S 3231APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPER'FINO BUILDING - FLECrRICAL
BUILDING])[VISIONAPPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENI'IFICNUON
PE ff No.
� 3231
BUILDING ADDRESS: n
SANITARY NO.
APPLIC'mON SUHmi rFAL DAPE
ini 8I , o lie CA�n��a� CA 9<snr �1
�- 2C r-97
OWNS BNAME; PHONE -
NNc' 17LIOA ONE,4-(;UtJE'
"I NAMP,: LICNJZI3�
t7
NIC
C09FROL0
ARCHIEC I NG SHEI : LIC NO:
ADDRESS:
IZ4cGA 'L-4
CONTACT PHONE
BUILDING PERMIT INPD
/� /1 O _
/.TLE6A!/
❑ Colwltant Ftts Paid by Applicant(Initial)
BLD MLECf FLUUyME ME❑CII
El [9
LICP.NSPA COMRACTUR'S UCCIARA1l)
1 M1ertM1y a1Bma mw 1 alar 1'Kcn•c1 adder Irtm+iamn. lar Caper 9lnmmmming�
QTY ELECTRIC PERMIT FEE
JOB DE.SCRIPI'ION
PGHMITISSUANCC
with Smitm ]IXp1 of Diviniun J of the Hu•in¢a ab 14ufasiom Rde, uml my rims, in
atullfrevo,"cR �/ y^
C S
RESIDENTIAL:
❑SIUWI. ❑KUCHFN REMODEL,
APILIANCES- RISIUINTIAL
:;? ✓d
,)all 1.5-1 Tun mel •E&TC&I
ARCHITECTS DECLARATION C,
I mom .band uty plun,,hall ho urcd m public rccont,
❑ ADD[ TPON ❑ PLUMBING RE.PIPF.
❑MULTI -UNIT ❑NTRUCIT)RAI.
MODIFICATION
PANELS
UP'IOl XIAMIS
❑INERIOR ❑CHIMNEYREPAIR
IMPROVEML'NT �SWIMMINO POUTS
Licrnwl Pmlcsiional
2111-IDXIAMPS
OWNER-BUILDERmDECLARATION
hrmaclayeaso affirm on l nm cBuntt from the Comms Cov Liccnre ty1W for the
(Salina 7031.5. Hu•ima• mrd ams fide: Any city a county
tollowire
❑BATHREMODEIII CLAIR �DEMOLII IN
T(!'
OVER 100 IPS
SIGNS HLIiCI'IHCAL
which tum, a onvo ve, ik in rmmr nY •IPKolre
require a permit ne elan alucr, imfxlave, dcmm .,
SYECIAI.CIRCUITIMLSC
I,
ra the vah Permingonn,c gml wuonum
,in, Atha,
pinnuaIneused
�T
that he is inmemllcam
Iruluunl to the fmwiv Wo of the C-mltmel.. liccme law (Clvper 9
Pu.wrt in
(con cia,,a Scdlobinantl of oNKBusincwsanOf Coke)
TEMI'.MCI 'CR OR POLE INNS'.
COMMERCIAL
he is exgwilh
umn. Any vi bonof
bank for Any vifln:n of
Wt he is catnip aany ape and the buil for dK elkgN eaemaut
❑ NEW BLDG/ADDITION ❑
POWER DEVICI'_S
to
noc,irn ]Hour by nnyopPllcanl lnrn 100). nuhjcum the uttlkanl lg acivll florally of
dal more dw five bodhed J011gn ($]n0).
.i I,a,lu, rgf,he ithearnYrr mymnployaswilM1wnal losmcir
i•dNs lc(Sm. 0,ltpcnsminn,
(Sec.]pW,
will JoaIle Wark, mvlthehat of
FOOD F.RVI
❑TENANT ❑IOOU SERVICE
OTHIER IMPROVEMENT
❑OTHER
SWIMMING IYK)L ELECTRIC
Lkcn,orow Ric wms
Cor not toan
and T'ry,winrn•Caki,"o TM1c Crntmencn Leenrc Law, ucuuk
OUILCIS-SWITCHIS-IrU'NHPS
hir ifr tmrof
MnpmlY wMr krida m imttovtt dnen, ami WM Joe• euh walk hinuclf m through
hie own employee\, Irov'uld ,hal such iminuu ments an not imenJed m offered for
sale It. bowever. the building or mpmvement is cold within me Yeerofeompknon.th:
NEW RESIDENDAL ELECIR SQ I.
SQ. II.00R AREA
LSQ.IT.
nm buidcr will ha•'e IM1c burden of Printing thl he did but henikl m imtrove for Pur-
pwco1 sak.1.
❑ I, n• Ower of the, leyen)', am eactuaively marina anp wr0 Beamed cesublelCO m
TOTAL:
momn the µnjceo (,Sec, 7(nW. to -ono,,• mal 1'mf—on, CWe:) The ConmKmr, Li-
mcWdm
wnesnnl'Iyannwnerofp rr'Who build• or imee tnwdKrtan. alQT'y.
PLUMBING PF.RMR FEE
whet t u! sucM1Fmj:S:d wilM1vewnlnelu(n) ecnuH o rrwmnlln111e GmarJloM_e
PFJIAIIT ISSUANCE.
