S 2453-APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF RTINO RUILIIING - RLIiC'I'HICAL
BUILDING DIVISION APIa1.ICATION/PERMIT PLUMBING -MECHANICAL
RUII.IIING PROJECT IDI'.N l'IFICCI'ION.
PERMIT' NO,
RUILUINGADDRCSS'.
22179 HAMMDIQth WAY </;UpE-zTMb 9SO14 Z
SANf['All Y NO
,IJ%/
API'I.ICAI'ION S'l BMITI'AI, DAH!
- TI 4
OWNER'S NANIE: PHONE:
THF - o $21EW GI20L1P &0-377-03Ov
CON'TRACTOR'S NAME: IJC NO:
-1NE,0'SRltnl GRP- 6R I
N/C
❑
CONTROL at
ARCIII'IF.CI'/ENGINEER: LIC NU:
SorCasTAaa4i7-v-C= 2440
ADDRESS: ^�
13Cc¢li�R4Tf flA7/r #71oi`:A)f�k7
CON 'JAM: PHONE:
�92.l010(7
.. 13U ILDINO PEIiMI'f INFO r
p
Gv AESUA 41S -669 -48o; -7y —7
�Rz
�Gl
❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECT PLUMB MECH
LICENSED D CONO RAC ORS DECLARATION
-aft!.... o
I 1 by th 1; I lCImN ' he � g
withS I J00e dU '- 3uflhs l3uk ess ngyn,fcsst "�J( dmllttn-e is
inf full force I Bal Y (/
QTY ELECTRIC PERMIT _ FEE I'
JOB DESCRIPTION
RFSIDENTIAI.:
❑SFDWL ❑ KITCHEN REMODEL
PERMIT ISSUANCE D
APPLIANCES-RESIDHNTIN,
LIr CI.:s GCN
Dal:— C -s OHCJ(
A CIII'rreare D,imbli est--,
mukrsanW my plum mall reared m public record.
❑ADDRION ❑I%UMHING RIi.I'IPE
❑h1UhTI-UNIT CI STRUCTURAL
MODIFICATION
PANELS
UPT02W AMPS
❑IN'rPRIOR ❑GIIIAfNIiY RIiI'AIR
IMPROVEMENT E) SWIMMING POOLS
❑ BATH REMOTEIJREPAIR []HE MLUTON
❑ Ofi1ER
Liamed PmfcAinnal
Oin Time iUH.DEIt DI3 he ContractoRATONr's Law for the
I barely . tSe. that 1 vm exempt from the G,niara,ode: An,
following mous... (Section J Business and Professions Any city nr county
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL.
h,m
1 my ...... I I I h p J I' p y srodmre
—ha
ryl E
/ L n
prr t I I. rcq ❑ ell by 'O rl b J:I mmum
,n
SPECIAL CIkCU1T/MISC
utE I J1 io, s
a 11 p r t0 Contractor's I' (ChapterY
'r1:Ml'ME'fEIi OR IalL131N5'I'.
�,TL-��
COMMEI2CIA .:
❑ NI7W BLDG/ADDITION ❑ DEMOLITION
e
(u„nc umals Section JraN3)n1 have, 30 he HBs nu nllnit sines Unit) or
("unmeaning
Ihut he rs exempt thvrcfrom and th, basis for the alleged exempmn. Any violation of
POWER DEVICES
Sectlon7031.5 hy:my applicant for n Permit subjects the applicant four civil penalty (i1
not morelhon five hundred dollors (851X).
❑ 1.asownerains, propeny, or my omployces with wages as lhedrsolecompenmtion,
will do the work and the simctareis not intended or offcred for sale (See J04J.Iff"iorss
❑ TENANT ❑ 1,001) SERVICE
IMPROVEMENT
❑OTHER
S GPOOL ELECTRIC
and Professions Cnde: 'rhe Con scio s License Low docs Bol apply m on ower, of
O-SWITCHIiS-FI OURES
prefer whp builds or improves thempa, and who does such work nintself or through
hi,,mpleyecs, ..00id ,I that such impro encs one nal intended .. offered fur
NEW RESIDE rlAI. ELECI'R SQ PT.
SQ Fr. FLOOR AREA
VSQ. Fn
site. 11. awevcr.the haldingorm,porniver s sold within one yeas, I'suplction. the
-
owner -builder will hate the buMen of proving that he did not build or improve fnrpur-
,� e of solo,).
.IA I. us nwncr of the proper, am ciclinoely m earefing wilh licensed comb: cons to
IOIAL:
TTT xmtcl the project (Sec. 704TBusiness and Professions Gaic:)TTc Conlrnesors Li
,en,p Lawdor, nut upplymm: nwncr nfprnperty who holds or Improves lhere,mnml
QTY. PLUM PERMIT FF.Ii
wharh) wit pn.aam to Iheeammetar,
PERMIT ISSUANCE
License Law
]Ism e.¢n undrr Sec. a& PClarthis reason
-
AhIT3ft-DkA1N & VENT '-WATIiR WA)
O t IG� •fit'¢.Dan 1 -7
VALIIA'r10N
BACK FLOW PROI'I!CT. DEVICE
WO ili'S COMI'ENSA'IION UECLAItAfION
I- I hereby affirm andeti'emsllyof perjury one of lite following deciaradnm:
DRAINS- 11.00R. RO(YEAREA, CONE.
