99080159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL E IT NO. �n
HUII,DING DIVISION APPLICATTON/PERMIT PLUMBING-MECHANICAL ap
IIUII.DINGPROJF.CTIDKNriFiCAT10N DV
BUILDING ADDRESS'. „ � k� �1� 1 / /S J- SANITARY NO. APPLICnT10N SUBMITTAL HATE
Pr' IV\ Il 11,1 Il.K.,• Nl `J/vl 3 - 2 3—g
OWNER'S NAME C PHONE ���� CONTR OR'S NAME: L;OIC NO:
J ` l NIC CONI'kOLK
CHITECTIENGINEER: LIC NO: ADDRES e �j rt'N- 1:1�l 5 • klwSCo
coNTACL � � (- ,fP vxonE:•''� q n HUILDING PERMIT INFO
Sq C �1 Sim�Va �� /—�� 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT F.
c z z I hereby nmrm that l atm licensed ander provisions of chapter 9leamnnendnI, JOB DESCRIPTION
W00 with Section 7000).l Division 3of,he Business and Irmbeisiom Collard my license is PERMIT ISSUANCE RESIDENTIAL:
F�ki,F in full force anJl forvc eqd ❑SFD W L ❑KITCHEN REMODEL
a_u Li.at Cl LiC.X - APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RI PIPE
yG u1 Dmu Contractor
L ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURN,
zo.z Iandersandnry,lnn.%shall be...Jaspulhimercords PANELS MODIFICATION
OZ1O UPT0200AMPS [I INTERIOR POHIMNHY REPAIR
Licensed l're.I...i lI 201.1"AMPS IMPROVEhIENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER IINN)AMPS El BATH kEMOq,t EPAIk (] EMOLITION
C C Q I hereby affirm that 1 all exempt from the Contractor's License law lot the
L+1'3c.U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
1+•N which requires a permit m construct,alter,improve,demolish,or repair any structure ( L �t
F]W0Q to its insuanee,also then Meant for such Int file a signed 10
N.] poor requites pp panni gnc SPIiCIAI.CIRCUIT'/MISC _ Q
h
that lie is licensed pursoamOothe pruvisionsolthe he Busidolshicensclrw(Chapter
�a 2, (a)r be is iomap, Sention add of basisob rns,u l,ed e%snnJ Yn.An, icCodelor TEMP METER ORI Ii INS F. COMMERCIAL:
ti a e IY That he is exempt thcrelrom and the basis for the alleged etemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
w
Section]0315 by......tlum far.Penni,wbjeeo the up,heam m v civil penallyof POWER DEVIC [I TENANT ❑FOOD SERVICE
more than five hundred dollars(5500).
F Z Y r
wi Lerthewrof the k.andpestrac.oh mycmntende%with wages le(eir Sole enmponsuuun. SWIMMIN '001,ELECTRICp. willdoth¢work.C,.1c suuau¢is notroona Livens Lawoffdoes notlapply t oan owner of ul'- and Pmwhob Gnlc:The C es thems Llccmc Law do r no, rkhi s if owner of QUI'L' S-5WITGHES-FlX'CUkEShnpro,am,who builds or improves t such i and who does m ra work himself ofi throughbinown employeese provided That%nch meet is sold w thin ot intended nr ollered for N' kLSNEN"1'IAI.ELIC fk SQ FTown,lhowevegtheveth burden of penen,isat hedid noneyen,impro le,to,pr- A �Sd5Q.14.ofrac .).will have the burden of proving res he did not build or improve lm Aur-owrn Pam of mwne❑L ter the P of ct(Seepeny.am exclusively convecting with licensed mnaacmrs ns TU1AL: 7f1f1❑construct the esono pply o as wner or sad ay whoho ds or i Theves themon. 1.7A0c ¢law forstapplytoanawncrofprapery whored purrantto ma Coura.and QTY. PI,UMHING PERMIT FEwhocommas Tolman projcaswith ocamnaor(s)liansed,urmum est theContruchtisLicense Law. PERMIT ISSUANCE
I am exempt under Sec. ,I1&P C fonhis reason _
ALTER-DRAIN&VENT-WATER(RA) VALUATION
Dane
wash WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hcrehy offirat ander,sonny of,crjury one of the following Jed...tions: S�
