30941 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN.ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 30941
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY, APPLICATION SUBMITTAL DAT
O2-1�2- C-, F:SqDrll�S
O NER'SNAME: PHONE' CONTRACTOR'S NAME: LIC NO.
H - EH MpNNCtaL�i LAi hT2-fi we corvTRo x
ARCH ITECT/ESIGINTER LIC NO: ADDRESS: ❑
Ffome�d
PHONE: BUILDING PERMIT INFO Its
❑ Consultant Fees Paid by Applicant(Initial) LIB )C_ ELECT PLUMB MECH
LICENSED CON TRACTOR'S DECLARATION OTY ELECTRIC PERMIT FEE (�jJ(_
affirm that 1 am licensed under pruvisiom of Chapter 9(commencing JOB DESCRIPTION
F�=Zwith 1O)of Divixion3oftM Business and Profassinns Code,and my license is RESIDENTIAL'
w= effect. 1 1112RMI'f ISSUANCE
aUVLica ❑SFDWL ❑KITCHEN REMODEL
zwCunlreclnr APPLIANCES-RESIDENTIAL SZVDdTION ❑PLUMBING RETWE
h
ARCHITLL SDECLARATION PANELS MULTHUNIT ❑STRUCTURAL
O `�-'�' Iundmsl'end my plunx shall he used nx public records
UPTO 200 AMPS MODIFICATION
Z
1-C t:W Ldcnsed Professional ❑INTERIOR El CHIMNEY REPAIR
�yE; OWNER-BUILDER DECLARATION 2111-1(X10 AMPS IMPROVEMENT
y
W=
Q 1 hereby affirm that 1 am exempt from the Comrarmr's License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
x 3a F following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL [3 OTHER
DI li y which requires o permit to construct,alter,impose,demolish,or mpair any xwaure
F.
prior to its issuance,alnomlaims the ccppllr m for such fr
en lIn file a sleranI encrent SPECIAL CIRCUIT/MISC.
Ban,at M1e is Belied pursuant to the provisions ofthe Commctors License Law(Chapter 9
Its
ac (commencing mmencing with Section]gxgof Division 3mme Businessad professions Code)., TEMP.METER OR POLE.INST. COMMERCIAL
C.c.c C thin he is exempt them refroand the busis Iia me alleged exemptica Any vinimmm of ❑NEW BLDG/ADDITION C1DEMOLITION
�y Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than live hundred dollars($500).
Cl as Dener of the pmpcny.or my employees with wages aslhcir xelecompenwtinn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the swcture is nm]mended oroffered for sale(Sec.]UW,Business ❑OTHER
m and Professions Codr:The Contractors License taw docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who build,or improves thereon,and who does such work himself or through
his awn employes.Previte,]that such inrprovmuems ore an,intended or offered far NEW RESIDENTIAL ELECTR SQ PT,
sale If.however.the building or improvement is.sold within one yearofcompletion,the SQ.F1'.FLOOR AREA $ISQ.IT.
,-builder will have the burden of proving that he did not build m Improve forpar-
po,eersmvin. - a l3
Kas owner of the property,am esdusivdy commeting with licensed contractors to
wet theprojeat(See.](164,Business and Profus,lam Gde:)The Contractors Li-
nseLaw does not apply toonowner ofpmpenywho builds orimprimis,lherton,and QTY PLU 7BING PERMIT FEE
who contracts for such projects with a conrucmr(x)license,]pursuantto the Conructors
License law. PERMIT ISSUAN
❑1 am exempt under Sec. B&P C for this reams
0 Or
IJI-j lU ' oDate /sALTER-DRAIN ! VALUATION
WOR RSCOMPGSATO r10N
BACK FLOW PRO'FCT.DF,
1 hereby affirm order pcnahy of perjury Inc of the following Jttlarutions: '� _�
I have and will maintain a Cenilicute of Conscnno self-more for Workers Compcm DRAINS-FLOOR,ROOF. A,C STOR 'S TYPE CONS'fRUCTt01
satins,as provided for by Section 3]00 of the labor Crde,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will main Win Worker's Compensation Insurance,as required by Section
My Worker"
Labor CoJe.for thepair,c Ice oaths work number
this permit is issued. GAS-FA.SYSTEM IINCA LETS OCC GROUP APN
My Worker's Compensation Insurcume carrier and Policy numhr arc
Cartier: Policy Nn.: CAS-LA.SYSTEM-0 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
CIMcarinc1'IONINSURANCE GREAS[IINDUSTR.WASTE RCCPTOR
lTTis s«tionncetnot be completN ifthe permit is forme hunJreddollars($I(X) BUILDING )IVISION FEEGREASE TRAP
or less.) PLA
NCHECK F
Icertify that in the performanseofthc work for which this permit is issued.l shall SEWER-SANITARY-5 M Pf.
not employ any penin in any manner so us to become subject to the Worker,Confer- ENERGY FEF.
Z sation laws of California.Date Is
z Applicant WATER AER W/VEM ELECTR GRADING VjhAVf A ' 11
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYS'TBMIfRF.Aq'ING V
a ? become subject to the Worker's Compensation provisions of she labor Code,you must SOILS
forthwith comply with such provisions or this pennitfiall 6e deemed revokeA, WATER SERVICE ��
OL Q
DZ
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMBSQ. PAID rik
L0 Iherebyinirm that[here u construction lending agency for the performance of
ReceiptN
LL U e work for which this permit is issuM(See.3097.Civ.C.)
Leader.,Name
tenders Address T
P. I certify But I have read this application and state that the above information is BUILDING FF
TZ) contact.l agree to comply with all city and county ordinances and state laws relating ro QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby uuthonec representatives ofthis city to enter upon the SEISMIC FE
abo none,boned property Iia inspection purposes.
(We) me to save.indemnify and keep hamdess rue City of Cupcnino agaimt PF,RMI'1'ISSUANCIi ELECTRIC F:F, XE
liabilities,judgments,costs and expenses which may in any wayweruc against said City AI.TERORADDTOMF,CH.in consequence of the granting of this permit. PLUMBING 'IITApppPPPUUUUUULICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNIT(TO 10.000CFM)7RCERIiGULA'fIONS. MECHANIC E''..( __ � L^-0.0 —. �_t�J���-�� AIR HANDLING UNIT(OVER IO,p00CFM) CONSTRUCf10N TASignatureofApplicant Contmccttor I Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or bundle haeardous material IIEATING UNIT TD)I00,(XIO BTU)
as defirteJ by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Senor 25532m)P HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE REID) PAID
Will the applicant or future building occupant use issimpmem or devices which Dam Rmcipt
emit hazardous an mnmmirWms as defined bythe Bay Area Air Quality Management BOILER-CO.MP(3HP OR 100.000 BTU)
Discs, TOTAL:
E]Yes ❑No BOILER-COMP(OVER HM000 BTU)
I have read the havWuus rrmmdals AIR CONDITIONER
rt,25533 tux under Chapter 6.95 of the Call- - ISSUANCE DATE
building
gdoes net Curieafety Cuda.Sections 25505.255JJ and 25534.1 undeny the
that if the NEW RESIDENTIAL MECH. SQ.fT.
building dos nuts which have a tenant,that it is a.responsibility us notify cc pancy,m
of the requirtmen¢which mon be met prim to issmnce of a Ccnificnm of Occupancy.
Owner or authodzeJ agent Date TOT L ISSUED BY:
OFFICE