S 1436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO BUILDING.-ELECTRICAL 1'IiS fr Na. 1436
nU11,I1IN(_DIVISION APPLICATION/PERMIT PLUMHmG-MIOCHANICAI. \v
BUILDING PROJF,C1'IDENTIFICATION
It LDING DDO.SS; � �ON SANITARY NAPPLICATION SUHMI'l'II(ATALL.DAP I!
YLt
OWNIERa'S/l/NNAAMN 6Le� VIONNE CONTRACTORS NAME I,IC NO: ��O `�
NIC CONIAO�L�N1
ARC ITECT/Fl.'GINEER; L.IC NO: ADDRESS: ❑ X111
\ YV�1
CONTACT;I PHONE: BUILDING PERMIT INFO
N 0 ❑ Conmltant Fees Paid by Applicant(Inided) BLDG HLECF PLUMD MECII
LICINSI:D CONTRACTORS DECLARATION J J
y a proviournO o peen g QTY IiI,ECITtIC PERM Hr FEF,
1 nereb Ron thin 1 am lianwe alder fCna J(commencing _ 7013 DESCRIPTION
OaZ wi1h So...on7(9)0)410lvisio 130 be lwaino.mw l'mr—ion"Cwe,nitJmy heorse'la RESIDENTIAL
W 0 0 PERMIT ISSUANCE
in full more nml eRmt. ❑SFDWL ❑KRCHPN RIA10UfJ,
aUw [)are an fie.
Cl ( APPLIANCES-RE41UINr1AL [:]ADDITION PLUMBING BE PIPE.
I-+aa DmC cnnlNenN
'❑ao ARC]IITF.CI'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
OZvnZ ]umklumd on"ho shall be wmord.to mblic MODIFICATION
DPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Llccnacd Pndcoitml 2111-INXIAMIS IMPROV EV ENT SWIMMING POOLS
-a OWNER-BUILDER DECLARATION OVER 1001)AMPS [I PATH RENODEIIIIEPAIR�UII.IOLTDON
K Q I hereby Fri.Ilial 1 em exemp from Ilio ConlraCl«s Lianse Law for dw,
ftik O G O Gdlwving reason.BSc on 70315.Huaiteas end B'rule,inn,ctr]e'.Any c'ay or mmntYSIGNS 1!hECIXICAh El OTHER
ly 3 LL H whmh reyuirea a permit Io cnatucl,once Ion"vc.Control OF attention,
any.fterc
0 prim to iB tomemee,also requites the applicant for wch pmnit to fk ailment TD
a aiFnseSPECIAL CIRCUMISC.
<.} thathe is licemed punoto ,,mepovisitms of the CumraOint'n Lion.¢La.(Clo,mr9
aa� (.nlmnencing wi,h Section 70(1 Dimow.3411m Itmuress ulx]Pmfmaions Cork), TEMP.MOOLR OR POLE INS.. COMMERCIAL:
a a o oC
that ho is Cxcmp,IhvCfrom amt Ohl hook for Ili allege)eumpdm.Any vio mum of Cl NEW BLDGJADDITION ❑DEFIOLITION
^'LL Semen 7(111.5 by any epplicwt for a Peit rmsubjects the applicant lo.civil prnally of POWER DEVICES
-In [I TENANT ❑FIX)D SERVICE
nx1,as manfivebu Mred odiumyemp.
G.Z+Q IMPNfIVEMEN'I'
ASO ❑ La.rrwer of the Prupcny,ur my employees wim wage va heir role cumpenatinn. SWIMMING POOL ELECTRIC
WIII Jo IM1e wort,oro the]IN:Iurt it Ito imetded W offered fm sola(See.J(DJ.Busircss ❑OTHER
6 3 and enty I ons Cede, The o,o, Clar'a Liana Isar des r.tt apply In en mo of OVII.I:TS-SWITCHES-IIkTURIS
p,,,.o who M1uilJsorImpmvS sooh uMwM1n Acesmuchworkhimwlf nIlIfor
hi,,,.o emPlgem,motion) i <,,,.M1 impmvetrcnB art tux iyamofi m of ion for NEW R[SIUIN'1'IAL ELECIIi SQ FT.
ale. .miv' ,ills:buibo liorimpovement imet be
noneth or in"',
SQ.FT.FLOOR AREA S/SQ,FT
mrbuikkr will havr the M1urJcn of Pnwing mm he did not hullo aft improve for Pur-
ptm of r:da.t IL /�G�/
O B,to usurer M do pmpm ny aeacluvvely voinneting with hiet It.to 'T(yfAl_
ne.I the project(!kV.71W,fllaurc.a and Pntfessitma CNet)The Cortlrstrtrs 1i-
w:law dosnxs,my collo owrerof Pmpcny who Into impmvca mcrcon.and Q'Fy, PLUMBING PERMIT FEE � '
wM conlr:Is for wch pnjals with s cnnuaclogs]lilemeil Pulwam Iu t]e Commen✓x
Liccnsc Law, PERMIT ISSUANCE
I em esanptmi Sec. ,11&P C for this reason
Owner IFaa AL'DiR-DRAB TION
IRKERB COMPENSATION DECLARATIONBACK FLOW = .