❑ have and will maintain a Cenifica,e of Consem to self-insure for Workds Compel- DRAINS-FLUOR,ROOF,AREA.COND. ,STORIES 'TYPE CONST'kUC'1'IOD
aa,ion,us Pmvidcd Iia by Section J]110 al tM1c Labor Code,I'onhe prfonnvncc of the
work for which this Permit is issued. FIXTURES-PER TRAP I
1b have and will.,.matin W am,Comper,clum In.....re,as marred by Stram
3700of the labraGale.fort he Performanceof,he walk far which,his permit is i.%sued, GAS-EA.SYSTEM-]INC.4 OUTLET OCC GROUP AI'
My Worker s"Lp��Papp,ion l txnr c �c and PulicY nu y� ._r1
Cartier: Z7zatl'a ..nil Policy No.: �y�4�-'I9 -7 GAS-EA.SYSTEM-OVER4 EA I'
CEIHIFICATF.OFEXEMPTION FROM WORKSS' AO�
COMPENSATION INSURANCE 131/.,to 06 GRF,ASFJINDUSTRI,WASTE.1 ERCEPTOR
('I his section need not be completer if the Permit is normae hunarcddollart IS 100) BUILDING DIVISION FEES
mm".) GREASE TRAP PLANCHECK FEE
Icenifythutitda,pefmarance.fdrevmls ferwhich thispenrt is....ed.Ishall SEWIiR-SANITARY- 'ORM EA.2INIIT
not employ any person in any manner so as m becameuo
subject the Worker:Coattail, ENERGY FEE
Z sa,ion Laws of California.Date
Q WATER HEATER W ENT/F.I.ECTk
Z� Applicant ) GRADING FEE
fn NOT ICE 10 APPLICANT:If,after making this Crnificar,of Exemption,you should WATER SYSTF. /TREATING
a Internal subject to the Worker's Cnm,cn,sminn provisions of the Labra Cale,you must SOILS FEE
W mardwilhcomplywalt suchprovisiomorthispenai,shdibedeamallevoked. WATER SE ICE
Q
UZ CONSTRUCTION LENDING AGENCY NEW RF DF.NTIALPLMB. SQ,ET. PAID
V Q work
rwhich rnvhm@ere issued(Sec,ion lending agency for the Performance of D. keccip,X
O .. the work for which this palmi,is issued(Sec.JIN],Civ.C.)
F' lender's Name TOTAL:
Ixnder's Address TOTAL:
1¢oily that 1 have real this application and.%tate that the above information is RU.-I., PEE
IA) comet.l.gree no comply win all city and county oNinanms and slam laws u1nag m QTY. MECHANICAL PERMIT FEH
V Z budding construe,ion,and hereby authorize representatives of Nin city to enter upon the I SEISMIC FEE
alnve.menlioned propcay for inspection purlwscn. PERMIT ISSUANCE(We)agree m save,indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE
iabilitic,pdgnmen,co...and expenses which only in any way accrue against said City ALTER OR ADD TO MECH.
in meauence of Ore granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIT'II ALI.NUN-POINTAIR HANDLING UNIT(1010.1100 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Si,nalue olApplicauCcourinEW Date EXHAUST HOOD(W/DUCT)
HAZARDOU.!C14ATERTALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle Isommos material HEATING UNIT(TO I00.000 BTU
as dcfinN by the CuPcnino Municipal CMe,Chapter 9.12,and the Health and Safety
Code,Section 25532ft)'I HEATING UNIT'(OVER If10. BTI))
El Yes aNu
VENTILATION FAN IS 'LE RESLU) PAID
Will,he applicant or future building oserpan,use equipment or devices which ])all Receipt N
emit huuNnus air conmmiramas as dclined by the Ray Area Air Quality Management BOILER-COMP POR 100.00D BTU)
Diaticl^ ']CHAT
El Ye,, '®No BOILER-C . P(OVER 100,1X1!1 BTU)
1 have mad the hamJous m too.[,re,liremcmx uMer Chu M1.95 of the Cali- AIR C ITIONEk
('nil ISSUANCE DA'I'S'
lamia g Health&1commonly
my Crile.Sections 255115,25533 and 5534.1 understand that if the N RESIDEM'IAL MECH. SQ.FT.
0 tirengdoasnommendYM1weatenatn,that it is my resp f Cerii Tical fOccupecupant
ul,he ruquircm.n hien ams,hes •, r sdm ofa Ccrdfiem of Oecuponey.
1-I
Owner m inthoneed gen, Date TOTAL: Ir
IS5IIBD BY. r 'P
OFFICE