28984 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT IND - BUILDING-ELECTRICAL. PERMITNO. ^ 8 w 8 a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L yVd ��J/ 4
BUILDING PROJECT IDENTIFICATION
BUILDIfJy1p ES� SANITARY NO. APPLICATION SUBMITTAL DAT(
OWNS :SpNvyA,ME: /1� ' /
PHOM. OMR^A R'S NAME: //�� LIC NO:
NS M W 1L��EL/Y� y � / ,47-,. r NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: Egg; ❑
9 ICoeK6/1oJE .C/4n/E
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial BLDG ELECT PLUM R,. MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S OECLAHA'HON - M201-HWAMN
LECTRIC PERMIT FEE
x I hereby mins,Nm I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
TION
CZp with Section71)(g)oftivision 3 ofthe Business and Professions Code.and my license is
W
in full farce anJ ellen. NCE RESIDENTIAL
0z0 LicenseClve Coco ❑SFDWL ❑PLUMBING BE
�6� Date TS DE nr NL•SIDENTIAL
❑ADDRION ❑PLUMBING RE-PIPE
F.GN"/ai ARCHITECTS DECLARATION
C z N Z 1 understand my plans shill be used as public recoNs ❑MULTI-UNIT ❑STRUCTURAL
.' MODIFICATION
PS ❑INTERIOR •El CHIMNEY REPAIR
ay�LWfs� Cleansed Pm(eamotml IMPROVEMENT
OWNER-BUILDERan'beC uracagz1 hMano affirm on I am exempt from the Comm,Co License Law for NeELEPS ❑BATH REMODE IR 0 DEMOLITION
4 U which mason.(Section]031.5.Business and ve.dkiiall Cade:repair
t or taunt ❑OTHER _
�'3� following Yc'Y Y SIGNS ELECTRICAL
O which its mu u permit re construct,eller,improve,demolish, file
rtpaig.ny structure
h
Prior to its issuance,also requires the applicant for such permino flea signd statement SPECIAL CIRCUIT/MISC.
p. that he is licensed pursuant to the provisions of the Contractors License Lowe(Chapter 9
p� (commencing with Section'/(KKBof Division 3 Oflhe Business and Professions Code)., TEMP.METER OR POLE INST COMM _R IA�•
6 p.M e' that he is exempt therefrom and the basis for the alleged uclunion,Any violation of El NEW BLDG/ADDITION F1 DEMOLITION
Section 7131.5 by any applicant for a permit subjaIS
rs the applicant to a civil penalty of POWER DEVIC
notwimore Nan five hundred dollars(55oo). ❑TENANT ❑FOOD SERVICE
❑1,as owner Of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC' IMPROVEMENT
ll do the work,and Ne stronure is not intended reoffered for sale(Sec. Business OTHER
and Professions Code:The Contractors License Law does out apply as an owner of OUTLETS-SWITCHES-FI%TURES
property who builds or improves thereon,and who does Inch work himself or through
his own employees,provided and such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.IL however,the building or improvement is sold within one year ofcompletion Ne
o SQ.FT.FLOOR AREA USQ.PI'.
nena did
buildwill have the burden of proving thus he not build or improve for put-
uofaek.).
w er of Ne progeny,am exclusively contracting with licensed convectors m TAL: e
onswcc t n lar*-(Sec.AH4,Business and Profession®Cale:)The Comntcmrh Li- � pID
cense Law Mas notapply loan ownerof Pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE W
who contracts for such projects with n convactodid licensed pursuanuo the Contmetues
License Law. PERMIT ISSUANCE �#� O �
❑lame viandet Sec. • ,B&PCfor this reason y
net ACfER-DRAIN&VENT-WATER(EA) V L s�
WORKGR:S COMPENSATION DECLAMATION BACK FLOW PROTECT.DEVICE
�1 Vr VU L ,
1 hereby affirm under penalty of perjury one of the following decimations: - 1
I have and will maintain a Certificate OfConsenflo self-imiam for Workers COmpen- DRAINS-FLOOR.ROOF,AREA, D..
