S 1656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPIiRTINO
BUILDING,ELECTRICAL PI:R`p11r NO.
BUILDING DIVISION APPLICAFION/PERMIT PLUMBING-MECHANICAL V 1656
BUILDING PROJF,CT'IDEN'I'IFICA'1'ION
ILDING ANNUISS: SANITARY NO API'LICAI'ION SUI3MITTA1,IlATIi
N-RS A. :+ PHO '� C I'RACr(IR;SNAME: LIC NO:
La rs�n NIC CONI ROLA
• ARCII I ECT INGINIDIR: LICNO: ADDRIiSS:
CUNI'ACT: PHONE: BUILDING PERMIT INFO
❑ CDnsuhanl Fees Paid by Applicant(Initial) BLDG :CECT PLUMB MECH
J LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
lherebyaferm mat I ant licensed nrLixh,n.nr Chaphor 9 mn,mnenaing JOB ESCRIPTION
WO2 with Scad.n7W)iorDlvislon Sof me Businessoid Pmloo.00s Code,und on,license in RFCIDENTIAI
Pi in full force and effect. PERM)'T ISSUANCE.
Q�UU L.ccnsc Class Ide.N ❑SFOWI. ❑KITCHEN REMODEL
FF 2(V Dalt Cmmaclor APPLIANCES-RESIDEN'11AL
yQ4 ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
2 O'" I undersand my plans chaff he use an pu lie .cords
024-O UP TO 2W AMT'S MODIFICATION
F- ucemed Pmmssmnul ❑INTERIOR ❑CHIMNEY REPAIR
.1 201-IOW AMPS IMPROVEMENT
q4y � OWNIiIt-RUILDBR DECLARATION ❑SWIMMINGPOOLS
4 Y 1 harm. afhnn Inas I um exempt Bu%ine sant the r Coni ns Cn Licence Law froths OVER 1000 LE TRICMPS ❑BATH REM lyiiyAl R-❑ LlZlp,���
X 3 4 F following or remno.(Section]OILS,Bu.iness anal Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER KK L }1•y—��=
F O yG which requirvx a pannit to cnnstrua,o lmq nupnwe,deumlish,or repair nay slmdure
HtiJ piiunoits issuance,aka requires theapplicam unianch .are BiessignedammmemNPERMIT
AL CIRCUITIMISC.
�6� flea h'c;IicenseJ pu,uannnThe pmviei.ns oche Contractor's License Low(Chapmr9
tY (um Ing wi,M1 Senion](XND nr Divixion3 of the Business and Prnrcsni.nc Cede)orCOMMERCIAL
D O METER OR POLE INS'1'.
Thal he is exempt Therefrom and the ba is for the alleged exemption.Any viola ion of ❑NEW BLDC/ADDITION ❑DEMOLITION
W,�y Section 7031.5 by any aPPEicant for a permit subjects the applicant to a civil penalty ofR DEVICES
F+2Y Bol loom than live hundred Unllars(gSnOt. ❑'TENANT El FOOD S17RVIC17
FO Lox owner ufthe pmpeny,or my employees with wages penesIMPROVEMENT
O payees ver gerrtheirsole compensation, SWIMMING IY)OLRECTRIC DOTTER
ca well do The work,and restriction Co is nm Emended a Law does
for rule(Sec.](N,,Business
4 and I'rnlessinnn Cale'fhe Comraclorc License haw Jnes Bol apply In an owner n( TS-SWI I-CHES-FIX" S
Pmpeny,who hands nr improves thereon,and who does such wad:himself or though
his own coulai pmnded met such improvements Ira nm intended or offered forP,SIDBNTIAL ELECT SQ FT.
.sale.If however.the building or iunpmvemmni is cold within one year of complefian•theS 5/SQ PI'
owner-builder will have the burden of Proving that he did not build or improve for Dur- QfIDONA�A
Doer
❑I,as owner or the prepcny,am exclusively connecting with licensed conlmclars mT 1i�
Instruct the poled(Sec.]IM,,Business and Pmfescians Crile,The Contactors Li. MAY 1 /IIIS'D
Move Ura does not apply loan owner of property who huilds or i tnpr.ves lherenn.and PLUMBINGPERMIT
whoe.nifacts f.rsuchp feels will,a,muacar(s)licensedpu,uanr rmhe Convenors
License exioLawT ISSUANCE. CITY Uf wruiIINQ❑Ium rxemtf under Sac. B&P C fur,bis rnrsn -DRAIN&VEN'r-WATER(IiA)her DaeVALUATION
WORKER'S COMPENSATION DECLARATION PLOW PROTECT.DEVICE
1 horny affirm under penally or Pe jury one nfthe following declarutinns:
_ ❑ I have and will maintain a Cenamod,ofComcm m self-,Brum lir Worker's Counter. DRAINS-FLOOR,ROOF,AREA.COND.
