30757- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY i
CITY OF CUPEKI'INO BUILDING - HLI?CTRICAV
PERMITNO. I�O
BUILDING DIVISION APPLICATION/PF,RMIT - PLUMBING-ME.CHANICAL
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nuu,DlNc rftndper n){tNrH'Icn'noN
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BUI'LD^INJGGAA)DDIESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWN[JIf NAME: P ONE: ALTO 'SN ML': LIC NO:
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COM'ROE, p
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\HCH E /1?N KIM: LIC NO: DIJRHSy; �� RcyN^ �
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COI�N�TACT PHONE: ./V\
BUILDING PERK IT I
C UL S/ ❑ Consultant Fees Pald by Applicant (Initial)
a 9-0%
BLDG BLE PLUMB MECH
❑ ❑
WOO
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�FUF
IJCI?NSEOCONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby offirm that I am licensed under provisions of Chapter 9 (cco m acing
with Socllon700B1 of Divioinn3ofthe Busineasamd Professions CWe,andm license is
y ice PERMIT ISSUANCE
!nfull force unJ lett a��5�y
License Clas — Lic.N �YCJS Z'Z
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL.
[]ADDITION ❑ PLUMBING RF.PIPF,
❑MULTI-UNIT ❑STRDCfURAL
MODIFICATION
N<d
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Dam Comtmcun �� APPLIANCES-RRSIDENTIAI.
ARCIII'THCPS DECLARATION PANELS
WemonJ m plans shall h u as public rccoNs
OZ�
UPT02MAMPS
C3 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR [IDEMOL[I ION
EI OTHER -
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{iC � 6 Ufollowing
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Licensed Puifessiumal - 201-IOfp AMPS
OWNIart exempt rmthe CommentRATION OVER 1000AMPS
I herchy afEml this 1 nm exempt I'mm the Comrndor'x License Law for the
rcasom. (Section 7131.5,. Business and Profir,ians Code: Any city ar county SIGNS ELECTRICAL '
whish 1 pe m u n: mct alt r i npr I T h p y t cture
prom 'I ce al regi es the ppl tf hp tt II g d t temens ,SPECIAL CIRCUIT/MISC
Ihmh 1111cen. Ipu ll thep s III C nn t r-I' n.e La (Chapter9
1 '
COMMERCIAL: "
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DGIADDITION ❑DEMOLITION
❑ TENANT
❑TENANT ' C1 FOOD SERVICE"
IMPROVEMENT
❑OTHER
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S e e•
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(I ... anarriciii, wifir Section 711310) f Ut t t 0 ill the lotisincy, and P f . C d )or TEMP METER OR POLH INS I,
that h x eprthettf t t 11 the he : f the 1111rind pf A Y f I n of
Sccf 7011.5 by y vppl'c ill f p i I q t II ppli n n I btnahy n[ 1'OWPit Df VICIS i
II y'nipl
not t o live s. Property,
rte Indth pay Yeplry II aB.aa,(See nbensfSWIMMING POOL I?LPCIItIC-
and to k and the t I Immnd d rofferedf IS .an Business
who builds or improves thereon, hi to if owner of OUTLETS SWI "fCHI!S-FIXTURES
pro eProfession, CWc, iThemp Urnteereo L sense Luo s sac nm applywork
who does such work himself or through
his ..it
own p ere not intended of offered for NF.W RI?SIDI?NTIAC I!LECI'R SQ IT.
building tam such mentis
SQ. FT. FLOOR AREA
SISQ.fT.
sal however, sold within year o(cmmpletion. the
ihat
,colaeLhnweveglhevethngudtnpnwtmenl
ery Imdid in Ie
will have the harden of proving that be did nal build nr improve for bur- n
pose of halt.). -
,ode.)r
❑ I, as owner of the property, em and contracting with licensed m
A B
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unnttacmss
mnswenhe project Pin. 7044. Business and Professions Code:) The Contractors Li-
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cense Low does not apply to an owner of property who builds or impmves thereon. and QTY, .UMBINGPERMIT hLE
who contmets for such pmjems with o conwnor(s) licensed pursterm1. he Connector's _
License Law. PERMIT ISS
Lamexemptunder Sec. ,B&PCPm Nisreason
/I (] q
art
il
C'
4J ((��
Owner Date ALTER -DRAIN&-WATRR(12A)
'• WA4yf,T7f�ry 1 I1
) V ` I hyv
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WORKER'S COMPENSATION DECLARATION BACK FLOW P CT. L
I hereby affirm under penalty of perjury one of the following dcclamtiona
�0
Ihave arW will nuinmine Cenifiam ofConxm mxlf-insure far Worker's Comp<n- DRAINS-FLOOR. ROOF GOND.
anion, as provided far by Section 3700 of the [aM1v Code fill the a fmcname, of the
STORIES
TYPE CONSTRUC ION
work for which this permit is issued. '' FIXTURES-PER
- .0 1 have art] will maintain Worker's Compensation Insurance, as required by Section
-
3700nDheLabelCsair.forthe arlormance ofnne work fppur�whheicgqh this Permit is issued. GAS-EA. SY . -11 403 LETS
rr is mpensu inns rant cage
OCC. GROUP
APN
Carrierpal cY Nay LI( La—IiOI-o�A�U GAS PA. SYSTFM-O ?
