S 1819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEKFINO BUILDING-ELECTRICAL PE IT No
BUILDING DIVISION APPLICATION/PERMITPLUMBING MECHANICAL 1819
BUILDING PROJECT IDTN1'It'ICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMI'TI'AL DATE
e T�o (, ._/r-t�-7 0
OWNER" AMI?: I''fIP)NE 31 1011 RAC NAMI?: I.IC NO
O
OC J _ NIC CONTROL
L'✓�C 3 #
ANCHITEC E (]INFER: LIC NO. ADDRESS: ❑
CONTACT:JOL w4#�O PHONEBU ILDING PERMIT INFO
29�-j�7/) ❑ Consultant Fees Paid by Applicant(Initial) BLDG (ELECT PLUMB MECH
❑ ❑ ❑ ❑
1,10E,N SHDCONTRAC'I)R'SDHCIARA'OON QTY ELECTRIC PERMIT FEE
1 hereby amort that 1 cart licensed under pmvidor d1 chapels(colorucn,m JOB DESCRIPTION
WON wilM1 Sccnon]aXp of Division Jnf the Busines anA Prnfe..iom Code,and my license i. RESIDENTIAL:
F O 'n full force and PERMIT ISSUANCE
(yWF ' ---Jess}T . 6� ❑SED\VL El KITCHEN REMODEL
QUU Limnm Clad++ Lie APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PIXIM3ING RE-PIPE.
f~/i a a DaIC con DEC
F-W y AHCIIITECTS DECLARATIO PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O ve ZZ I l ndemmeJ my plum shall he need as public armada MODIFICATION
OZ4W UP10200AMPS El INTERIOR ❑CHIMNHY REPAIR
F4.L-W I.—rov!Professional 201-1000AMPS IMPROVEMI?NT
Qf4 OWNER BUILDER DECLARATION ❑SWIMMINGPOOLS
C C Q hereby vflinn Ilial I um exempt fnnn the Cnntrunnr.Licence Luw fits the OVER IyW AMPS BATH kEMUULsIIRI?PAIk (]DEMOLITION
X 3 L U 1'ollnwing reason.Nee ian]1131.5,Busiac%,and Profession,Code:Any city..cumdy SIGNS 1?LF.CItICAL ❑OTHER
W LL LL h which requires a permit tu mmamm,aper,improve,dcra ieh,or m,a uny aniame
E--�Q prior to its issuance.also requires the applicant for such pound to file a signed+mlemcnl SPECIAL CIRCUI'VMISC. t�
C IyQf that he is Eccmed Pursuant o the proWersofthe Contractors Licenu Law(Chaper9
W� O (commencing with Scnion]INXq of Divixi.n3nfthe❑u,inea+and Pmfaauom enNcl ar TEMP.METER OR POLE INST.
COMMERCIAL
1E X e C Ilial he is exempt IhereGam:rod the basis for the alleged exemption.Any violation of El NEW RI.DGIADDITION [IDEMOLl DON
Sacllon 7031.5 by any applicant for u pintan'uhy's the applicant,,a civil penally mf POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hit mhed dodam 5500).
IMPROZ'Q OTHER IEMENT
❑ Lo+ownerk,the pestructnr myyemntended wonered ersale(See,coopuneatinn, SWIMMING I'OOLf?I,ECTRIC
F will dathe work.ande:1he Contractor's
License Law
lerotaply to an,limina, ❑OTHP,R
6'3m and Pmfano mils or
Cees damos License Laws sucnotapplysaorowner through OUI'LETS-SWI TCHES-I'IXTURIS
hpro,emyis own who builds or impedes theehn,and who res a such work himself or ehough
hi+nwnemployees.e provided that Such mentisoldwarc not in¢ndedmpeeed for NEW RESI DENTIALELELTR SO ET,
owmn4how,,with,buildinghhanerrofpmen,issoldheiihinoneyea.Immpleton pthear- S IT.I'1-OUk AREA VSO.CO.
erhuilder will have the harden of proving Wm M1c did noI bold or improve for pur-
p,aetram rte
1,a of the Selwrly,ren exclusivelyna- and
contracting with licenced eun...to. to TO AL:
nsuuct thcepmjeel(Sec.91141.13us enJ I4nl'e. lar Cale:)'Ihe Gmvuenn{s
seLawdoeno,apply to anowner.fpropcnywho mild,or improcs lharemn,and QTY. PLUMBING PERMIT FEE
who mtnrans for such projects with a contractors)livensed pumuanuo Inc CommdorLx
Liana law.