Lknoc I aw. ac
7 1 onmutant, odder S. . II h P C far thle ren
aw
ALTER - DRAIN k VENT -WATER HuO
O W her hale
VALUATION
BACK .LOW PROTECT.I)EVICE
WORKER'S C'O.MPINSADON DECLARATION
_p,L
'C:�5Ba
I thereby affirm it er febalty of lcrjury me of dre following 6Kluuimo:
Cif. �1
DRAINS-IR.00R,RCR)F.AkEA,COND,
❑ I have and will maintain aCerifvmcofComcm m aef-inner, fm Workcr'e ComEno
:mou POV'oled fur by Sadon 3700 M doe Talar Coale, flat the perf., of al
n
STORIES
CONSTRUCTION
rk for which thio prom., ie iuuoJk
ILM URES-PCH TRAP
1 have and Will maintain Warkmra Comlrns tint fireem ri n• sl by Salim
Xlgf the lulrn COR, lar the perfmtmoecofdn work for which thisl'cmdtls mo,d.
GAS -EA. SYSbM-I INC. J OUTLETS
OCT:. GROUP
APE
My Wo 99 mminnlnmunce cunier aml Wl�]' a [[��
Cvm-err Work
fro I'oliryNf:%1 Int V
GAS-FA.S1;SIM�OVF,R,IHA)
CERTIFICATE Oir EKEMPI ION IE OM WORKIiRS'
COMDNSATION INSURANCE
(REASEINDU.STRL WASTE INTERCEPTOR
BUILDING DrvISION FP,P-S
pctit i. tax ortchurdnd di (SI W)
('Ibis uKliim duel not hcnimpinNif the m
m kss.)
GREASETRAP
PIANCIIECK PCE
.artily.hat in the pan'Lmwrccnf,he work Grwhich lhia l.`rmit Li.cwdl,laM1all
dN cmillnY any luso, in any manrrtr sn Iobp� �' Wmlrfi Ctmpcn-
tt
�
SEWER-SANITARY-STORMEA.200FT
INERGY TEL!
WATER HEATER W/VIM2LECfR
scion Lnwa o��JJ��lifo n Uum / b 7 /
Applicant ,JIJ� LXI TFR MA :5, 711
GRAVING FEE
NOTICE TO N'PLICAN'DIf. afar making this Ccnificam of Excarrirn, you 0ould
becare wbjaa to the Worker's Compemmion ravuimu of the I,abnr Cdk, you rount
WNI I;K SYSfHMT RHA'DNG
SOILS FEE
Inhwiah arnplyw'iboch proomons-bok Pcnit fall 1w dcmmed revokod.
WATER SIiRVICF.
CONSTRUCTION LINDING AGENCY
I hereby affirm Nal thele la'amm,mclim leddingagency. ar the µafimaarke gf
NEW RESIDENTIAL PLMIO. SQ. PI'.
PAID
1
Rec"at#
the wank fm which Ihia permit is issued (Sec. D097. CV. C.)
flatter '%Name
f<MxN AdJrcc.
TOTAL /
1 eenify IM1c, I have,O,J,hln attlicelinn and Mule fta the at int..
III LI N r
QTy. MECHANICAL T'ERMIT FEE
urta.l agreemmmply Wilh all cagy ord rnumy laNimn<s and Nue h.a reWin�ao
buiMinecmamminn, and hcrchY amhimrc relrzcunu,ivrm nf,hia lily locmcrurym ted
S Flit$
PERMIT ISSUANCE
above.mommorwd prtrycray, for innptcrien purio,,.
(We) aerce to an , idlcmnify lard kcp ho rob,, IM1c Coy of Crivonim against
1? WC fJ 6
(•I v 1999
ALTER OR ADD TO MECH.
1' MHING IFF,
llubdnlm,judgments. a Bund espcnscs wIbwh may in say wav mcruc againu mid City
in'
n dau:qurdc nfl .� i•tcmhl.
AIR I IANDUNG UNITOTO 10.000CFNE
Ali NICALFPJ?
AVI'LICANfU .ANI W ,C LY WITH ALL NON -POINT
SOURC' F S,
AIR HANDLING UNH (OVER 10,gp CIM)
C
v
Si lurch Attliconl/Cnn Dom
HA9ARDOUS MATERIALS DISCLOSURE
IiXHAUST HOOD(WNUM)
HOUSING MTIIGATION FEE
I I Er,ATING UND(11) 11Xl.k)o HTUI
Will the applicant or future building oceupum vmrc or han.le havaMtus maher.ul
v rkf ml by Ne Cuptnim• Municipal Cab. Chatter 9.12. ark the Health vrd Safety
I
C 1t. Satin 25512(,,)? __</
LD ye,, M
Will dam heart lar forum huildin 1 uw Nur J[VKet WhicM1
app grccuµon egwpmc
emir harardma an conformation, u defrKM by Jx Iiay Arm Air QualityMmmgemrna
Dludcol
C3 Ya 0
HEAFING UNIT (OVER 100'roo H'I'U)
PAID
Oilt Raeitt M
VENIT[ATION FAN (SINGLE RESID)
BOILEIR- COME COHP OR 11X1000 IIIA
BOILER -GDAIP (DYER 100,00(t) BTU)
AIR CONDITIONER
I have real the, hvxJrru maaiata reyuirtmcNs neater Chapter 695 of the Cali-
ISSUANCE DATE
NEW Ri sunNf1Al. MECH. SQ. 1'I',
flame Ilralth.& Sabo Code. See 255(15, 25511 and 255;1. 1 nd4 'mrd that if IM1c
him" gllre•dN lyha. I.Ihat it i•mYrt•paNHM�f�ItY doe rnculwx
i
(� /
�`t^11rCCaidfY
Imamnl'r- GlJ�7
ofthcrory�i /
ISSUED BY:
Chvnrn, auahomeJogrnt Dale
TOTAL:
OFFICE