S2828 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PIiRMONO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. Q 2828 O 2 O
BUILDING PROJEC'TIDEN'I'IFICA'I'ION \J o v
BUILDINGADD ESS: ,�1 SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNFW Is PHONE: C 'IRAC )R'SNAML. L1CN N/C CON'IAOhM
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ARCHI'1'F /ENGIN.ER: LIC NO: ADDK 35: ❑
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CON'I'ACI': PHONE: 13UILDING PERMIT'INFO
❑ Consultant F...Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONI RACTORS DFCLARAUON QTY., ELECTRIC PERMIT FEE
I hereby notion den I f 1 d l fu a pl 9[ nt 'ng JOB DESCRIPTION
OaZ nh Sroi on 7"bolD 'bn 3 ofthe Bmir a mf 4W d vl^ RESIDENTIAL:
Ir+100 wt PERMIT ISSUANCB
rola!!forccanJ c! ❑SFDWI. ❑KITCHEN RE,\IODEI.
aUV Bit- cClass Lic.A APPLIANCES—RF.SIDEM'IAL ❑ADDITION ❑PLUMBINGRE-PIPE
F 7e.W Dem Conwm� Lo
FOy ARCIII I'EC'I DECLAR ION
PANELS
❑MULT'I-11N11' ❑STkUCI'URAI.
Z O h Z 1 understand Iny plans shall M used a.public records MDD1F'IGATIDN
OZ—n UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F�I:u`) LicertN Professional 201-1 WAMPS IMPROVEM FIST 0SWIMMING POOLS
OWNER-It1111.DLR DECLARATION OVER ItX10 AMPS C]BATH RIEMODP.hIRI?PDB [I DEMOLITION
1—aaQ II by fl ' thatI exempt t ( n ', I' L In Is
yKj 3 LL F folln g (Section 7031.5.nosd l I :' n C d A y ty c unty SIGNS ELECTRICAL ❑OTHEK
W Oma' wh ch miim,aleant to scurearson. Its, p e demolish,h p y mani 2 n
< pdn Io it%issuance,alsorequicas theapplicaratf h permit to11e a%igriedstatement SPECIAL CIRCUIT/MISC. 0
y (he,hit is licensedpac,uara to the pookion,aftheCsramen,Le,n,y Law(Chaffer9
L dp�0 (crmmemngwth Sea int 70a)(fof 1)'v's'rn 3 of the Bt:iec, d Profaiunx Coda) f fHMP_ TER OR POLE IINS'T. d COMMERCIAL.
a d 5 that he is exempt duccal ;at and the hnsis for the alleged exemption.Any violation nl' El NEW BLDG/ADDITION ❑DEMOLITION
X^a Section 7031.5 by any applicant for a p[mtil silences the applicant In a civil penalty of P 1) 'ICES
V: w
❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars!851X).
IMPROVEMENT
�^Z'Q (] I,ns owncrofnhclropeny.nnnYcmpl...a, ,in wmge.x rodar.nfn eompenmtion. SWIMMING ELECTRIC
will do(lie work,and(lie mrwom is not immadedoruffed ihraule(See 704LB;sincvr El 01
tail m and Prolecsions Calc:The Connector's License Law docs not upply to an owner of UTI.FAj2Kj'rCH.S—FIXTURES
1'3 property who b Id:or im,m,a,floymon.and who does such week haersaffitir through
his u pl provided deal sh impowerecint,arc not intended or oftered for NEW RESIDE,V .ECTR SQ EI'.
.ale It hi th hi g l t sold withiny f plat m the $/SQ.FI'.
p eetbldeT w'll ural h hnolPne 6 t.a hada non h 'll !Wanefafar
f 1 )
n 1.by owner of the p pen) norclu: 1 I tg withl'ed contractorsth 'rOT f
cranNumerth Pwi Stec.]Bid B -andP f . Cody:)Tha Connector',L- 1 5
cense I d tapply I f progeny h builds l th rc APR d QTY. PLUM NC PERMIT FEE 1999
who co hares hi pny.ctwill,neonelvus)licensed Protean mihe Contractors
License Law. PERMIT'ISSUA
0 1 ant exempt under Sec. .Ii&PC for this reason
AL TER—DRAIN&V.. '—WATER,1 A) VALUATION
Owner Due
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DI ICE O
I hereby affirm under penalty of,equry ono of the following declarations: 13 .11
❑I have and will maintain a Cenificate of Consen it,self-insure lin Worker's Confer- DRAINS—FLOOR,BOOP.ARE . 'OND. STORIS TYPE CONSTRUCTION
,anion,as provided for by Section 311X1 of the Labor Code,for the perfnmtance of the
work for which this parmt o isxned, FIXTURIi$—PER TRAP
❑ I he,,and will euinmin Work,e,Comp,matiun Insumn(c,us raryioeJ by Section
3700A the Labor Code,for thepeHin'mumenf the work fol which,his fro-,it is lsxunl. GAS—EA.Sit"'EM-1 INC.d OUT.-TS - OCC,CROUP N.