CER TIFI ATL OPIi%LMI'I'ION FROM WORKERS' 01,
(/
COMPENSATION INSURANCE GRLASPJINDUSTRLW ER !1'TOR
(This section need not be tpline.Bite t -
oAl
pcmd is formic hmndeddollnx($100) GRF.ASE'I'R
or less.) �
IL N IVISION PH IS
I'LANC KFE
I nfy lh t' th paf abbe work lnrwh sh th p mT' aued, [,hall
tin an, mor son as uv bcorre sueectt soh W k e'Cmmpdn. SEWER SANITARY STORM UA 20B �
mvemply yl tu
samonla ICalr ilia Ute
z,Z, 0 APPlmui WATHR HEATER W 1 11 /VI NI/F:L1'C] It
WE Y
(ARAUN .E'
rt Cil
GQ
NO7'ICETOAPPLICANI If It'r making the Cen titan nl'Gxemption, you shmulJ WATERSYSTrwrRCA'I'ING -
become subject to the Worker's Compensation provisions of the Labor Cade, no must
forthwith comply with such provisions or (his rnnit shall ho deemed evoked. WATER SERVICE
SOILS FEE
L) OI
r CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL. PLMB. SQ, IT.
hereby affirm thnuhere is a construction lending agency for the pafformenct, of
PAID
Date c p
rksH
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Ne work for'which this permit is issued (See. 3097, Civ, C.) -
Lande's Nome -
OTAL:
BUILDING
O Li
Lender's Address TOTAL:
EA
V Z
1 certify that I have read this application and some that the above information is -
roam. I agree m comply with all city and county on inanccs and sone laws mlming to QTY. MECHANICAL PERMIT FI?F
building construction, and hereby authorize represenonivesof mis city to enter upon the
above-mentioned pm,m y for inspection purgtxs.
(Wal agree to save. indemnify and keep harmless the City of Cnpemint against PERMITISSUANCE
SEISMIC fi6& it
ELECTRIC FEE
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Imbifides,judgments, costs and expenses which may inany wayeccmeogaiirm said City gLTP.R OR ADD TO MECH.
conxquence of Ne 6mnting of this permit.
'COMPLY
PLUMBING
APPLIC NT UNDERSTANDS AND WILL WITH ALL NON-POINT Alit HANDLING UNIT(TO 10,000 CIM)
OUR REGULATIONS.
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MECHANIC 1: FEE
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?—d✓� AIR HANDLING UNIT (OVER ION p CFM)
'Ln� /�/^-- � �I,�/"���s 7 _1
CONSTRUCTI 'TAX
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Slgna�fApplialmCUnnictit//CCCC////SrIIj
Dole E%HAUST HOOD(W/DUCT)
HAZARDOUS MAE ERIALS DISCLOSURE
HOUSING MRIGA NFEE
II
Will the appiicant or future building occupant stoxarhandlchacamous material HEATING UNIT(TOI%." BI LI
,
as defined by the Cupenino Muni ipal Code, Chapter 9.12, and the Health and Safety
CWT. Section 255326d? HEATING UNIT (OVER 100,000 BTU)
❑Yes a VENTILATION PAN (SINGLE RESIDE
PAID
�s
Wndomll the applicant or future building l bfli occupant use equipment or dM.. a ennod -' 'BOILER -
st ict? ua air cnnmm(its v definul by the Buy Arca Air Quality Management COMP (911P OR 100,(MIB IITII)
District?
Date Receipt.
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•TOTAL:
❑Yes 'BOILER '-COMP (OVER IIg),IM)I HTU)'
•
-Ihavarendthehezardousle mIsre mmena under Ch terri.95 mfthc Cali- AIR CONUITIONI!R
qur p
ISSUAN 'I'E
f min H-101 & S ty C S t n. 25505 25533 and 25534 I understand that dtho NEW RESIDENTIAL MI?CII: SQ. FT
holding I I urtently.h v I n thin t y :p ldaymmafy the occupant
_
ofthe remm�o wh ch next hcymt pr mom' a mfa Cc r ate or0aapv,cy' .
ISSUED BY:
Ownerm uthnrivet agent - Date TOTAI<
OFFICE