S 2823 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO IIUILDING-ELRCI'RIL'AL PERMIT NO. /1�1
BUILDING.DIVISION APPLICATION/PERMIT PLUhIHING-MECHANICAL C 2823 8 / K
BUILDING PROJECT IDENTIFICATION J N L J
BUILUINC ADDRESS: SANI'1'ARV NO. AI'I'LICAI'ION$UEkiITTAI.DAT[
O 'N'R'A. 1Q Il 1'110NE: C 'I H:OI'UHANAMIi: LIC N.O:
/V 9/-l/ NIC CUNTHOLp
C-63 (344 19
CI '1'F.CIIENGINIi1:H: LIC NO: ADUNB55: / ❑
lin c�1� SO 2 7
CONTACT: vFIONr BUILDING PERMIT INF
❑ Consultant Fecg Paid by Applicant(Initial) BrLDGG 17LLECT PLIIJJMMRR MECII
L La-
1J
LICENSED CONTRACTOR'S DECLARATION QTYELECTRIC PERMIT FEE
m ma
1 hereby afhral 1 licensed under provision.of Cheaper 9(commencing JOB DESCRIPTION
"Z O with Sermon 7000A Division J of The Bnxiness and Profoselons Cude,and my license is RESIDENTIAL:
LL00 PERMIT'ISSUANCE ,,c
5WF in full Lrrecande 4L 3 Q ❑SFDWI. LTc11 t,HIiN REMODEL
EUV 1'tccn'u CLaLic.p T /----- APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE.PIPE-
F-ZW Date [I Cnnlr'.tor f,�y`�y
may ❑MUUrl-UNIT [I STRUM DEAL
ARC IITECf:S DEC ARATIO
F.p m PANELS MODIFICATION
OZN Z I understand my plans shall be used as public records I
-� / UP_ES. -AMPS C1 INTERIOR ❑SWCHIMNEY MING POOL
F4ts1 Licensed Professional 2PAIR
( )A IMPROVEMENT SWIMMING POOLS
QY�J OWNER BUILDER DECLARATION OVER I"AMPS BATH NEMODEDREPAIR [I DEMOLITION
CG 6 I hereby affirm that 1 am exempt from the Commemrs License Law for the p
iqS O F V following reason.(Section 7031.5,Business and V Cassino,Code:Any city or auumy SIGNS ELECTRIC MAY2 6 ❑OTHER
n+3 LLh which requims a permit to c.namct,cher,improve demnlixM1,or npnir any xwmurc
Og prior m its issuance,also requires the applicant forsuch permit in File a signed statement SPECIALCIRCGIT SC.
y mat fuels licamcdpumumn to the pmvlalnns of the Contruetnrx License Low lChapmrY
u�$E COMMERCIAL'
�yp0 (rommencing with Sc.ion]W01 of Division of the Ousinczs and l'mfessiuns Calep+r TEMP.METER OR O .INS'i'.
L%mthat he is exempt therefrom and the basis ror the alleged exemption.Any violation of [:I NEW BLDG/AUDITION [j DEMOLITION
�-,Vi Sal 7031.5 by any applicant l iaapermitsubpoadhe),loom In a evil anodyof POWER DEVICES ❑TENANT' ❑FOOD SERVICE
?O not more then five hundred dollars(4500). IMPROVEMENT
❑ I.as owner of the property.or my employees with wages a their sole cnTensation, SWIMMING POOL ELECTRIC
will In the work,and Lha structure is not intended.r uffered ba sale(Sec.7044,Businces ❑OTHER
and Professions Code:The Contractor's License law docs not apply t.m owner of OUTLETS-SWITCHES-
FIXTURES
tl3 y,.,.y who builds or improves th.mn,and who does such work himself or though
his own employees,provided mut such improv..ants arc nut intended vroffered for NEW RESIDEN IAL ELECTR SQ FT.
sale,If,however,the building of improvement is sold wad inaneyearoRomplction,the SQ.UL FLOOR AREA VSQ.lT
wancolnuilder will have the burden of proving that he did not build or improve for purol
-
pase of sale).