❑ I have and will maintain a Cenificotnnf Consent toself-inmre for Worker's Compete
stolon, ax ....iff mi for re Section 1]1X1 of the LUM,r Gale, for the pm'lirtmmac of the
work for which this pemdt is
$TORIES
�
'TYPE CONSTRUCTION
FIX '1UkFS- PER 'I'RAP
❑ I have and will ewer' w Insurance. ns respired by Section
Wnrkm's Ceocc
odmaintain
3900 ,h Codethe forreoccur do work forwhichm,h istread,
GAS -13A. SYSTEM -I INC.hOU"I'LHTS
OCC.GROIII'
APN
yWih Con sort are:
My WorkcYs Compensaion Insurance carriar and Polity numncr are:
Cnrnur: Policy No.:
GAS - EA. SYSTEM OVER J ILA)
'
CEIt'1'IFICAI'12 OF EXEMI"1'ION FROM WORKERS'
COMPENSATION INSURANCEGREASE/INDUSTRI.
(11r,wetin incest nm be completed it the pem,tGe for one hundred cloth,,
or In,,)
WASTE INTERCEPTOR
BUILDING DIVISION RFS
GREASE 'I'12N'
PLeiNCHECK 17EE
I mnify that in the performance of the work fur which Ibis pennil is issued. I sM1ali
not employ any perste in any local sousm beconm.mblect In the Workers' Com m
SE\Viik-SANITARY-STORM EA. Fr.
ENERGY IPE
WATER HPA'1'ER W/VENT/ELECTR
Applecant Laws of CeliLemia. DWc
npph
Fre
NOT ICF.1'0APPIACAINL:IL afsrnukingthis CrnlEcataof Esmnption, you soon ld
bemmesnbjeet Io ihr Worker's Comp re'reion Previsions of the Labor Cnde, you must
WATIiR SYS'I1iM/1'ItHATING
SOI
WATIiR SERVICE:
farhwalt enmply with such provisiem or mit his pershall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affinm that there is a cnnslmctisn lending agency for the perrnnnance of
the wort: to, which ihls pem,it is issued (Sw.3097. C'iv. CJ
PAID
UJ to Receipts
NEW RESIDENTIAL PLMIL I
SQ. FI'.
Le ethos Name
TOTAL:
Lender's Address
I OTAL:
I cedify that 1 Neve feud this application tied .mar ihm the also, inferno, a is
BUILDING ?E
- - -
Ql'Y. MECHANICAL. PER 1'f
i agree mramply want an city and rnamy orhwnraa anJ.umc mwsmmnng a.
huttect
ilJing conswmion, nnJ hereby ewhonze rupresen Wlivea of this city to cote upon Ibu
-
. .: NIIC hili
'
YEItMI'I' ISSUANCE
ELECT RIC FI 3 d O
abroe-mentioned properly for inspection pari -es.
(We) agree to save, indemnify and keep harmless the City of Cupenino against
AIITLRORADDTO MECH.
PLUMBINGI '
Ilnhilities, judgmentu,costs and expenses wbicM1 may in any why acerae ugain.a said Ciry
,re"re"we or g o
tiro granting lof
p
AIR HANDLING ONI'r(TO 10,000 CFM)
MECHANICAL 'E
APPLICANT UN CRSTANDS AND WILL COMPLY WITH At.[. NON -POINT
APPLICANT
SOI1kCE iGU COO'
AIR HANDLING UNI'I'(OVER 10,000CFM)
CONSTRUCTION X
LUwe /
Signaumoof Applicant/Gra l
MATERIALS DISCLOSURE.
EXHAUST IIOOU (WIWCr)
HOII5ING MI'TIGAHDN THEHAZARDOUS
HEATING UNIT (TO 100,009 BTU)
Will the applicant or future builiingrrenpant store or handle hazaNnus material
as defrvd by the C'nperti nu Mur lcipul Calc, Chnplcr 1) 12, and the Ileahh l I Safety
Cala Scrimp 25532(a3^. �
HEATING UNI', (OVER 11X1,1100 BTU)
El Yes ❑Nn
PAID -"
Ilam R -my, #
VEN"I'ILATI(IN FAN [$INGI.Ii RLSID)
BOILER -COMP (3HPGR 1(X).000 R'IV)
Will the applicant or Tuts a building by the ml use ea Air rue or devices which
emit haennlnus air contaminants as JcOncA by the Bay drat Air Qnoliry Management
District'
E] Yes (?�No
AL'
BOILER- COMP (OV HR 100,000 BTID
AIIt GOND I'I'I ON17R
I have rwd the heart lmyuiremmns unnrr Charterer b.95 of he Cnli-
mal Heald, ably Cdsle, tions 355115,15533 and 355:6. I unJCNanJ that if hire
nrti11 nnc� trarmn ly : - I,,' ,th' 11 is n,v re.npomihi ily to mice,, mo accrtnant
ISSUANCE mm
�,
"'eeelll
NEW RFSIDENTIAL MECH. SQ. Fm
nb car em t�wni< ripe mi asa:mro ofacelnfrlthanr
ISS LED BY: I
Owner nc:utt horinnl agent Duo
'r(YPAL',
OFFICE