' 1 M1ereh) Grm undcr peoA y of tcrjury ore of the folnwing declatmiom: utGI
-
thetaladwillnuimainaCanif am of Cnmenl In sof-imus G.W�rAer's Canpen- DRAINS-PL R,RWF C —gfORItS TYPI!CONSTRUCIION
smimm as Ilmsil]e]for by Section 37X1 of he Latex Code,for tle per(mm anee of the
work for Whichdia print is iawi. FI(TURES-PITRAP
1 have nil will nufmlwn Wrker'.v Cnlnlcnw
nsetion Imueq as rtyuires]by See'ion
3700ofine Labor Code.lathe pdormvice ofthe Work forwhichmis prmil is LsaueJ. GAS-EA.SYS C_a OUTLETS OCC GROUP APN
My Worker's Canpnation Imumnc'e carrier and I'nlwy nuMv art:
Ciny
mnml. PMicyNo.: OAS-PA.SYS - (U)
Cl2RIIFICA'1'li OF P IN]7[ON IROM WORKERS'
COMPENSATION INSURANCE GREASEINDU.STRL WASTE IN-ERCEPI'OR
BUILDING DIVISION FRES
Mi,section intend but lcrnmplaul if the pntut is for ane hutldml doll.(SIIXn GREASETHAI'
or I—)Mi,
FEE
Iccnify that in the pdumrarecnf be workhr uM1ichlhis pemlitisis In ab
in any Con,a-ldl SEWER-SANITARY-S'tORM EA.2100 FT.
not certifier,certifier,any croon trlatulca w as to henxne ject Ilr Wwkeri CumpGtIJiGY FEB!
O Z whom Lmwa of California.Dale WNI ER HGI'ER WNPST/ELECfR
Z APMicum GRADING IBiE
to
NOTICE TO APPLICANT:If,alter making(his Cenifcare of Exempmn.You soul, WATER SYSTEM?RFATNG
bttnme ohinct lode w'arkera Com'moni'n Pr-Wort;of the Lahr Cale,ytu nlou SOILS FEE
hrE illi comply wish ouch Pro wore,or thio Peron,n1,nll h:d-o"revoked. WA'I FR SERVICE
aQ
CONSTRUCDON LENDING AGENCY NEW RESIDENT AT PIJNH, SQ.FT PAID Aln Az
(J Q IM1or hie Ermthat r...iis to(See,3(o Cing .) Erz the performance of )al RecciptR
V. 1M1e walk for which(his pcnnil is InsucJ(SCC.3lXl].Civ.C.)
Q U Intro Name TOTAL:
V 1<Ma' Andreas TOTAL:
W
1 I ccnify that have mad this apllirntinn most state Out Ili above inf)mllaiml is BUILDING .1?
IH. N Correa.l agmc to comply Wim all city and county ordimmc'es and stain laws miming to QTY. MECHANICAL PERMIT FEE
U Z buidingcrmslmotiono thereby Mlltpllre re matertativm oflhiscityto enterupvn the SEISMIC
aMrve-mentioned pnlpeny for impaction lml . s PERMIT ISSUANCE
(We)agmc nt aav'e,indmni
efy it keep hnnea nlthe City of Capnilw agm r. HLIiLT IC FEE
Iimillooi-jldgmotta.cots and Capnaas w'h¢h maymany way accmc agino said City ALTER OR ADO TO MECH.
inter gunnccof dei granting d this pttmil. PLUMB. ,FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WHII ALL NONPOINTAIR HANDLING UNITpO IEn)( CIONS
SOURCE I!GUTA'IIONS. /y///yyySSl MECIIANICA E
l ��YVJ AIR HANDLING UNIT(OVER Ig(Iro CFM) CONSfRUCH( X
Nwnao c WlicmWComnanrDue EXHAUST H(R)U 1 HOUSING MITIGAI'1\1 FEE
IIA7A DOUS MATERIALS DISCLOSURE
Will the applicant or future betiding raxvparn axe nor harvlk IntamJnua mlucria] HTATI NO UNIT(TO I Motion BTU)
ax define)by the Cu,nir.n Mun kipml Cale,Chorl9.12,and the Ilcahh an]Safety
Cask.SnnLm 25592(1 HHA'IINC,UNIT(OVER I(Xi"H'U)
E)Y, ❑No VENA I,ATION I AN(SINGLE RES IU) PAID
Dam Reecho x
e WII111a wr somlorfutum Funding by di
irQutx Jcv'mmemont BOILER-COME(JHP OR 1W.W)Bl'U)
mil hvardra dr Mltumiwnlx as dcRled by IM1C Hay Area Air Quality Flawgemcnl TOTAL
Dimnn4
❑Yes No
BOILER-COME(OVER 100.001 B'IU)
❑
I have lad the,hvaanwB mvaon.nequirttrcma unvlm Cluptn h 95 m ie Cali- AIR CONDITIONER ISSUANCE DATE
Erma Hcallh&So Cud:.Sono ,255n5.3533 anot 2554.1 utdcmmrd draft tribe NEW RESIDENTIAL MECIL SQ.Il�
huisfing docs not or-i ly haven Imtam.Il ov it ix myrynaibiiny to runty he tr'cll,vmt
offt rn uiremomo;which must to tort per to Lvsuarce of x Conifem,of(keupmo
flosomviror minim Nagent Uu1c T( 1'AL: hSSUFD BY:
OFFICE