❑ tont comp,under Sea ,RR PCfor this renmasonMR-MI T ISSUANCE
O
Dae ALTER-DRAIN&VENT-WATER G:A) VALUATION wner
WORKER'S COMPENSATION DECLARATION (SACK FLOW PROTECT DEVICE
I heresy affirm ul d"R sena y of perjury lac el the noluwing declarations M
1 Olhave and willnu.ineinu Cenifcue of Consenl lu.ulfinmre for Worker',C.ngrun- DRAINS-FLOOR,ROOF,AREA O S'IOINII3S 'Qr :Y :)B CIIN$'I'ItUCTIOh
,'allot,as provided for by Section 3]00.(the Luber Coda for the perforates of the
Frk for which no pcnnil is issued. FIXTURES-Mull RAP
1 have and will maintain Workers Compensation Insurance,as required by Section
X)of the labor Code.for the performance afthe work lin which this pcnnil is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP AI'N
My Wnrke +Com thio Ilxyyma carrier and Policy n mberare:
Carrier Policy No.:� GAS-IEA.SYSTEM-OVER 4HIA)
C13RT114G\Th OFF,a�'EMVTION FROM WORKERS'
COMPENSATION INSURANCE GREASIYIN'DUSI'RL WASTE.INTERCEPTOR
(This semion neednot he mmple,N if the roolit is furane handed dol l...(Sla)) BUILDINGDIVISIONRISS
ur lux.) GRE I'hANCHECK IIiIi
I wnily that in the lcd'oniance ofthe work lin which Wl"collil is leaned,I®w11 SEWI?R-SANITARY-STORM EA.
not employ any person in uny mm�ner m a v to become subject to the Workers'Coopen-
OZ action Lawx of California.Date NATER HEXI'ER WNENDELECI'
O Applicant
GRA N LE
NOTICE.TO APPLICANT:If,after making this CeniGcate of Exemption,you Should WATER SYSTP.M/IAEATING
a > became wbjw in the Workers Compensation pmvisinm of the labor Gude,you must SOI
aQ forthwith comply with mch provisions or this pemtit shall be deemed revoked. WATER SERVICE 1
oz CONSTRUCTIONLENDINGAGENCY NEWRESIDENTIN,PLMB, SO,ET PAID
V O Iherehyalfm.than their is aconsauc,ion lending agency forthe perbnmm�eeof Pace ceip,#
Hthe work!or which this Iwrmit Is issued(Sec.3097,Civ,C.) B
O Lcndcr's Name TOTAL'
U Lender's Address .1.
Ir' d 1 certify dead 1 have mail this application and slate Na the above information is BUI 'FEP
Z) correct,l agree to comply with all city and county ordinances unit state laws elating to QTY MECHANICAL PERM I FEE
f) z building 0...mtetiam,and herchymallarire repreantmive— this city,.cnerarym the SEISMIC
FEE
ubrvamentinned pmpeny for impcaion purposes.
(We)a me to save.indemnify p City per b PI?RMIT ISSUANCE a
g y and keep harnticsS the GI f Cu lino n•ainxl ELECTRIC PEE
is.il.Guq ere,ofm.',mal.enJ c:pcnxcx which nmy in:my way ntt'mc upvina said City
nxcyncncc of Ibc grunting nl'Ihix pcmhil. ALTER OR At)])10 MECH. PLUMBING 1:1113
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IILIXNI CPM)
SOURCE REGULATIONS. MECHANICAL RE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION'TAX
Signamreof ApplicanifConmo:er Date EXHAUSTHOOD(WMUCD HOUSING MITIGATION LLE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building xccupvnf store or handle hamrdous anderial HEATING UNIT LTO 10.00 BTU)
to defined by the Cupemno Municipal Code.Chuper,9.12,and If,Heahh and Saley
Crud,Section 25532(a)I HEATING UNIT'(OVER 110,000 11'I'U)
❑Yu Fl No
VEN"IILATI ON FA N IS INGLE RES]D) PAID
• Will The applicmn or future building occupant use equipment or device%which Date Receipt#
emit hazardous air contaminants as defined by the Bay Arca Air Quality,Management BOILER-COMP(3HP OR 110.1000 BTU)
District^. TOTAL:
❑Yea FlNo BOILER-COMP(OVER 100.000 BTU)
I have read! he hunndouxmateria].reyairentents undo,Chapter 595 of the Cali- AIR CONDITIONER
INS AN E A'I'F;_
Ism 11'Eh&Safety
inedy S I' ni.that it
ansii41 d .f It'd The NEW RI3SID1?N'fInL MFAI{, SQ.IT. /•�^ f�G(t
bon bd mnllyl t nl.aha , )o, 'ITyt unify the pod lI / JJJ
nl'Ih y ' t:whit tM ,prior to aunts,da Cen flea,of eupmcy.
If
Owncrorauhomzedagcm / ase L TOT 1.:
ISSUED BY:
OFFICE