27212 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP.ERTINO 11 ILUI G-LLECI'RI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTBING- IDENTIFIC n72 n
BUILDING PROJF,CT'IUF.N'TIFICA'1'ION G L 1 L
BUILDING ADDRESS: �� A /a SANITARY NO. APpLICA'nONSUBMnTALDATE
sla 0'7 6 Via 6 Ol r UNIT# / /Q// OC LOT, I
O ERS AM'' PHONE' CONTRACTOR'S AME: LIC NO: —NIC CONTROLN
i A ion ,oro eS hC 985-6 l�cvn e r
ARCHITEC A NGINEF.R: LIC O: ADDRESS: ❑
CONTACT: PHONE.: BUILDING PERMIT INFO
1 QTY. ELECTRIC PERMIT FEF.
T L'G Co% �� qgS-JSO6 1 PERMIT ISSUANCE BILpD/G F,LppF.C��T PL�UMYtl MIE�CyII
10 N 8 Id
LICFNS17D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCWI'TION
cwz IhrmbyvffimUhat l am liummdander pmvisi.mofCbapw,9(commeacingwuh
�dE Smforceand.fDivision 3ofNeBusinessandPmfessionsCode,andmylicenuisin PANELS
a V full force and efleat
4ZZR Liunse Class Liap UP T0211tlAMP5
HQy Data C.ntrsecr 201.["AMPS
Z8yK ARCHITECTS DECLARATION OVER Bad AMPS SQ.FT.FLOOR AREA 3/SQ.FT.
O Z,_G I understand my plans shall heated as public records.
SIGNS ELECTRICAL 9 / / 0
/ O
4��ddE Licensed Professional
L pd f�6 OWNER
not exempt
the CATION SPECIAL.CIRCUIT/MISC.
1 herehy n.(Se that 1 am<xemPt from the C.ntmcmr's License iLow for Nc
[v130.y
following inasna(Section70lL5,Business and PmfesaionsCode:Any cityorcounty TEMP.METER OR POLE INST. 3q`/ /
which requires a Permit m someone,construct,alter,improve,demolish,or¢pair say (•J�
zEyRJ>:F prior to its issuance,also requires the applicant(orsuch Permit to file asignrimsoment POWER DEVICES
y1CQ0 Nat he is licensed pursuant to the provisions ofthe Connor's License Law(Chapter
�Xp� 9(mrmmencing wird Sration7IXq)of Division3of the Business end Professions Code) SWIMMING POOL ELECTRIC UVALUATION
y)_y or lm is exempt therefrom and the basis for the alleged exemption.Any violationof /9/ 603s
ZQ, Section 7031.5 by any applicunt fora permit subjects the applicant civil penalty.( OUTLETS-SWITCHES-FIXTURES
not more than five theprohundred dollars($ere). NEW RESIDENTIAL.ELECIA _SQ.FT.
50 ❑ Laaowncroftbepropeny,army employceswithwageaes theirsolecompensed.n, STORIES TYPE CONSTRUCTION
a will Professions
end the he Cor ares'm License
Law
does
of apply to an owner
of
and Professions Code:The ves the ors ndwho Law does such or apply m an owner of
pmpenywhobuipowidmPmvesthimprovements
mprovndwhs dom ,imemle ldmsclfor through Ne OCC.GROUP M.UNITS
Iran employres,provided Nm such i mpr.vemem s arc not i mm�deJ or offemA far sol e.I L
however,the building orimprovemenr is sold within one year Mcompletion,the owner- /_,wa 5 -
builder will have the burden of n that he did not build or improve for a TOTAL: //VV W
rousing P purpose of
ale.).
