S 1040 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CBUILDING DN BUILDING-ELHCTRICAI.' PT ITNO. j
OF 1040 ERTtNO APPIACAT• RMIT PLUMBING-MECHANICA
IIUIT.DIND 1'ROJF. P IIIENI'IFICATION
41�ILDING ADDRESS: - SANITARY NO. APPLICATION SUIiMITI'AL UATI
Wall
NER'S ME: PHONE: RACTOR'S NAME: LIC NO:
Is NIC CON'1'IiOl.a
60 F. 46140SO&I
RCHITECIDENGINHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: NO
PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG elx.I' PL� MECH
LICL'NSLD COM'RAC'IGR'S DLCLARA'1'ION QTY ELECTRIC PERMIT FEE
I hereby o0rm]hat 1 am licereed under provisions of Chapter 9(commencing JOB DESCRIPTION
,O,VQC with Saadon?0010 of llivisimn Jnf mul{nsinays mN Profenslom Cale.and my license is pERMII'ISSUANCE RESIDENTIAL•
f�= m full farce end eft ❑SFDWL ❑KITCHEN REMODEL.
azw hicenn_ C.mV !1�''�6: APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RI PIPIT
Fz a nate comm tat
rn60. RAL
❑MULTI-UNIT OMODIFI MODIFICATION ARCHITECTS DIiCLARATION
PANELS MODIFICATION
Z O 1 understand my plate shall locust.,puM1lic recoNs UPTO 21X1 AMPS
OZ 0 [I INTERIOR El CHIMNEY REPAIR
F� f�c I.I.Vued Professional 2014000AMPS IMPROVEMENT OSW'1MMINGPOOIS
OWNER-BUILDER DECLARATIONOVER 10M)AMI'S BATH REMODEUREPAIR �DIiMOLIT�IONN
d I hereby allism mm :un exempt from the Contractors License Law for the C3 OTHER Sl.Rom
5 O 6 U following reason.(Section 7031.5,Business and 0xdeasions Cache:Any city mcemnY SIGNS ELECTRICAL
fr7 a
nst; which requires a permit m construct,alter,improve,demolish,or repair any income e
priertolut...ance,also mqums the applicant for such p:rmitto file a.signed statement SPECIAL CIRCUIT/M ISC. 0iM & L
} thum . t.
at helm licensed pan,ssthepovisioas'f the Contrac ,x License Law(Chapter9 COMMFRCIALa s•
(commencing with Section 7")of Division 3 atone fosintasand ProfessionsCade)m TEMP.MET ER OR POLEINST.
that he is exempt Ihercfmm and the basis for the alleged excmpoion.An,violation of [I NEW BLDG/ADDITION ❑DEMOLITION
W..y Section 7031.5 by any applicant for a permit subjects the applicant lea civil penalty of POWER DEVICES ElENANT OFOODSERVICE
not more than five hundred delta,($5110). IMPROV EMEN 1'
[J 1.as owner of the property at my employees with wages as their sale compensation. SWIMM ING POOL ELECTRIC
will do the work,and the mmmare is not imended erolTered for sole(Sm.7M4,Basin's O OTHIiR
mand Professions Cone: the Contractors License Law does nm apply.un owner of OUTLETS—SWITCHES—FIXTURES
4' property who builds er improves thereon,and who does such work himself or through
his own employees,provided that inch improvements am not intended m affercd for NEW RF.SIDLN9'IAL HLECTR SQ IT,
;4;�:,sale.IL hmvever.3he building or improvement is sold within on cyearofcomplctioathe SpIpFT.pOLOOR AREA 5/SQ.FT.
