27899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY ON CUPESIONHUT - "' PERMITNO.
APPLICATION/PERMIT PING-PROJECMECHANICALIC
BUILDING DIVISION BUILDING PR(1dRC'I'IDENTIFICATION 27899
/.
BUILDINGGADDRESS: / 'f'^/ ' SANITARY NO. �APPLICATIONSURMITTALDATE
1-76.,// Z �I , "A, /v � UNIT# LOT#
OWNNA E: V6 S10y E: CONT Cro1rE: doi.S �LIC NO:
cYa.S2
N(c CONN fRDL#
ARC,�yyITECf/ENGINEER: V LICNO: ADDRESS: AIL ElG'. Ac.oMS ZZs& G'ow,e< J
coNrncr: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
f`14Y 37i Son p BL INK
EyE T PLUMB_ ME li
PERMIT ISSUANCE ! Y`, VMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pCZ Ihereby affirm that l am licensed underpmvisionso(Chapter9(commencing with
W00 Section]000)of Division J of the Business and Professions Code,and my license is in pgNP,f„S Q '• `!--# 1 sg 1 `�
C W8. full force lass effect. v�aS.�N It\1T�•
F 2 W License Class Lia p UP TO 200 AMPS
m?� Da¢ Conaaaa 201-IfXq AMPS
Z FO y Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O Z_p I understand my plans shall be,used as public records.
F,,Z F W SIGNS ELECTRICAL
Literi Professimmal
EMS,Q OWNER,BUILDER DECLARATION SPECIAL CIUIT/MISC.
KRC
Oa V 1 hereby affirm that 1 am exempt from the Conlructors License law for the
413 a h following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MIST.
which mcp ire,a .am r.mmuo,aper,imprnvc,demolish,nr reper any momme,
EW}2to its issuance,also re r the applicant for such Do file a signedstatement POWER DEVICES
prior y pp pi
W K¢p thin he is ncinuJ ffi See o the 'ions n 3 of Contractor's License Lew(Chapter
9commencin i ' SWIMMING POOL ELECTRIC
( &whit Sec n]WU)o rasion Soflle Business and.Any violation
Cad e) 1�VA r J
W=m Srthm h7031.5 by to fromond the is foatjetsthedexemption.Anyviolationof OUTLETS-SWITCHES-FIXTURES
5EQ Out oto]031.$hy nn applicant forage subjects the upplicam to«civil penalty of .
SSp
Out mnrc than five ndred dtllws(SSW). NEWRESIDENTIALEI-EM SQ.FT. STORIES TYPECONSTRUCTION
wF22 ❑ Lanowmodevour Ihepmarty.ormyemmaded it hweguutheirsolecompensimeas
ly3— will Profs won a,ands: hemamemn imm�dese fie does n ,apply.ll k4,Business
and Profess s Cede:The ves i mon License la does not apply m an owner of
properly oca,motrimprovul m whtdcess inworkhlmulfmthrough his OCC.GROUP RES.UNITS
nwne Igees•pnrviJW rM1at nuc m uarenot in dedtrofferW forsale.IL
In. ecthebuildingorim o t vldwithind yemofcmnplaioo,theowrcr-
buil will have the bode Thar he did r build do :p
improve for pmpom of
role.)' QTY PLU TNG PERMIT FEE FLOOD ZONE APN
❑ 1, x rad exclusive contractingwithlicensed cnnhacmisao
onslmet awns n duct and Professions Code:)The Contractors
License La edasno pit loromoor propenywhobuildsorimprovesthereoo,and PERMIT ISSUANCE
whoconarm such ects with omrenor(s)liansed pursuantmthe Convacmrz gL'fF.R-DRAIN VENT- ATE A) I'EE SUMMARY
Liar,Lew, n
❑ lamuemplu uSce, ,B&PC for thisrc n BACKFLOW t' CT. : E ' OI ISIDE FEES
SANITARY Y N
Owner Dar° z
DRA ,R FpAR COND. RE.CEIPTN
WORKMAN COMPENSA]'ION DECLARATION , SCHOOLTAX YN
❑ Iherehy u[frzm thmlM1uvevanifiram of consent to self-Insum,or ee,thiete of FIXTURE :R TR RNCEIPfp
Workers'Compensmion lnsumnec ora certified rnpy thereof lSec.38 ,L.bC)wh,rh PARK FEE Y N
covers all employee.x under this permit. GA / AS- .SYSTEM-]�:CAOUTL RECEIPT#
Policy It (( BUILDING DIVISION FEES
Company O EASY ;M VER4HiAI PLANCHECK PEE
❑ Certified copy is hereby famished. tL
❑ Certified copy is filed with the city inspectia division GRT: SF NDUSTRLWASTEI ERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOILS HE
COMPENSATION INSURANCE
(This section need not Is,completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-ST MEA.10OFf. FNERGY FEE
tales'.)