Nation,as provided our by Seninn 3700 of the Lobar Cute,for the perl'eneurc of the STORIES TYPE CONSTRUCTION
work for which this permat is issue. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700ol he Labor Code.Lathe turf nacre or flee work for esh fele this permit is lesuAl. GAS-IiA.SYSTEM-I INC.,OUTLIi'r5 ANN
My Workers Compensation Insurance Gamer and Policy number are: OCC.GROUT'
Carrier: Policy No.: GAS-IiA.SYSTEM-OVER,(EA)
CBR'fIICATB OP EXBMPfION PROM W011KER5'
COMPENSATION INSURANCE GREASOINDUS'JRI.WASTE INTERCEPTOR
(Trisector need not he eard"od unit,Tomtit is Fortune hundred Jolla,(S 100) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEF.
Toy any main-he ponfamminsanyanourof thew.rkfor which his the Woris kers
Conqhot]uer- SEWER-SANITARY-.
noren+Law anype,onin any manners,asn+hecome sukjecuo the Wurkers'Contpem STORM EA.21X1 Ff. ENERGY FEE
,� section Lawa of Califomie.Dune
0 Applicant WATER HEATER W/VIiNT/ELIiCTIt
,Z GRADING FEE
` her no TO APPLICANT:EL afterferking pCe of of lixeunpliod you mould WATER SVB'I'IIMITRIiA'i'ING
bourne subject m the Workers Compeor This pmvisions of The Luber Cee,you must SOILS IEE
� QForthwith comply with such provisions or this permit shall he deemed revoked.
WAT[R SERVICE
z CONSI'RUM]ON LENDING AGENCY INEWRMID!�Vl PCMB. SQ.W. PAIDV O (hereby alBm+that them is a constmrnion lending agency for the Perfoomtance of Dam ReceiptFthe work lir which this permit ix issued(Sec.3(197,Ci¢C.)
Lenders Name
ULender's Address TOTAL TOTAL:
I unify that 1 have road thisapplicadnn and sane,hat the above iar.mndon ie BUILDING YI3E
c.tren.l agrecmcomply with all city and cnunry uNinances and nate laws reWtingm QTY. NICAL PERMIT FEIiZ buildingc.nsuoction,araffouby anthunce representatives of, is city Trani ummme SEISMIC FEE
above ntantiancd tmpedy fnr inepeclion(We)agree In cave,indemnify and keep harmlca,he City of Cupenino against ELELTHIG FF.Iiatcruso,oftMECH. '
nscq me nl the gr:mting of this Pcn PLUMBINGFFE
APPLIC, UNDRRSTA \ I.COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.00(f)CFM)OU EGUL4TIONS. MECHANICALI'E
lO AIR HANDLING UNIT(OVER Iff"CIM) CONS'1'kUCr10N TA
Sgnalureol Applieant/Contra&Z eio `Date EXHAIJS'1'HOOD(WIDUCII
HAZARDOUS l,1 NJIPRIALSDISCLOS U RE HOUSI NO M II IG ATK FEE
Will the applicant or future building occupier store or handle Interactions mmmnl HEATING UNIT(TO 10o.olXi B'FG)
as defined by the Cupevi no Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P IfEATI NO UNIT(OVER Ihina IO RTU)
❑Ye. 11 No
VINTI LATION PANS I NGLE RESID) PAID
• Will,he applicant or future building oua+pern use equipment or devices which Dam Reccipr N
emit himnrdnuc air cunmmipanu as defined by the Bay Area Air Quality Managcmem BOILER-COMP(3HP OR I W,(100 BPUT
Will
❑Yes ON. BOILER-COMI'(OVIiH I00 BTU)
I have read the hmardous aralcrials requirements under Chapter 0.95 of the Cali- AIR CONDITIONER ISSUANCE DA'fli
fomin Health&Safety Code,Sections 25505,25533 and 2553,.I understand mm if the NE\1'RESIDENTIAL MECH. SQ.IT.
building does not currently have a mord,that',is my msrymnt
sibility lI unity rhe occupa
of he requimnmma which all be net prior 1.i...rrceof a Canilieme of'Oacti'my.
Owner or athoned agent Date
' \ ISSUED I3Y:
OFFICE