S0368 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
CITY OF CUPF.RTINO BunaBNC.-ElECTRICAh 1'I'cgn+°'No
BUILDING DIVISION APPLICATION/PERMIT rLulmTNc-MFCHANICAL �J 0368
BUILDING PROJECT[DEN'rIFICATION
BUILDING AUURESS:.-. 17 62 / A SANITARY NO. APPLICATION SUBMITTAL DATE
011" 2
0 : •NAM I' ONE NTR CfOR'SN ME: LIC NO:
7-36
. NIC -CONTROL p
L.
A* 6121
'p VHIT,CT/ENGINEER: LIC NO; AODRESK ❑ 05-33
O X J
CON Cf: BUILDING PERMIT INFO
-Pick y� r,�� ��/ ❑ onsul[a t eel Paid by App i ant(InHia � BL :LE vSt 9
MF
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
f-'�Z wiN Section JnBO)of Ui Jofthc Business nnJ Pnuf sionsC Jc. n T nxt is
W O PERMIT ISSUANCE
��O i force and elTecl. sT n p Q� 'L. El KITCHEN REMODEL
dUU Laenm Clus Lich APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F Zy) Doe Getman.
v)da �✓ MULTI-UNIT ❑STRUCTURAL
FOy ARCHITLCTSDECLA PANELS
ZOr�Z lura eta Plans sha}b udmpublic R MODIFICATION
OZ=C UPT0200AMPS [3 INTERIOR OCHIMNEY REPAIR
P'��lld LicensedR es - 201 ["AMPS IMPROVEMENT LJ SWIMMING POOLS
OWN: B II_DIiN DI3CIARATI(IIOVER IMDAMPS OBAT]1 RIiM000IJREPAIR Ll DEMOLITION
C C d I hercM1y affirm that I win exempt from The Contractor's license Law for the
Dl W F following reams.Nectinn 7031.5.Business and Professions Gude:Any city or county SIGNS ELECTRICAL ❑Ol'HIiR
XO ,l' which requires a perms m construct,alter,improve,demolish.or repair any swemre
Faa� prior mita issuance.alto rcyuires the applicam Grt wch perminu ole aligned nammenI SPECIAL CIRCUIT/MISC.
� } that he is licensed pursuant In the prm'isionv of the Connectors License Law(Chapter 9
W�d0 (commencing with Scdioa700l)Of Uiviviun Jof the Basinassand Profession.Code)or TEMP.METER OR POLE INST. COMMERCIAL:
. G y a y thin be is exempt therefrom and the basis for the alleged exemption.Any violation ofBLDG/ADDITION [I DEMOLITION
u�^� Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penalty of POWER DEVICES iNAN'T ❑FOODSERVICE
not more than live hundred doll...($50ft I OVEMIiN'r
�Zd1,as owner of the property,or tleccs with wages as their sole coo nsation, SWIMMING POOL ELECTRIC
❑ pmpo Y Yelrp Y g° . OQTIIIiR
F and Finite wo.k,and,:Ihc Clocnot,tended License
dosnoed to(Srn:.'1O44,Foxiness
W 3 m
and Prnfcssions Gde'rhe Consunur's hkcnw Luw Anes nrn opply m nn owner of OUTLETS-SWITCHES-FIXTURES
Q' pmpeny who builds or improves Tbcrcon,and who anus such work himself m though
his own employees,proviccc dan wch impownncnl.s ere not imcnJeJ ur nllbroJ for NEW RESIDENTIAL FLEC'I R SQ FI'.
sale.It,however,the builmngori mpmoonem is Into within nnc ycur of mmplmian.the SQ.IT.FLOOR//A11k AREA SI$Q.FF
owner-builder will have The burden of noving tint he did not hood Or improve(m par-
❑I asowner of the property,
c.7Wa Business ly tach gwith T< :d I aors to I
tet nth e j t(Sec .nojsim— JProfessionsC,, i mT se t' ors Li 4011460a
ceam with
who build ' .p roses Coalnend QTY' PLUMBING PERMIT. PBE
who contracts,Lfor such projats with a atmocmgs)licensed pursuant the Comracmrz /
License Law. PERMIT ISSUANCE.