s tion,as provided for by Section 37M of the Labor Code,for the performance of the RIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
C] I have and will mainuin Workers Compensation Insurance,u rcyuired by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
My Worke s Compensation Insurance carrier and Policy number ore: OCC.GROUP ppN
Carrier. Policy No.: GAS-EA.SYSTMFOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASU'INDUSTRL WASTE INTERCEPTOR
or IeseJ
finis Whom need not be completed itches permit is for one hundred dollars GREASE TRAP
(SME BUILDING DIVISION MES
' leerily that in the performance orate work forwhich this PLANCHECK FEE
pe,W.rco'C,lehall SEWER-SANITARY-STORM EA.100 PT
Z
not employ ony permm in any manner so as m become auhjem to the Workers'Crmpen- ENERGY FEE
Lebon Applicant
of Coliforniu.Date WNI UR HEATER WNENTMLECTR
�y NOTICE - GRADING FEE
.�E•yt rA' NOTICE TO APPLICANT:IL after making this locuicmm of E Labor
o d you should. WATER SYSTENUTREATING
L>!i bemnuh cons ly the Wakere Compensation erm'xams mf the Labor Cale,you must SOILS FEE
Q forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUME. SQ,PT. PAID
V 0 (hereby affect Nat there is a conswction lending agency for the pMormance of Date Receipt 11
{T4 rthe work for which Nis Permit is issued(Sec.301 Ci,C.)
Lenders Name
V
W Lenders Addrtu TOTAL: TOTAL:
Pi I emify that I have mad this application end tame that the dwve inforirution is l !BUILDING FEE
rA contract I agree m comply with all city and county ordinances and state laws Ivlacingto QTY MECHANNICAL PERMITV z building construction.and hereby authorize representatives of this city In enm .poa Ne FEE FEE
above-mentioned pmpcty for inspection purposes.(we)agree m save,indemnify and keep handless the City of Cu cium a ainst PERMIT ISSUANCE
P< 6 IC FEE
liabildies,judgmants,costs and expenses which may in any way accrue against said City ALTER ORADD TOMECH.in consequence of the granting of thinpermit. NG FEE
APPLICAN'P UNDERSTANDS AND WI.L COMPLY WU'I1 - ) AIR HANDLING UNIT(TO lo.al CEM)S RR .REGULATIONS. n - NICAL FEE
AIRHANDLINGUNIT(OVER10.000PM)NNl /� �aA� UCTION TAX
Sngnamn"RT ApplicamnContmcmr Data EXHAUST HOOD(WMUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store Or handle hazardous material HEATING UNIT(TO I W."BTU)'
as defined by the CuPamin,Municipal Code,Chapter 9.12,end the Health and Safety
Code,Sarion 25532p)? HEATING UNIT(OVER 100,0110 BTI)
❑Yes [I No
VENTILATION FAN(SINGLE MID) PAID
LWill the applicant of furore building Occupant use equipment or devices which Dice Raeipt is
ot hazWous air commodious m defined by the Bay Area Air Quality Management BOILER-COME QHP OR 100.000 BN) -
Oiit ct? - NT
' ❑Yes FI No BOILER-COMP(OVER 100.0))BTU) ,
AII
AIR CONDITIONER L.
HealthI have read the h ask.S s tams al,255 5,2553 an nailer ,1 uncle rsta d t the Calle ISSUANCE DATE
Ibmia building does A Safety Coda,Sections 25505,25537 end 25534.1 undersand that if Ne NEW RESIDENTIAL MECH. SQ.ET.
Of hoJ ncuum which
y hust a Rnet a arm,,.
is mme,of.aCe"ifim notify tho acupent - V.../
Of the reyuimnems which must be met prionnissuance nfu Cenifcutc of Occupancy. '
Owner m mffiam¢ed.gem Date TOTAL:
ISSUED BY;
OFFICE