B0365 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y(�'
CITY OF CUPF,RTINO BUILDINGMB -ELECTRICAL %/S{ N40365
BUILDING DIVItiION APPLICATION/PERMIT rLUMaTNc-S+F.cunNICM' 5000 l/
BUILDING PROJFCT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLIC
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:
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BUILDING PERMIT INFO
❑ Cir a hunt Fees Paid by Applicant(Initial) X'.'
ELECT PLUMB MECH
❑ ❑
I.ICINSEDCUNTRACIDRS DEC ARATION QTY ELECTRIC PERMPr FEE
1 hereby affirm mn i 1 mn hcanNd trade Pnwisit rorCTapta 9¢mtmemmg - JOB DESCRIPTION
0=Z with,S. tine(")of DM,ien Jofthe Brumeas noPn�fanionz Codc,and my beano:ix RFRIDFNTIAI.:
1x100 . PERMIT ISSUANCE
F full fome and eRcn. ❑SPEWL ❑KITCHEN REMODEL
=WE License Clus licX APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING HE PIPE
NH G0 W. Dem ConmemHf1Ea
CTS
DECLARATION
❑MULT-UNIT El STRUCTURAL
Z O taaas public rtcwds PANMODIFIC
TION
OZ 1PT0200AMPS [I INTERIOR El CHIMNEY REP
A
IR
F.4 Fp-u1 I. c fcsmnal mil-ItritAMlS IMPROVEMENT [DSWIMMINGPOOIS
�y2•�] O NI' -BUILDER DF.CI.ARA'I'ION OVER IOMtAMPS ❑ItADI NFMOi)ELl1UJ'Alit-�YNiMQNiiH
IY C 6 1 hereby affirm I um exempt Ga^the Co nmwlm'N License Law Gx Tho
K 06 U following rmmn(Semon 703 L5.Bti,m.and Podedlmv Cade:Any aU,,,r coumy SIGNS EI.I=RICAL ❑f1I
3 LL which ryuiry a permit to emurvcl,eller,uupwe.Jenwlish,a refer any muctme r� /��
F�Og oto its heart¢.ab,o requires the appliau an such permil to file a signed smtamcru SPECIAL CIRCUIT/MISC.
Y�y 'Wr he is licaud pesuent to the lvovuionsof the Comranors Liaose law(Chepttt9
�4CC�O (rommencing with Satim7LO0)ar Divisim Jaf the Bueire.0 gad Rvfusiom Code)m TEN+R METER OR POLE INST ,IY g1�1 �Qa.�,199
a a IY flat he a exempt dxma m and the buil fa Ibe allege)exemption.Any violation of ❑NE '� LDG�ADDITIOIT LJ OGSfO ffl
y Sadiron 70313 by any.Whimnt fare permit subjecs the appheant for civil 1mIty M POWER DEVICPS ❑FOOD SER
Oanm marc Ilan five M1unlrcJ J.Ilars($AID). I OVEMENT
D Lon rvwrcr of lha'.pn,Ptrnyonty cmpkyrcn whh wagon an lbUlr mlc contPenwtmm, SWIMMING POGI,B ECfBIC
50 will odthe wok,and tla structure).ria intended or offered fin;svlcSec,7(WL Business ❑OT BR]
N
lat"�
and Ihofa�ms Calc:Tie Ctxvmclas Lianx Lew dean rod a%XY to nn muerte of OIIRETS-S -IIXTURIS C)O
ptr'rrty who builds a impove.s asmon,and who Joos such work himself or ilauugh NEN'RESIDINf1Al.L SQ IT
his awn employees,pravW i that such impovemew are on,intttald ar dfeml fa
ale.U,howe.er,Bre building or impmvcmmt is sold within mm)Te of cmoplefiar.IM1e SQ,FT.FLOOR AREA VS Q.FT
mnerbuik win hare the blmlem of ptoving Nat he donot Nita orimposerapar-
Pose of mdc.).