I am exempt under Sec. .B k P C for this mason
ALTER-DRAIN D;RAIN (QA) VALUATION
Owner tame l) / -7 /
WORKER'S COMPI7NSAT10N DECLARATION BACK FLOW PROTECT.UF.VICE �/\
1 and
welan under penalty of ofCon one of the fnllewior dela tions:
,](have andwill mnimainaCmtificam of Conserv m.dGinwre for W'nrkers Compen- URAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE.CONSTRUCTION
Other,as provided for by Section 37W of the Labor Code.for the performance of the
work for which this peon is issued. - FlXTLRES-PER TRAP
O 1 have and will maintain Workers Compemation Insurance,as required by Section
37W of the tailor Cade.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUT' ^ APN
Cy n/�F/�� rPoltyN and Poli , ir GAS-EA.SYSTEM-OVER J(F.A) S
CERT FIC ATF,OF EXEMPIIONF )M R E S' GREASWINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE NO DIVISION PEES E
(This section need ten beemalldN if the permit is for nnc hutdreddollars(Sl(SIM) GREASETRAP57
1'LWCII[CKI iii
or less.)
Ic.mfy that mine perfomtancenf the work linwhichthis pooh i.issued.[shall SEWER-SANITARY-STORM FA.20D FT. p rt-�
not employ any porton any manner so us nt become subject to the Workers'Compete ENI?RGY FE' _J V
Z nation laws of California.Dale WATER HEAT ER W/VCNT/ELECTR GRADINGFI '
z Applicant I
NOTICE TO APPLICANT.If,after making this Cersilicme of Exemption.You should WATER SYSTEMOREATING
ity" Fla.
a ' bmomembjem out Workers Compensation Provisions of the IaMt Cole,you must
fJ•I forthwith comply with such provisions or this pcmut shall M1e deemed revoked. WATER SERVICE,
PAID
U Z CONSTRUCT kaIIDN LENDING
me AGENCY NEW RESIDENTIAL I'L,MB. S0.PC D tceipt
UO 1 hereby kfor.1affiniscNcreioo.cd( eetion len Jing agency Tonic perlitmnmce of
fA F the work for which Thi.pcnnn is IswW(See 30(0.Civ.CJ TTA
Leaders Name �
U Led Ada ld till , (NCI ill I • O
rifythtIh drillT,li'I ' I.oT hnl ab l tans ..
a '.I agreero comply with all cirynJ cornay ordhoraces aid sero,law.rtl n"o) QTY. , MECHANICAL PERMIT FEE SF MI'I
U Z building eonstrctom.Td hereby amherlre repmsenbniver Of this city leaner upon ate
ubnvo mcn.loned pro,eity lotinxpectinn pa pores. PERMIT ISSUANCE I. !CGHC tai
(We)agree to save,indemnily and keep harmless the City Of Culvoinu ugdan
liahilhits,jrdgmenu,cols anA ea Tenses which nuay in any wry ncenie ugxinsl suit City ALfERORADDTOMECII. PLUME 19i,
PLICANT UNDERSTANDS AND WILL COMPLY WITH^AL ON-QOINT AIR HANDLING UNIT(IO 10.11S)Clod) MIiCf1AN CAL IEE
5 UL ION N /
AIR HANDLING UNIT(OVER IU.IMH)CFM) CUN$TR Cl,(
ca m 'Idly
S omctor Date EXHAUST HOOD(W/DUCT) IIOUSI I'1'IGATION FEE
HAZARDOUS MATERIA(S DISCLOSURE
Willmeupplieanlor future huildingtecupanlstore tolmndle hazardous mmeriel HEATING UNI'I(TO 100.0100 BTU)
ex dented by the Catania.Municipal Code.Chapter 9.12,and the H.11h and Safety
Code.Seetion 25532bo? BEATING UNIT(OVER URIM10 BTU)) Y L}
El Yes [:1 NO VENTILATION FAN(SINGLE RESIU) PAID" am
p
Wilt the applicant nr future M1uidding occupant use eyuipmear or device,which BOILER-COME 13HP OR IW,Mtl BTU)
.vnrdous air cetmminants as defined by the Bay Are.Air Quality Mawgeatent T TAC:
u:.c1? BOILER-COME(OVER IO0.0MIBTU) _
E]Yes ❑No
I have most the haraNrm,nmmmd%"Wermans,under Chapter 6.95 of The Cali- AIR CONDITIONER ISSUANCE DATE
don
fomite Health&Safety Csde,ea mason.chat,25533 and 25574.1 ility to notify
dweeif Bre NEW RESIDENTIAL MECH. SQ.FT.
building does nmcurrently hastatenant.inttnis .nee Of
Certificate
Ofytheoccupant
of the n;airements which tun M met prior m isuuttee of a Cenifcate of(kcupancy,
Owner or uuthorizN agent Date I ISSUED BY:
SnL�
OFFICE