27634 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING,ELECTRICAL
Y OF CUPEPERMIT NO.
BUILDING nrvlSIONloN APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIPICATION
27634
BUILDING ADDRESS, SANITARY NO. APPLICATION SURMITTALDATE
x—" UNIT# LOT
NE/RS^NAME: PHONE: C TROR' NAME: LIC NO:
0 �� C SV/f N/C CONTROL#
ARCHITECUENOINEER: LIC NO: ADQA�aS. /1 ��� � m���� `]" ❑
CONTACT: - PHONE:
q qq)) QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLDG i F,LO PLUMB ME❑CN
LICENSED CONTRACTOR'S D,CLARATION APPLIANCES-RESIDENTIAL rLTJJ/ `
0wZ Ihembyaffirm[hall am licensed underprovisions ofairpter9(commencing with JOB DESCRIPTION
1400 Section 70ap of pj is of Ne Bmine a dProfessions Code,andmy license is in PANELS
K ful l force wd e 1V�� /_e�rjh4 / �J
<<d'yty License Cies Lic.# &SIS / UP T0200AMP5 /'✓'ems/"' � I`^-� e
vfiQy Date Cutin. 201 IIT AMPS
Z O y ARCHITECTS DE LOA �� OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.PL
CZ-0 I understand my plans shell be used as public records. ,,
W SIGNS ELECTRICAL
LsenseJ Prmfesmonal
0 04 OWNER-BUIL DER DECLARATION SPECIAL CIRCUIT/MISC.
1 hereby affirm that I stn exempt from the Contractor's License Law for the
to following reason.(Seelioa 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
to mwhich requires a Permit I-construct,apart improve,demolish,or repair any structure
C2a� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
ty g p that he is licensed pursuant to the provisions of the Contractors License law(Chapter
L oX 9(commencing with Section7000)of Division J of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis forte alleged exemption.Any violation of
aP
Second 7031.5 by any applicant fora permit subjects theapplicamto v civil penalty of OUTLETS-SWITCHES-FIXTURES
Onot more than five hundred dollars(SSW). ✓
f $ ❑ hasuwnerofNepropeny,nrmyemployees withwagesastheirsol¢compensation, NEWRESIDENTIALELECTR _SQ.FT. STORIES ECONRUCTION
will do thework,and the structure isnot intended oroffered forsale(Sec.]044,Business
and Professions Cade:The Contractors License Lew does not apply to an owner of
progeny who bu it ds cr i mproves thereon,and who does such work hi mself or through his
ownemployees,provided thatsuchimprovementsarenot immodedorofferefforsale.If, OCC.GROUP
however,the building or improvement is sold within one year of completiao,ihe owner-
builder will have the burden of proving that he did not build or improve for TOTAL:
sale.). P purpose of
❑ I,as ownerofthe property,amexclusivelycontracting with licensed commuctorsto QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lawdoesnot apply manownerofproperty whobuildsorimpmves thereon,and PERMITISSUANCE
who contracts forsuch projects with acontractors)licensed pursuant nothe Comuactors
License Law. - ALTER-GRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUT DE FF,ES
Owner SANITARY YN
Date DRAINS-FLOOR,ROOF.AAEA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
yperioathat lhavcacertificete of consenno self-insure,oracertificete of FIXTURES-PER TRAP RECEIPT#
Workers'CompeneeJon lnsur ceoraoOmm�opdco�pIy thereof(Sce.38W,Lab C.)whichc.sPARK FEE Y N
era all emploxea' tui is penni'//7///a i/ GAS-EA.SYSTEM-t INC.4 OUTLETS RECEIPT#
Policy is Gf diff YY// BUILDING DIVISION FEES
C pafB� ?ATEti
entitled copy is hereby modified. GAS-EA.SYSTEM. VER 4(PAT PLANCHF,CK FEE
�
C1Certified copy is Ebert with meaty inspection division. OREASRNDUSTRL WASTE INTERCEPTOR GRADING P80
CERTIFICATE OF EXEMPTION FROM WORKERS':;."` GREA SOILS FEE
COMPENSATION INSURANCE owr
(This section needaotbe completed lithe permit is foronehundred dollars($1M, 7)WER1 SILNIARY STORM EA.2WFT. ENERGY FEE
or less.) �
Icenify that in the performance of the workonwhic� is fa,
�$ .W. W
not employ any person in any manner so as c beco �jecto the Workers') v N /ELECTR PAID
z Compensation Laws ofCalifornia. Date F.P.S i Wa UREA LNG'
O Applicant
t, Date Receipt#
NOTICE TO APPLICANT.If,after ranking this Cenifi<at f empiion,you sh R IALPEMB. `1 SQ.Ff. TOTAL:
become subject m the Worker's Compensation provisions of ,ebur Code,ynu m t
forthwith comply with such provisions or this permit shall be deemed revoked�1�� BUILDING FEE
uWs�
zWa Q CONSTRUCTION LENDING A NCY SEISMIC FEE
r
Z I hereby affirm that there is i cued(Sec.
3 lending g#�i i.'y for the pertormance of
U O the work for which this permit is issued(Sea JW],Civ.CJTOTAL: ELECTRIC FEE
�r Leader Nams c n.f•::"•m1•; •.`
Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
WI certify that 1 have read this application and state that the above information is
LL, come[ (agree a comply with all city and county ordinances and suite laws relining to PERMIT ISSUANCE MECHANICAL FEE
Lin construction,and hereby outha in,cepresenmtives of this city center upon the
U above-mentioned property for inspection purposes. ALTER OR ADD TO MSCI I. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupemno against
liabilities,judgments,costs and expenses which may in any way accrueagainstsaid City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Convactor Date EXHAUST HOOD(W/DUCIT
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazmdous material
as defined by he Cupenino MW
unic' Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100, 0 BTU) L;
Cale,Section 25532(a)?
❑Yes No VENTILATION FAN(SINGLE RESID) as
Will air contaminants
as gilding by the
nBay Areequa eamuality Management
BOILER-COMP(3HP OR 100,010)BTU) ISSUANCE DATE
Izardous air comeminanis as ted by the Bey Area Air Quality Management BOILER-COW(OVER IW,(I00 BTU) R
svim? ^G
❑Yes n No NEW RESIDENTIAL MECH. SQ.FT. /�
1 have read the hazardous materials requirements under Chapter 6.95 of the /� Fl 4
California alit&Safety Code,Sections 25505,2 533 and 25534.1 understand that Cq y�p 3d 19y
ifthebuil i dcesn to renJyhav tenant�teh tismyrespomibmaymimaythe
occupant he one is c t ssusnce ofa CertiBcq{pof
Owner or authomed agent L DaTOTAL: ISSUED BY:-e---�!V
OFFICE