❑ 1,as ownendthepropeny,amexdusivelyconraering withlicensed emntmetorsm QTY-1 PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Bus n
and Professions Code:)The Contractor's
License Lowdoes not apply to an ownerofproprnywho builds a improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contmctogs)Iiernud pursuant to the Contractor's
License Law. ALTER (EA)) FEE SUMMARY
❑ I sin exempt under Sec. ,B A P C far Nis¢goon BACK ROW PROTECT.DEVICE O S LFEES
SANITARY Y N
Owner Date R[CEIPI'p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ thereby affirm thatlhaveecertificate of consenno self-insure,oraccaiftcamof RECEIPTx
Worker Compenamion Lnamnce or a certified copy flemof(Sec.31100,Lab C.)which FIXTURES-PER TRAP PARK HE Y N
covers all employee's under Nis permit. GAS-F.A.SYSTEM-1 MC.40IITLETS RECEIPTp
Policy p BUILDING DIVISION FEES
Company GAS EA.SYSTEM-OVER 4(EA) PLANCHECK FEE �s
❑ Certified copy is hereby furnished. O(
❑ Certified copy is filed with the city inspection division. GREASMNDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need net becompleted ifthe permit is forone hundred dollars 1$100) SEWER-SANITARY-STORM EA.20017T. ENERGY IEC
or less.)
I certify that in the performance of the work for which this Permit is issued,Ishall WATER HEATER WNENT/ELEM
not employ any person in any manner so as to become subject to the Workers' PAID
Cnmpermlim Lowsof Culifianow Date WATER SYSTEM/IRFATING Data Raxiptp
oApplicant
OO NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
G V) ba,marsubjceno Ne Worker'sCompcnsetion powni.m.fthe Lmor CMe.you most
FKi 7 forthwith comply with such provisions or this permit shut[he deemed invoked. BUILDING FEE O ! ��
;� CONS'IRUCION LENDING AGENCY SEISMIC HE ' SD
I herehy affirm Not there is a construction lending agency for the performance of 4 �-a/l (_
V O Or work for which this pernat is issued(Sec.300,Civ.C.) TOTAL: /. /R/a 47
ELECTRIC FEE 70 , OS
Lender's Name
C U Lender's Address QTY. MECHANICAL PERMIT FEE
PLUMBING FEF.
V / 740, ops—
I ramify that 1 have read this application and also,that the above information in O Qs—
building
cored m I agree comply with all city and county ordinances and stem laws relating to PERMIT ISSUANCE MECHANICAL.FEF.
construction,and hereby aull odze repinsenlstives.f thiscity so enter upon the CONSTRUCTIONTAX
V z uhwe.mentioned property far inspection Imauses. ALTER OR ADD TO MECH. S
(We)agree m arse,indemnify and keep homeless Ne City of CuPrrinu against
liabilities,judgments.costs and expenses which may in any way eceroe agwast said City AIR I IANDLING UNIT(TO 10.000 CFM)
in pyup/ue of granting of this Permit. I9
Iona rev sApp�,, '1'^ AIR HANDLING UNIT(OVER IgIXp CFM1)
+.tet r /V 1/ II aT
signature of Applicant/Contre{—'—op Dem EXHAUST IIOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00r)BTU) Data Receipt x
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.(100 BTU) 'TOTAL:
us defined by the Cupwaso Municipal Code,Chapter 9.12,send the Health and Safety /�[.� /�
Code,Section
0Yes El N. VENTILATION PAN(SINGLE RESID) '7J g/ p(
Will then Iicantorfutumbuildin occupant BOILER-COMP(3HPOR I0B4O009TU) ISSU NQ DA
PP B equipment Quality Management ra�/,
hazardous Lir cnntuminents vs defined by the Bay Aua Air Quality Management BOILER-COMP(OVER 100,WU BTU) t #
Districff �-s .Y
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.IIT. I�y(Jr 1995
1 have read the Escomf us mm uads requirements under Chapter 6.95 of Ne (a UN
California Health&Safety Code,Suctions 25505,255]3 and 23534. I understand that r/r \
if the building does not currency have a tenant,that it is my responsibility to notify the
occupant of the teyuiranents which must be met prior m issumce.f o Cenificme of
Occupancy.
Owner or authorized agent Date TOTAL: 170, ISSUED BY: M
OFFICE