26901APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
NO APPLICATION/PERMIT HICAL
CITY OF CUPESION PLUM BING-MECHANICAL
BUILDING DIVISIOME
BUILDING PROJE(:T IDENTIFICATION
PERMIT No.
26901
BUILDING ADDRESS:
SANITARY NO.
APPLICVRONSUBMUTALDA 'IE
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OW EISSN ��IM PtION
CONT 'S NAM IC NO:
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ADD ESS: /
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CONTACT: PHONE:
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QTpY ",.,ELEOTRIC PERMIT - -FEE
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ISSUANCE
rio-PERMIT
❑ El
LICENSED CONTRACTOR'S DECLARATION
1 hereby affi am that I am I icenscd umler pravisiam of Chapter 9 (wmmenci ag with
APPLIANCES - RESIDENTIAL
JOB DESCRIPDON
Section 7") of Division 3 of the Business and Professions Code, and my license is in
PANELS
fullfLicaomeandeff IF `� �& /
Class 4fJ
UPTO 200 AM�
� 1
Dino Contract
,�1'
ARCHITECTS DECLARATION
I undersand my Plans shell h used as public records.
201 - 1000 AMPS
- SQ. FT. FLOOR AREA
$'SQ, FT.
OVER 1000 AMPS
SIGNS ELECTRICAL'
Loomed Professional
OWNER -exempt RDEC Conan ON
1 hereby affirm that 1 and exempt from the Canoamr's Lioonse law for the
o Code: Any city mentally
following reason. (Safiuo 70313, Business and Re,
SPECIAL CIRCIIIT/MISC. I , n
J tom. rte,
II i
TEMP. METER OR POLE INST. L U
de
demolish, my structure
primmitsch i......1res a tmcmauum,almFimprovgdemntut t ale.si8odwatecsum
mgaims ths si Leal mmtmnt
iunsed
tfousuchhe
pemdrs
Q
/ a I
POWER DEVICES ATE
Palso
that heProvisionsCo Lt.,
than he is licensed parsuant 7the provisions of the Ce Business and Pro Lew (Chapter
9(commencing with Section 7(NX))oFDivision 3of the Business and Professions Cade)
SWIMMING POOL ELECTRIC —
VALUATM
or that he iseaempt therefrom and the basis for the alleged excmpfion. Any viohtim of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Faulty of
OLITLEfS-SWTTCFIFS-FIXTURES
,not more than Eve hundred dollars (5500).
❑ Lasownaofthepropmy,mmyemPloyeeswithwagesasthi...I.eamprnm0on,
NEWRESIDENTIALELECTR _SQ. FT.
STORIES
TYPECONSTRUCTION
will dothe wurk,and the structure is not intended proffered forsale(Sca. 9014, Business
real Professions Code: The Conhactor's License Law does not apply to an owner of
property w ho bui Ids err improves Nerean, anJ who does such work hi tuelf or through his
own employees, provided that such improvements a renotintindedorofferedforsae. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the buildingor improvement is sold withinoneycanofcompletlon, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY I PLUMBING PERMIT FEE
.IF.).'
[II,uownerofthepropeny,amexclusivelycmtncOngwiNliunsedcontrenon to
FL DZONE
APN
construct the project (Sec. 70dL, Business and Professions Code:) The Contractor's
L i cense Law doss not apply m an owner of property who bui lds or improves thereon, and
PERMIT ISSUANCE
whocmn mforsuchpmjatswithaconm ctor(s)licensedpunuutmthe Contractor's
License Law.
ALTER - DRAIN & VENT- WATER (EA)
FEE SUMMARY
(J I ore exempt under Sea , B & P C for this masonSI
BACK FLOW PROTECT. DEVICE
E
SANITARY Y N
RECEIPT
Owner Data
DRAINS -FLOOR, ROOF, ARE A, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ Ihereby .ffirmdol l have. certificateofcorountio self-insuo.oucertillcateof
Workers' Compensation Insurance or a Fortified copy thereof (Sm. 3800, Lab C.) which
coven allemploy«syn9e pcfiL / �^ ��
Policyp OO ��yyPP M.]
FIXTURES - PER TRAP
PARK
PARK FEE Y N
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
Cumpt
❑ Certified copy is hereby famished.
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
GREASFANDUSTRL WASTE INTERCEPTOR
GRADING FEE
Certified copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 3001T.
ENMGY FEE
(This section need Fath completed ifthe Permit is for one hundred dollen(5100)
in as.)
I certify that in the, performan<eof Ne work for which this permit is iaued,lshall
WATER HEATER WNENT/ELECIR
Fm employ any person in any manner m as to become subject to Ne Workers
PAID
41,
Compensation Law.of California. Data
WATER SYSTEMIMEATING
Data Receipt
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
laxome subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such Provisions or this Permit shall be doomed revoked.
t
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby aff that there is a cansvucdm lending agency fm the perfmmanee id
the work for which this permit is issued (Ser. 3097, Civ. C.)
ELECTRIC FEE
Lenders Name
L . _l v
QTLY i„•,;� MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Address
1 certify that I have mud this application and sate that Ne above infomaum is
charnel. I agree to comply with all city and county oNitaams and sane laws relating to
”" `
PERMIT ISSUANCE
MECHANICAL FEE
buildingcommuction, andhcaeby authorize rcpmsenanivesof discity touterupan the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
"
ATR HANDLING UNIT (TO 10,000 CFM)
(We) agree to save. in kap as a City of Cupenim agaiut
m
liabilities,judgmena, esw anywayaaruea,i said ity
AIR HANDLING UNIT (OVER 10,0IX1 CFM)
in mose,time is it.
/
EXHAUST HOOD(WIDUCI)
PAID
Sig. cdA tan Has
HEATING UNIT(TO IOL0M BTU)
OUS MATERIALS DISCLOSURE
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
theappli n rfummbuilding«cuputstomorimdleha ousmaterid
u def.,d by the Wino opal Coda Chapter 9.12, and the Ihealth and Safety
VENTILATION FAN (SINGLE RESID)
Code. Section 25532(e)7
13 Yes
ISSUANCE DATE
Will the applicantorfummbuilding mcuprilmomuipmentordevims whichemit
BOILER- COMP(3HP OR Hill," BTU)
1�✓
BOILER - COME (OVER 100,000 BTU)
h..a .s air conmanne m defined by the Bay Arco Air Quality Management
Didnet?
❑ Yee No
1 have rcuJ the hazurduus materials acquit gnu under Chapter fi.9S of the
p Ur 1 8 1994
p
NEW RESIDENTIAL MECH. SQ. FT.
California Health & Safety Codc, Sectio 50 5533 and 25334. 1 underhand Net
1I)�U
if the building alms not cimenJy hav on,Net it is my responsibility tp notify the
CITY OF VV i��
ccupant of the re outprior m iuuance of a Ce 'fiwm If
Occup /
/�
ISSUED BY: �����(F/�l
C�
Owner awh a Dom
TOTAL:
V OFFICE