❑ 1,a owner of the property.am exclusively contracting with becnsed.+mmetoTa
consmr. d prone.(Sec.]Tuna Rusinexs and who
bui Coal,improves
Comra.on,Li- / 1
cera lawdnmr suchplytaan with
aofpropeny whrnsed sarimpnrvea Contractors QTY. P, BIND IT FEF. ✓•'1
who tnntras for such proJecn with a nnttm.ar(s)Ilce.ud pursuant m the Commemrs
License Lw. PERMIT ISSUANCE 117
�
10
-- - 1 1 Inn exempt under Sur. ,B&P C for This at /
Owner DALTER-DRAIN IES ATER(EA) VALUATION
me 1,..�
WORKER'S COM PENSATION DECLARATION BACKFLOW
_1T7/Jl /fAv�R�YVII
1 hereby affirm under Certificate
enahy.r perjury one of the following decturaiWader''s Co
In,as anti will f..by Se Ceni ofCousent Car"her Code,self-insurethe Workers Camper- DRAINS-FLO F,ARBA,GOND. STORIES TYPE CONSTRUCTION
smimn as pmviJed fur by Semina 371X1 of the labor Code,Taube pufnrmunee of the
.,it far which this permit is ioued, FIXTURESAP 2,; -
l//t
❑1 have and will maintain Workers Compensation Insurance,as required by 5e<tion (/ (� V
3'/1X0 of The Lubar ClAr,for the performance ofthe work far which this pemul is isrmml. I GAS-EASY E .I OCC.GROUP /_ APN
hely Warker'a Compensatien In...mr.carrier and Policy number are: •f�
al
Carrie'. Policy No.: GAS-EA.SYSTEM-04A(
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASEIINUl15TR1,WASTE .
INTE PION
COMPENSATION INSURANCE BUIIA
or II..,) INIJ DIVISI(1N FEL5
(This arm need Trot lc completed India permit is for ane hund¢ddollan:(tl0lq GREASETRAP
I' HF.0 EL' -Z — -w
2-�
lernifythutintheperlimnance nl'Ihewnrk fur which this permit is i...nd,Israeli SEW17R-SAN]'LARY-STORM EA.200 FT.
tat emplay any penin m any manner to hec a s •. a Workers'Cahalan. ERG CRA/E
smi.a Law.of Cadifr>rin a / WATER HEATER W/VENT/ELECfR GRAD G
Z O Applic.a(( J�� ,� QS
NOTICE I O APPLICAM':If,after making mix Cenrimam of F.xnnption,you should WATER SYSTEMORHATING
F ti become subject to the Workers Curalimmum provisions of the Lahr Cole,you mita SO SFE'
Lail forthwith comtply with such powisinm nr this permit shall Me danmd revoked. WALL 14R SERVICE
n' Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.ET. AE Date ReeeiptN
1 hereby affirm that there is a construction lending agency or the perfornonce of
[LL the work far which this permit is issued(Sec.3097,Co.CJ O
U Lenders Name TOTL:
0 0
[t1 Lender's Address AL'Z'
y I rectify But I have read this application and state that the starve information is BUILDING PEE Z
Ft/] correct.I agree to comply with all city and county mummers and state laws rximingm QTY. MECHANICAL PER IT FEE S IC FEE
U ,7, huilding namnonimt,and hereby antborize representatives of this city m enter upom the
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We).,ore ,,case,indemnify and keep faithless the City of Caplan..against ELECT FEEin 4/j no
Iiubillties,judgmena,costsnndexpenses whichmmyinany wayuame againxtsaid City AI.TERORADDTOMECII. PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO lo.adviCFM) MECHANICAL FEE 3
SOURCE REGULATIONS.
y' 90
AIR HANDLING UNIT(OVER 10,0X)CFM)
CONSTRUCfION'1'AX
Slgtutlun of Applicant/ omractur Dae EXHAUST HOOD(W/DUCT) D HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazallous maradW HEATING UNIT(TO[On"BTU)
as defined by the Capertiou Municipal Crate,Chapter 9.12,and the Health and Safety
Crkc,Section 25532(.)^� GRATING UNIT(OVER IMiss)BTU)
Yea �ipN
'� VfJJTILA'f10N FAN(SINGLE REST[)) PAID Dae RaNptM
Will the applicant or future Wildingnccupunt axe equlpmant or devins which BOILER-COMP(3UP OR HN).00011'CU)
mit hira dons air contaminants as defined by the Bay Area Air Quality Management TOTAL:
iariall BOILER-COMP(OVER 100,0p BTU)
❑Ycso r
. I have read the hazanluusmmmi.lsmquirementsunder Chapmo6.95 oftbe Culi- AIR CONDITIONER ISSUANCE DATE
fain Health&Safety Code.Section 25505,25533 an 125534,1 understand that if the NEW RESIDENTIAL MECH, SQ,PL
building docs not currently have a tenant,that it is my responsibility to notify the occupant
.flhe¢q ' uwhich mu bath.prior to issuance oft Cenificats. Dean use,
( F7� Date
T( 4 ISSUED BY:
OFFICE