovemcm is sold within one year of completion,the
SQ.FT'FLO(]{e eREA) SING.F.
owner-builder will have the burden of proving that he did not build or improve for put- VV
po c of salt.).
0 L as owner of the re pent'am exclusively contracting is ith licensed contractors to DT 8 2 q
umse sma th P ) t(Se 70.14 B a d l f .Code)TheC-t atm.Li- 1
\ cenLa d t apply to tp pent' h b 'Id p .thereo and QTY, PLUM11BING PERMI 'o(�6
FEE VJ
who contracts for such pn0ects with a conuamoRs)Icensed pursuant to the Contractor s L/// Ur
Lice;¢law. . rtH(Wp
I am exempt under Ser. 11 ,B&PC for this reason PERMIT ISSUANCE
/• Owner [)am - ALTER-DRAIN&VENT-WATER CEA) VALUATIO
O
RKERS COMPENSATION DE RAHON RACK PLOW PROTECT.DEVICE
IF
hereb Irm nude,Fri(Pe m,orwof the following Jeel...uons:
I have and will maimainaCcnif ore of Conscnudself-Insure lniWdrkcr's Compcn- DRAINS-Fl.00R,ROOR AREA,COND. STORIES TYPECONSTRUCTION
sada;,as provided for by Section 37M of the tabu Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will .,noun Workers Compensation Insurance,a%required by Section -
J7WoftheLabm sdc.for mrfo..nccof won frrwhichthapermitislssued, GAS-EA.SY5TEh1- usc.40UTLET$ OCC.GROUP APN
My Workers t
n umnc c ierf},�J.P ynumbcr are:Cartiee .p�(p GAS-EA.SYSTEM-OVERC(EA)
CE OF EXEM EDON FROM WOR K I7RS'
,MPF.NSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
lus section need not be completed Ethe permit is faimaloundreddullan($1 W)
C
or less.) IGREASETRAP PLANCHECK FEE
1 certify that in the penformance,ofthwork for h h this Permit is isvedIshall SEWER-SANITARY-STORM EA.200 FT.
I p1 y y t be q u thew k C pen. ENERGY ITE
0 Z sago L f2, Id to WATER IIEATER W/VENTMLECFR
Z Ape t A{.Vii-11 L GRADING PIiE
h NOTICE TO AI II T.If R 'k' bol'. C iil�c fl pt y should WATER SYS'1'EM?REATING
a ; M1eu�me subjrgy the Workrex Comps wan pro'tmons of the hebr r Cnde,you must SOILS I '
forthwith comply with.such provisions or this permit shall be decned revoked. WATER SERVICE
0. Q
U Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID, Date Receipt
p
V 0 Thereby alarm that there isaconstmnion lending agency for the performance of p
the work[or which Nis permit i,c izcued($w.JB97,Civ-C.)
Lender's Name TOTAL:
V Lender's Address TOTAL:
W 1 cert[ that I have mad this application and state that the of,soc infnit o wn is BUILDING FEE
0. y nand mm an
fA conen.lagree mcomply
mid harn1wl city and cxmntyntativ%ofthiJ stmt laws upon'he
QTY. MECHANICAL PERMIT FEE
U z building constmction,sued hereby authorize mprescnmives of this city In enter upon ohe, SEISMIC PEI;
above-mentioned pn),mly for inspection Puryous. PERMIT ISSUANCE
(Ne)agree to save,indemndy and keep harmless the City of Cu,imino against ELECTRIC M-E' ,
liabilioiesjudg 4.costs and expenses which may many way accrue against said City ALTER OR ADD TO MECH.
in con,r,.e of he ting of this permit. PLUMBING PEE
APPLIC I' U STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN,,(TO lo,,,CI�MI MECHANICALFEE
SOUR out IONS
'& AIR HANDLING UNIT(OVER I(1,IX10 CFM) '
CONSTRUCTION TA%
Si,ma n A,dicanVConoenur t DarE EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MAT12RIAI S DISCLOSURE
Will the applicant or future building occupant more or handle hazardous material HEATING UNTT(TU 100,000 BTU)
as defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
_ Codc.Section 25532mG HEATING UNI'1'(OVER IW,(IIX)BTU)
C]Vex L]No VENTILATION PAN(SINGLE RFSID] PAID Dam RecciPtM
weepers the applicant or future building weepause equipment or devices which
I harselems air connotations as JcOnn)by the Bay Arca Am Quality Management BOILER-COMP OHP OR IW,BW BTU) TOTAI
�Distrin^.
❑Yes El No BOILER-COMP(OVER 100,000 BTU)
1 have rend the hamolmis macfiaLs myuircmems under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
forms Health&Salley Code,Sections 25505,25533 sad 255311 understand Not If the NEW RESIDENTIAL SUCH. SQ ET.
building does nm currently have a tenant,that it Iv my responsibility to notify the occupant
of them mmmma%which must be met prior to issuance of a Cenificae of Occupancy.
Ownm or authorized agent Dare TOTAL: ISSUED Zjk:j=��
'OFFICE