S0001C0429cool IC&NTTn Fu I IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING -ELECTRICAL
CITY OF CUPF.RTINO
BUILDING
BUILDING' DIVISION APPI,ICATION/1'ERMI'I PIAIMIHNO-hlf]I)ENTICALFIC
' b - ' ItIJI1.DIN0 PRUJECI'IDh:NTIF'ICATIUN. r:%"
PERMI'TNO.
7
50001 e/
n.�-• "9
IRRLDINGADDRESS:
SANITARY NO.
APPLICAi'I ON SUBMITTAL DATL
o �
_/_0
O NER:YN M': 1'Ii)NE:
V
fdm1 %D6� 5e, M
COM]"RACTOR'S NAME: LIC NO:
f -
- NIC COMI'ROI.N "
❑
ASCI IIIC1lIiNG IiliR: hIC NO:
ADDRIitiS: 74Py 10 R.L/
16,P61f
COIsGA7L - PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
BLDG ELECT PLUMB MIiCH
❑ ❑ ❑
LICENSED a fiodr, d mad, S DECLARATION
I herby nffom mw 1 nm fa¢mren anter nrmviaiam lir Chapter v mtimtnenahtg
QTY. ELECTRIC PERlvfiT' FEE
r+_.'.
JOB DESCRIPTION
willh Scotian "1010) of Division 3 mf the Huainec and 1'rnftrsslnna Gde, and my limnse Is'
b full Carlo and a t.
��'�
LivensSyChas�j Com1
Cnnav
ARCall Main DECLARATION
I understand my plans shall be used as puFlic records
-
I'ERMI'I'ISSU,\NCE
RESIDENTIAL
>,
❑SFDWL El REMODEL
❑ADDITION ❑PLUMBINGRE-PIPE
_
❑MUhTI-UNI"f ❑S'ODIFI URAL.
h10DIFICAT'ION
APPLIANCF_S-RESIDENt'IAL
PANELS
UP TO 2011 AMPS
[I IN] FRIOR ❑ CI IININEY REPAIR
IMPR :MENT ❑SWIMMING POOLS
❑ II REMODI1112EI'AIR ❑SIIt.MO1.ITION
OTHERne41/=T_F_lZ_ .4FQ1 K_ .•
Liccnmd Professional
OWNER -BUILDER DECLARATION
1 heresy affimh that I ass exempt from Ise Commcmr's License Law fertile
following reason. (Section 9031.5. 1hi siness and Professions Code: Any city or county
201-IU(I(IAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
m
which requiresv tied m construct. alter, improve, demolish, or repair any structure
priorinit, "name. also requims the nppheind relators pround lo filen signed ammmenl
SPE CI At. C I RCUI'I'/MISC.
that he is licensed pursuant to the provisions of the Comadm sLicenseLaw(Chapter9-
(commencing with Section 9001 Division Sof the Business it Profession, Code)or
TEMP. M17EROR PO .INST.
COMMERCIAL:'
that he is exempt thererrnm and the Oman, for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICE
Sectio 9031.5 by any applicaml for a permit Subjects the applicant to it civil penalty Or
m more than five hundred dollars (5500).
❑I, as owner of the progeny. or my employees with wages aulheirsolc cimparonimn.
will do the walk, and the shucmm k n m intended oroffded lin saln(Sec.9fYl4, Businees
❑I1iNANT ❑ FOOD SERVICE -
IMPROVEMENT
❑ OTI IFR
SWIMMING LFIECTRIC
mJ Profecoimn, Code! file Conm ,lore's License Law it,,, nw apply m an owner Or
OUTLP' : -'z_ IRS -FIXTURES
property who builds Or ina,mv s thereon, it who does such work himself or through
,
his own employees, provided that such improvements arc not intended or offered for
sale If.however, the building or improvement is sold within one year of complained,the
NEW RESIDENTIAL ELECTR SQ Fr.
icoS .�T
mr-builder will have the burden of proving Paulin did not build or Improve for par -
01 Lal )
❑ I ren prapcny, an, exclusively t m g N bemaed contract ill
TOTAL:
constructate ct(SecAWLBusiness aadProfessions Ced,-.Cnnlmma I
cerise x Ladoes j I apply to an morel rtv p ty n n ld or improves tnereo I
JUL 13 1999
Q-.�. .. -.
TY.' - Ir+ I+r1 PLUMBING PERMIT+ I 1 PEE
who un0anf rsueh pnpc¢tswih teanh mrts)IimnxW pursuvm lmtn¢Commamrs
4±`
PERMIT ISSUANCE
License law.