I cenify lout in Ne peHormana ofthe wink for which this permit is issued,I shall TER IIEATERW NT/EI.ECfR
nm employ any person in any manner so as to become subject m the Workers' PAID
Cemamatioulawsof Califomia. Dara WATER$YSTEM/TREATING Date Receipt#
Z Applicant
Z O NOTICE TO APPLICANT:If. he,making this Certificate of Exemption,you should NE RESIDENTIAL PLMB. SQ,FT. TOTAL:
ybecome subject to the Worker's Compensation provisions of Ore Labor Code,you must
forthwith comply with such provisions a this penal Mail be declared revoked. BUILDING FEE --i
Rwi Q CONSTRUCTION LENDING AGENCY S17ISMIC FEE
z 1 hereby affirm that there is v coasvuaion lending agency for the perfomunce of
U p One wed rot which this is rssu W(See.3191.Civ.C.) T ELECTRIC THE
D. Lender's Name g4PLUMBING FEE
Lemler's Alm, QTY. MECIIANICAL PERMIT PEE
0 U 1 cenify that I hAc read this application and state @m the above information is MECHANICAL.FEE
correct.l agree to comply with all city and county ordinances and state laws minting to PERMIT ISSUANCE
buildingtommuction,andhe-by authmim mpresenmtives ofthisciry to enter upon the
Mrle-memioned property f CONSTRUCTION TAX
(� z pe y demnify ld purposes. ALTIiR OR ADU TO MECH.
(We)agree m save,indemnify orad keep harmless the City of Cup , against
liohilitiu,judgmentx,cot radoxpcnsuwhich mayinnny way acwe gra'Wsr svi City AIR HANDLING UNI'1'(TO IQOW CFM)
in cr quence of LMing it"hi,permit. n/
M44. /L /3 AIR HANDLING UNIT(OVER 10,000 CFM)
&gnutureaf Applicant t I coin am/ EXHAUST HOOD(W/DUCI) PAID
IIA DOUS MATERIALS DISCLOSURE HEAi'ING UNIT(10100,000 D'I'U) Date Rrceipr#
Will the applicant future building occupant scare or handle haaallou'material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cu,cmno Municipal Code,Chapter 9.12,and the Health and Safety
Crile,Section 25532(u)1
Yes No
VWi t ILAT10N 17AN(SINGLE RESID)
❑ ❑
ISSUANCE DATE
Will theapplicanmr future buildinguccupantuse equipmentordevices whicherriit BOILER-COMP(311P OR 100.00)RTU)
haeaNnux air eon arrimans as defined by the Boy Arca Air Quality Management BOILER-COMP(OVER 100.000 B'TIl)
f�Lbuildin,
DisOiaP C
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. qhp`
read the hanudous materials requirements under Chapter 6.95 of the ^rp 4,
alth&Safety Code,Sections 25505,25533 and 25534. 1 understand that 9g
g dissent currently live a to am,that it is my rexpnobibl,to notifythe 9/we reyaremems wbieh mast be met prier It issuance ofn Certificate ofhoced agent Dara TOTAL: ISSUED BY: -
OFFICE