My Worker,Compensation lvurunec c.rmrand folic,mmaber are: GAS—F,A.SYSTESI-OVCRdIF,A) O
Carrier: Policy No.: /
CERTIFICATE OF EXLNIITLON FROM WORKERS' GNF.ASFliNDOSI'RI.WASTE INTERCIiI'IUH
CONIPENSA'I]ON INSURANCE BUILDING DIVISION FEES
I'fhls section aced not he completed iffe,perotlt is for etc hundred dolfa-($11X8 GRI?ASF.TKAI'
or lased PLANCHECK FEE
Workers'I unify the into,performance of the work forxhichthis!condo rasei
rs'C rel[,hall SEWER—SANITARY—S'I OIM EA.21X114.
n�piny any Lenon in any mannur,o as m Iecnme subject Io the nENERGY PI31i
satin Lmwsnf Culifnntic.Date WATER 1117AIEk W/VEN'I'/BLECTR
o GRADING hili
.z AFPlicum
NOTICE TO APPLICANT If,afaroOking this Certificate of Escmptinn,you.should WATER SYS,FM,TR8A1'INC.
a > byamc.wblect film Worked Compensation provision ofthe Labor Code.Y"u must SOILS THE
{A forthwith comply with such prrvrums or this parotin shallM dcenmd re,oked, WATER SERVICE
Uz deffla HGDUNLf?NUINOAGENCY NEW RESIUIiM'IALI'LMIi. SQ.FC "PAIDI hereby alYinn potnhttcivanmxwaiun leningagency lr, c perh,rnum.c of iplNC.7 - the work for% ich this permit is ismN(See.309].Civ.C.)U Landers Name 'TOTAL:fanJera Address TOTAL"'l0.U I dre,h tlh d,l —plli t I:rn th nth M f nt n's
m cor t.l g t ttpy maB tyand ny 'd d.,aI F ,gm Q'IY MECHANICAL PERMIT' FEEz. g ......hezbrvc-mentioned property for inspection prap, . PERMIT ISSUANCG(W'e)agree m save.indemnity and keep harmless the City of CLperinn againstliabilifmijaufinenis.creu and expense,whichmny inanY way accmc agimuaid City ALTER OR ADD'TO MECIL
APPLICANT
SIbisI WILL
APPLICANT UNDIiONS.NDS AND RILL CUNIPLY l\'LTH ALL NON-POINT AB HANDLING UNITTC)IRIMIU CEMI
MEC AKICAh PEE
BOUNCE RF,GULN'10N5.
AIR HANDLING UNIT(OVER 10.000 CFNO CONST ICI'ION TAX
Signal u a of AppEcanVCunwmm Data EXHAUST'HOOD(W/UUCI) I LOUSINGN 'IIGNNONiI?li
HAZARDOUS MATERIALS DISCLOSURE
W5ll the appdcanlrrfmnm building wee....I amre or handle M1ezaMoue unmans! HEATI NO UNIT(TO 100,100 BTU)
as relined by the Calendar Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Scaion 2.5532(.)? HEATING UNIT(OVER 10gI,gX1 BTU)
0Vey 0 N PAID
V 13NTILAI'ION PAN(SINGLf?RESID) Dim Rcccim#
Will the applicant or future building(weepant use equipmnt or devices which
mit hazardous air contaminants as defined by the any Arca Air Quality Management IIQILEH—COMP(91Y OR I W.dUU ITTUI T 41 !T
Decrial Y`s ❑N BOILER—COMP(OVER IIX1.ot0BTU) p
I have revel the bvudous ata¢tial,"mmucei under Chapter 6.95 of the Cali- A IR CON OF I'IONER ISSUANCE DATE
fomiu Health&Safety Code,Sections ZF05.25533 and 255}1.1 undemand that tithe NEW RESIDENTIAL MECIL SQ.FT
building docs not currently have u tenant,that it is my responsibility nt notify the oecupunt
of the rcyuiremunb whi,li mux!Ni Pne,In olicalle of a Certificate of Omupunuy.
Owner cera imadm izcJ agent Data 'TOTAL: ISSUED BY:
OFFICE