M 1 am exempt under See. , B & P C far flus reason
OwnerDate
ALTER- DRAIN & VENT- WAfHR (RA)
VALUATION_
-
WORK17R'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I beach, affirm under penalty of perjury mne ofthe following dcdaraiona:5-)100
' Ihnve unJ will mnimxina Ceniticnm ofCmhsmn mself-insula for Worker's Cmnperh-
I
m on, as provided for by Section 3700 of the [,.,be, Code, bar the performance rot the
DRAINS- FLOOR. ROOF, AREA. COND.STORIES'I'YPH
CONS' I'RUCrION
FlXTURflS - PERI RAP
work for which this penal is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3?00ofthe Labor Coddfmrtheperfn mceof 0e work far cal ichmis penal is issued.
GAS-E&SYSTEM-I1NCAOUTLETS
OCC. CROUP
APN
c
My Workcj'x Cod'' told sura0 Mot, and Policy nyt
Cameo (•II} Ai �(\� rattly Na.:X IC/C.OW101,H
GAS- EA. SYSTEM -OVER CI EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASI%INDUSTRI. WASTE. INTERCEPTOR
BUILDING DIVISION FEF_S
ffhisawtinn nwA not he annpined if the Permit is lin one hndre
nJ dollars ($II))
rn lessJ
GRBASB'TRAP
PLANCHWK 14iE
SEWER-SANITARY-STORMEA.20(IfT
Icenifyfhaiminarryomhhnce of Ne work far which Nisptnnif isi.wed,lshall
any person in any manncrgq synhe�nryp3 bject to the Workers'Compem
nnf.a
ENERGY FEF:
WATER IIHATER WNENT/ELEC'Ut O '��
ishan lahwp.ufC liGJn. Data /�T�g/su
I,,
Applicant 114���r fit I Iia
GRADING FEE
NOTICE TO APPLICANT: If, infra, making this Cenificom of Exemption, you should
become auhowt to the Workers GomiTamoation provisions of the labor Code, you must
WATER SYSTEMO REATING
SOILS FEE
WATER SERVICE
herewith comply with such provisions or this moat shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I Fgrchy affirm that there is a construction lending agency for the perormunce of
PAID
Dote Receim0
NEW RL.SIDI!NTIAL PLMB. SQ, 14.
Ne work an which Ilia pcnnit is issued (Sec. 3097, Civ. C.)
[,ad,,, NameT(TI'AL:
Lendce, Address
TOTAL: e,
BUILDING THE
1 certify that 1 have read Nis application and sum Lha Ne move infomhnion is
mon.eft l eed t, u+nNy ,Ill ill 6tymd tr d'' : and a.te laws scLtgt
dinge.hamchmm and nerenr amnedaanpacmar .: unMs sty memerupan ma
QTY,'!. ) MECHANICAL PERMIT 'FEE'
", t-
SEISMIC FEE
PERMIT ISSUANCIi
ELECTRIC Fiil3
added mentioned proper for inspwtion puBa+scs.
m7,7
(We) agree s c, indemnify and keep Larealeas the City of Cupenino against
ALTER OR ADD' I'O M ECI I.
PLUMBING hili
arses which may in any way accmo against said City
'
lianllitiux,jnJgmZDERANDS
in mmuyuence o�2VB7-y-`i`7
AIR HANDLING UNIT(TO 10,0X) CFMI
APPLICANT AL1. NON -POINT
SOUR
hfECilANiCA1.IiF.AIR
IIANDIANO UNIT(OVER 10,0(X)CI'
CONSIRUCTION'1'AX
S' h Applican antmcmr Date
HAZARDOUS MATERIALS DISCLOSURE'
EXHAUST'HOODIW/DUCT)
HOUSING MI'1'ICATION ITE
HEA'I'I NO UNIT G 0100. 'IU)
Wlllihe uppllcuder flats mildilgoccnpanlsmra or handle luvarJousnunctid
as defined by the Chismar , Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Station 255320)1
❑Yes NOPAID
Will Nc applicant or failure In. ilding marepea me cyuipment mr dcviccs which
`emil hlam ions air a+maminanu as defined by the Bay Are. Air Quality Management
Uistdcl^
[:1 Ves AlsoBOILER
BEATING UNIT UOY447100,000 BTI)
--
I h RfRIPIK
VP.M'IhATI `IA N(SINCLII RESID)
BOIL-COMP(3HP OR IIIII,(N)pTU)
TOTAL:
- COM 11 (OVER 1000010 BTU)
AIR CONDITIONER
I have real the us ma¢ddsre remenu miler Chapter 6,95 of the Cali-
, rot
ISSUANCE IJAITi
NEW RIiSIDEM'[A]. MECIL SQ, FL
forma Health & Safe a . Se 5 as 05, 533 ay 2553L 1 undemand tsar if Che
building do., urn a ( E t,Ntmy✓/1� ably,, utility, be railer,
'role
of arc u' 11 ' I p no I�CcnU m
rcg6df 7-9l Ue yry/
l/
ISSUED BY: 5;j
TOTAL:
Owne um prized agcy Data
OFFICE