99080088APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1) 1� 00 IKK
CITY OF CUPF.RTINO - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
"j!,BUILDING PROJECTIVENTIFICATION
PERMIT O.
IJOILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
le
OWNER'S NAME: PHONE: lWJ
�' %M�i /.,t -P •J -z� c W r/
NTRACTOR :S NAME: LIC NO
N/C
❑
CON'IROLN
y
C It MCT /ENGINEER: LIC NU
OVCA4
ADDRESS: -
/'OEO � c C
GONTAC'P PHONE:
(�(7�•I,i zr /. �.BUI GPERMIT INFO I•p ". 1.
,(� �� /y.
._7xp %a o i-"1 —I ill —
J 7
❑ Consultant FMS Paid by Applicant (Initial)
BLDG ELECT' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
n
I herby nffrm thalum licensed underptovisions of Chapter 9(commecing
QTY
d
Pih!) , "l1.11.ECTRICPERM1Tir'�If}�rll (rs
1. L .'s I•., .n .J:ua Us �L '!
,yrr•FE51'nt
'trtJ 1. Jd.a
JOB DESCRIPTION
with9ection'1000)(fi ivi.i:m 3 of the Business and Irafesrionsewle,and my licen.ei.
in full farce and elf // p/ i/
License -k Lic.W �f Q' ""t'
V Date Contra �`
PI!RMI'1' ISSUANCE
RESIDENTIAL:
RESIDENTIAL,
OSFUWI. ❑KD'CHP,N REMODEL
E] ADDITION CPLUMBING RE. -PIPE.
❑MULTbUNIt' Cl STRUCTURAL
MODIFICATION
APPLIANCES - RYSIDEN'flAI.
,AiC111TEC1'S Il[CLAIIA'TION j�./�)
L I unilerna J my plans shall be used as public rceoNx
PANELS
UP HO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C SWIMMING POOLS
❑ BATH REMODF.IAREPAIR (]DEMOLITION
❑ OTHER
J Licensed Professional
OWNER41U1LDER DECLARATION
1 hereby affirm that I am exempt from me Counracmr'.s License Lew fnr the
following mrsoaa, (Section 7031 5, Business and Professions Coda. Any city., "only
which require% a permit to construct, alle, improve, demnlim, of repair any stmtlare
201- 1000AMPS
OVER MY) AMPS
SIGNS ISLECMICAL
SPECIAL CIRCUD1n1I$G.
prior 11) icmance, also armlims im.,dieant foreaeh penniuo Eleasi,mal statement
thou he is liceasedpmemal is thepm,odursnf the Cmnowbrs License Law (Chapter 9
(cranumnar, with Section )000)of Diskion3 ofthc Holmes, and Professions Code).,
Y that bell exempt thercfrnm and the basis fit, the alleged umnpdon. Aoy violation al'
TEMP METER OR POLE INS.
COMMERCIAL:
CNEWHLDGIADIJITION C3 DEMOLITION..
POWER DEVICES
Section 703 IS by any npplienm for npermit subjects the applicant macivil penuhy of
n
notional man live hundred dollar, ($500)
st ❑ 1, as nwnerofthe property, or my employees with wages as meirourcompensation,
will do the wnd...d theamcrure is not inlendedmol'fered Unlink (Sec. 7044, Bh,inesx
Z and Professions Cale: Me Contractor's License Law dces not apply m in owner of
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTH ER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FU TURFS
property who builds or improves thereon, and who does such work lumoolt or thrngh
his own employees, provided that such improvements am not intended or oBered for
sale. It, however, the building orimponnnentis sold within ono year n 1"Hildedmh ,the
NEW RESIDENTIAL. ELECT SQ M.
SQ, FT. FLOOR AREA
LSQ. ET,
owner - builder will have the burden of proving that he did not build or improve for pur-
low of sula).
C 1, as comer of progen la
y, am exclusively contracting with licensed empcmrs to
'TOTAL:
ma t the project (Sec. 9110 Business and PrdcAk a Code) The CoovnenrsL
ceme La does not pplyi fp perty M1 builds or improves there. d
who ct, fur such pu,r,t lh n"Mr 't (a)h,cn dphrsontin the Contractors
p - Is •.(, - .1-r -fsI,
Q Y s PLUMBING PERMIT,j 1.+
.ail
FEET; ;'•
PERMIT ISS . 'E
License lax''
❑ I han exempt under Sec. —,R & 1' C fnr "his noon
Dsle
ALTER - DRAIN& T- WATER(EA)
VALUATION
6
WORKER COMPENSATION DECLARATION
I hereby nfrrtn undo,mdry n[ porJury one of that falnwin6 dcdvmti.ns:
BACK PLOW PROTECT.