two
er-builder will have the burden of proving that he did not build or improve for pur- r A
pose mf sale.),
1,ns owner of the pnVpeny,an,exclusively cnnbucting with licenw:d enntrucmm to (l ^'
construct the pmjccl(Sm.7014.Business and Professions Crede:)The Contractor's Li- COT 16 FX-D
cense Law does not apply to an owner of prepany who builds or improves there's,and QTY. PLUMBING PERMIT FEE
.he contracts for such,.jects with.commm l(s)licensed pursuum m IN,Commmors
License Law. PERMIT ISSUANCE -"y Uf UUr
[:j1 an,exenpt under See .B&P C for this reason tH11N0
AUITR—DRAIN&VENT—WAILER PA) 'VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK R.OW PROTI?CT.DEVICE OV
1 trashy affirm antler penaltyer perjury one of the following declarations: IslQe
❑I have anal will maintain a Certificate of Consenuo self-insure for Workers Compcn- DRAINS—FLOOR,ROOHAREA.CONE. STORIES TYPii CONSTRIJCTIOh
mnion,as pmvideJ Ian by Section 3701 of the Labor Cale,for the performance of the w
work for which this permit is issued. XTURES—PER TRAP V
O I have and will maintain Worker's Cem,cnsmion Isau.c.,us Verlaine]by Section
37W of the Labor Cale,for me performance of Ne work for which mil Permit is issued. GAS—Ess.SYSTEM.I INC.40(ffLEf$ OCC.GROUP APN
I My Worker' mpc Isatin mace can, rind Policynnmbcrare:
Cartier: Policy Net: GAS—EA.SYSTEM-OVER 4(EA)
CF.RTIFI ATE COPESATIONIEXEMPTION FROM WORKERS' GREASUINDUSTRI.WAS'1'17.INTERCEPTOR
COMPENSATION INSURANCE BUILDING VISION RIES
(Thissection need not hecomplated ifine permit is formic banJrcd dollars($100) GREASHTRAP
art less.) PI.ANCHIiCK
I many that in the performance affix work for which this permit is ksmal,I shall SEWER—SANI'fARV—S,OJIM 1:A.200 IN.
not employ any pema
Pearson in any nners m 0 become subject.the Workeri Compen- ENERGY 17EE
z action laws of Calif.odu hale W'A'I'HR I IHATER W/VENTAFLECTR
ZApplicant GRAOINO F
y NOTICE TO APPLICANT.If,after making this Certificate of Eaem,oien,you should WRIER SYSTEM,TREATING
a L"t heu,me suhfem m O,e WmIao',Corrilmatien pmviolue of the tabor Colo,you nmst SOILS Fill
i� fonhwim rnmply wive such pmvisionx nr this permit shell bedeemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESILAINfIAL PLMB. SQ.FT. PAID
UO 1 herebyaffino mut there isacenswetion lending agency for the performance of Dme Receipts
LL F the work for which this Minh is issued(Sec.3097.Civ.C.)
O U lend',',Namur - 'TOTAL:
{2J Landers Addreas ) I'
I}r I m tify that I have read this ep,lic lion and state that the above infnnnatinn is BUILDING LEI �a
F (A comect.l agree to comply with all city and county ordinances and suite laws existing to QTY. MECHANICAL PERMIT FEF,
U� building conslmmion,and hereby amhimu rep aentaoivesofmi.scioy menlerup,n the SEISMIC FEE
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against ELECBIC FEE
Iiabililies,judgments,casts and expenses which may in soy way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in can
cc of the gran m,.f 1h, pa.h.
APPL .A f UN H NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T(TO 1(10R)CPM)
It,
MECHANICAL PL•E
son a 'a
16
AIR HANDLING UNI'I(OVER Hk00)CVM) CONST RUCTION TAX
?na,cfA anConwcmr tram MI IAUST IIOOU(W/DUCE) H00.SINGMITIGATIONFEfiHAY.ARDOUS MATERIALS DISCLOSURE
applicant ter future building occupant store or handle hmardus material I IERI'I NO GISH(TO 101,00 BTU)
the Cupeninn Municipal Cade,Chapter 9.12,and the Health and Safety
n 25532(4)? HEATING UNIT(OVER 1011,001 BTU)
❑Yes MN. VFNTILA'1'10N FAN(SINGLE.RIis ID) PAID
Data Reccipt if
Will the applicant m oture building by he Bo use .Air Quality
devices which
emit hamudoux air amrmninanlx as defined by one Boy Arca Air Quulily Management BOILER—COMP(3HPOR 100,000 NIU) 'T(YIAI.
District? BOILER—COMP(OVER I(X),000 BTU)
El E]No
I have read the hvaremua materialsm4nimmems under Chapter M1.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
`I fnmia flealm&Safety Code,Sections 25505,25533 and 25934.I understand mm it the NEW RLSIUENf1Al.MECH, SQ.IT.
buI'JingJces net cm.mly"sea recant,that it is my rcspmxibilioy m nooifY the rccupam D
of the re,ifements which must he met prior m issuance of a CmlGcam of Occnpaney.
Owner n r amhnrind agent Date ISSUED BY:
OFFICE