1,as owner M the pmpcny mor excluively contracting with Iiccrcal cmmeotxx to L 'I(yf
est.the Pmjwt(,Sec.7BW,Bunion',W Pr^fes,mo,Gala:)The Cmtmetcx'tl U. ���
rat mmc law Of—not uPPlyaoo, of Pmperty who bmIcf orlmp —nemw
s. xl QTY. PI RMIT FEE
wMxtmlricls forouch rojectx with aconvea.*)Iicclvcd Poauvmmthe Comraomr'n
Licrow Low. I PER s Abl
1 an asampt aadtt Scc. B B P C from Ni.neem
ALTER- RAI WATER OW VALUATION
t
er Dem
WORKF,RSCOSIPF SSATION OECIARATION BACK FLOW PR(T E .DE' "i O O O
1 hereby a0rm trader Penally of pajomy are of Bre following dcclvrwions: J
luvcoM illmintainaCenifcweof Ca ttowif-ins mfo Woktt'x Compen- DRAINS-ILIX)R,ROOP.ARBA.0 STORIES TYPE,CONSIRUCPION
nation,as pmvi ld for by Sccrmn 37(X)d the Igor Code,for the perfmoana of t1e
work for whwm
h this Petil ie iasucd. 19XTURES-1117R']RAP
❑ 1 hnvc and will mailmen Wod.cr's Gmtpcnexitn in-ra^ce.as rcquiad by Sw•nitn
3701ofthc LOW,Codefar lM perfomence.fne work Gtr whichthis Pemot i,—d. GAS-IA.SYS'IHM-ZINC OUTLETS OCC.GROUP APN
MyN'or/:er'vCmtpcuwim lnmmrtm ranitt edy No.:number art: GAS-ISI.SY,SEM� ER4(FA) � 32L_lao��
Cmnm Policy No.:
CERTIFICATE OF EXEMPTION INN]ROM WORKERS' GREASFAND RL WASTE INIERCEI OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This.vee recd rod le eomplad ifllw Permit is Twee hundi dollvn(gIW) GREASE AP
o leu) %ANCHECK FEE J 7J
IcrnifY that inthc prhorrom.oflbe work forwhi,h lhiNpcndl is mood,I,mil SEW. -SANITARY-ST ORM EA,21X0 FI'.
nm employ any"'m in any narme, aav m lceaoesubycn ht the Wokni ComPcm. ENERGYFEE -j
Z it..Le.,of Califon],Uwe AlT:R 11 PI UR WNENT/ELECUO
2 O Applicant f GRADING FHE
N NITTICE TO APPLICANT:It,etre making this Cenif to of ExemPem,you should WATER SYSTI?M/IRFATING
("' ^ became subject to dee Wor/:a's Compensation povisim rt layou mai
Jbor Cade.ymust .OILS FEE
W , mnhl ith comply with such pov'siwss or Nix pemul.shall be dl emM re.wad. WATER SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLF1B. SC.IT. PAID R¢.cip N
U O I baehy taboo that Him in a crve ins lending ageoy for the Perfa^nnm td
L! — the wad I.,,hieh this Pennine)seed(Sce.."7,Civ.C.)
tendo,Name TOTAL
[U Leader'x Aml 'I ON I;
Tye a. 1 ready that 1 breve rind this ipplic�tion and uwc tial Ne shove i.famlation in NUII,
L toy cartet.l agree to emolly with all dry and county,tmbannO,.s and state laws elating m QTY. MECIIANICAL PERMIT FEE
U z Wilding evnnvuel'uxr.end hereby auriwnx reprtsemuiscs M dos city l0 enter upon the SIRSMI
alnve rlrtmimN propeny f«ins hent Pro Pc . PERMIT ISSUANCE r I:LE -FEE V O
We)We)agree t.sue-iodemnify and keep hnrtnbu the City of CoParm.egainq
habllities,judgment,On Ls and npemea whichrmy in any story accrue egilna said City ALTER OR ADD TO N/ECH, 3 (V PI,UMBNG FEE
in cora iI.O.of Ile granting of Nis permit.
4OURC
ND STAN' D WILT.COMPLY WITH AI .NON-POINT AIR HANDLING IINI'1'CIO 1(1,(ID0CPM) 0
MOCHA CAL FEE
II- I' )NS.
SAIR HANDLING DNIT fOVHN ID,Igq CPMI CONgI RE LION TAX
IicamuCocree, etc EXHAUST I[GOD(W/DUCT) HOUSING MITIGATION FEE.HA R V MATERIALS DISCI.OSURE
Pplicw or to Wik4ng ncmParst stare or handue HEATING UNIT TO 100.000 BTL)
as defiled by IIrt Cupcnim Marsopal Cod-Cleaner 9.12.nod the Heats and Safety HEATING UNIT LOVER 100,000 RTU)
Code.Se oc 255J21a)'f
]Yes VENTILATION FAN ISINGLERESID) PAID
n Uwe RcaipN
WIII the a licun1 o future b dding a uryml urs cyuilxncnt.r ito i wM1ich BOILER-COMP(3111'OR IIXLINXI BUH
mit heamdarz ax a^mtrminomt ax defirod by the Buy Arca At,Quality Mine,tocm 'D AL:
C"0rin7 BOILER-COMP(OV ER 100.000 BTID
❑Yea O
I here reed the material rtquirevrrNn mdcr Chapter 6954 He Cali- AIR CONDITIONER (��$SDANCE DATE_
fano Hml Sof ode 'am 25505.255)3 aad 25511.1 i the NEW RESIDENTIAL MECH. SQ.F-E J r
WilJln . Ely 'c lendm.that ilvmy mptxsibiliymmtify �e
Friar Ire is'.a.Calif
f a g tD c OTA ISSUED BY,
OFFICE