J three and will maimaina Cenificam of Consent tool(- imsuln for Worker's Camper-
salion, as provided for by Section 3700 of the Cal Cole, forme perfmmancc of the
DRAINS - FLOOR. ROOF. A REA`1 N1)
STORI ..
-
TY PE CONS'IRUMION
work for which this pemtit is issued.
C I nave and will maintain Workers Comgonwtlot Inenrunce, as aegmimd by Section
FIXTUNF_S - PERT RA IJ
x
�la -
-
3700 film labor Cale. Bathe performance of the work for which this permit is issued.
GAS - EA. SY STEM -I INC, 4 OU'TLIDS
OCC, GROUP
APN
My Worker, Ci mperention Insurance caller and [Jolley number ate:
Carrier: Polley No
GAS - EA. SYS'IHM -OVER 4 (EA)
CHRTIF CA'fE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
0 'licuunion need malecrnnpld"ldffic ermit is fmonehumbed doll.(SIM)
nr le".)
GREASEANDUSI RL WASTE INTERCEPTOR
s UI VISI(JN
PRISE
GREASETRAP
PsI
f �,IIUILDINq
CHECKF
SEWER - SANITARY - STORM EA. 200 FE
I mini fy that in the performance of the work for which this permit is issued, lshall
nal employ any person in any manner so as In become subject to the Workers Comma,-
'4 Y FELL
WATER HEATER WNENTTLECTR
saion Laws.f Califomie. Date
Applicant
(�I�
kPINO FEE
IAI
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption, you should
become subject to the Workers Compensation gno,iMmu, of the Labor Code, you at,(
WATER SYSTEMOREADNG
S FEE
WATER SERVICE
� fmhwimcmnply with such provisions ur this permit shall be deemed revoked.
ID J
i
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PfA1B. SQ. FL
jntereny alR,at mat mere iaaennmm. Ima leading agency rmine pme,rmmce nl
+ the work or which this permit is issued (Sec. 3097, Civ. C.)
+ Lender's Nam,
TOTAL:
Lend r. Andres
-
tGIAL:
r„ ._ t .h�.
BUILDING FEE
_
eDfy bit Ih ttl' ppl. l Idat th the h I al
am t 1 g t ply Rh Il city ands ty b dot t I : mlarngl
[ holdng In4aclh i,adthereby huh r. prenentatne, Lb,cly to thomrtnn the
QTY
.
' MECIIANICAI PERMIT
-J. It / -
-• FFF.A '
.rf'
SEISMICF6E
I PERMIT ISSUANCE
ELECTRIC FEE
answe- mentioned popery for inspection purposes.
(We) agme m save, indcnmify and kecg hunnlmxs the Chy of Cwmnino aguinrt
ALTER OR ADD TO MECH.
PLUMBING PIiE
liabilities,judgntenis, costs and espenw% which may in anyway accom againstand City
in" i,,,br ,,.1 the grunting of this permit.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CI:M)
CONSTRUCTION ]AS
3a!/
it
Date
A% n DOUS h1ATER1 ,S DISCOID i
EXHAUST HOOD(WIDUC`H
HOUSING MITIGA'T'ION FEE
I I EA 'I ING UNIT I' 1'0 III.W0 Bq'Il)
Will the applicant tam be cuparl rune mhandle hamNmosmatianal
as delinW by the Cnpenino Municipal Cssle, Chapter 9.12, and the HeuIIM1 and Safety
Code, Section 2553200
-
IIEA'1'ING UNIT (OVER 100,000 It UD
VENHLAI ION FAN(SINGLERES ID)
El Yes
Will the applicants future building occupant use equipment or devices which
hit hvardous air m icurnmtnts as defined by the Bay Area Air Quality Management
farict,l
❑Yes
PAID
Date Reiry,%
BOILER -COMP (3HP OR 100,000 BTU)
TO
BOILER- COMI'(OVER 100,00(i
R
AIR CONIJI'f1ONHR J
I base read ore himmums material, ou, irement made, Chapterfi95al the Cali-
ISSUANCE DATE.
NEW RESIDENTIAL MECH. SQ. ET.
fomin Health & Safety Cude, Sections 25515, 25533 and 25534. 1 understand that if the
building does not recently have a moral, that's is my responsibility In tai y me ccupunt
��
nfine reyuimme stM 'r "once ofa Ccnft
(J %
,
7 ✓�
ISSUED BY: V �L ,y ��-T 04!
nr author d a • Date
TOTAL:
OFFICE