31118 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERFI NO BUILDING.ELECTRICAL PERMITNO. J(^ 111
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
NAM11.DIN'ADDRFSS:
BUILDING PROJKCT IDENTIFICATION
�'�' SANITARY NO. APPLICATION SUBMITTAL DATE
NEWS NAME: 7 7 sillNH'S ®- PHONH: CO�5ACI'OR:S NA '25Q �� /O.
(/ J N/C �F CONTROL#
e ECT GI 9D��,DRESS' YS-2??
u ) —C✓ l,6 /O acBoY los U/s4/ft IjJ�J
ONrACT:, PHONE: BUILDING PERMIT INFO
Rig U' ?64-0/77 ❑ CI nwltant Fees Paid by Applicant(Initial) BLDDDPG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ` ,
I hereby alarm that I am licen.ad enitr pmvi.dons of Ctaprer 9(commenein QTY ELECTRIC PERMIT FEE
s JOB DESCRIPTION
aZ dI
7:"X )MDwi mi3^fba Business and Rvfasion.Cods.and my fica ais
OO PERMIT ISSUANCE WL ❑KITCHEN REMODEL
Q CD.)tj DENIIAL
m`B 213 Sac.#
_ CmtnaaAPPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
R I 'ECT5 DECLARATION PANICS ❑M�LTI�JNjf ❑STRUCTURAL
ZO,f,Z plm h <usnl v.pMlic retortsT' f\ 1 MODIFICATION
OZ—O / UPTOMAMP5 ❑INTERIOR ❑CHIMNEY REPAIR
F tW l ,
`yam 6 1 hereby aftrm OWNER-BUILDER
1 em<ael�EfromF M.Comm,".� License Lew fix the OVER IIB#AMPS fikViF{(F�) IR ❑DEMOLITION
x 3 a U folbwing reason.(Nation 7031.5.Boniness and Pmfesaionv Gsk:My coy or cnumy SIGNS ELECTRICAL ❑OTHER
u] IL which reyu'ora a permit to croswe4#lar,improve,dermlisb,m ne sin achy swetwe
F'-O pia to its issuerhoe,alw mryim be,"icam for such permit to file a signed!wtemcnt SPECIAL CIRCUR/MISC. .
} Nu he is licensed punuum to the pmvis iifthe Cmuacbws Li.Law(Chaper9
(comnencine with Sermon 91100)#11vmm 3 of the Basirexemal Pmfd vsiom Code)or 'TEMP.METER OR POLE I COMMERCIAL'
d y o K Um he is exemp tureen n sod the lusis for tM ulleged exemption.Any volatio.of ❑NEW BLDG/ADDITION ❑DEMOLILON
iLLfl 4• lelion70ll3by—y,Mliceruflap illubjc"l Veli ll,acivilpenallyoI POWER DEVICES ❑TENANT ❑FOOD SERVICE
E Z mY Imt mac than five hummed dMlars(SSW).
SQp ❑I,v owner of the pgmy,amY employs.wish we�es ea Heir sole corhpwaim, SWIMMING POOL ELECTRIC IMPROV
❑OTHER =�`
will do the souk,erd de wucmrt ix ml inteMel uMlered fa rale(.Scc.IUW,Buni�s
and Pndcssims Code no Conuacmr'x Licence Law dma mg apply m m owner a OUTLETS-SWITCHES-FIXTURES
pmpeny who Wilds a impmvn diem o,ud who Nen such work himself a Ihmuph \
his ws.empbym.Provided but soh ImpovemrnD are not im meal a oRernd for NEN'RESIDENTIAL ELEC R. SO Ff.
salt.If.hmwevcr.ti Willingerimprovarcru is soil within ale yrs ofcompinien,the, SO.FC FLOOR AREA S/SQ.Fr.
n.W ildcr will have de boNrn of moving Thal le did ria build or Improve Rso
j-p -
pawofwle.).
❑1.v owner of he mpony.am exclusively cunlractine with liccnsai cmtrattun to
rnrutrutt Ne p^'jett(Sea.IOLt,Busimcm;and Rmleubm Castel The Conuamars Li.
acne,Lew docs Mapply toanowrrrofprmpeny rho builds«impmes N.mm,sod QTY, PLUMBING PERMIT FEE
who aohh.n for such projects will acomnaa(a)Ikrnad Wnucam to No,Cmvme,"
Liana law. PERMIT ISSUANCE
❑I am esemp under Sea ,H&P C for Nix lnwn
Owner Dma ALTER-DRAIN&TENT WA ) �)VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW'PROTE .DEVICE
I hereby affirm under stalty of pajay me of the following faclemlhvu''
❑ I hve amt will muialmo aCenificate of Cene,m malt-im me for Wotkels Compen- DRAINS-FLOOR.ROOF.AREA,C NII.
sa m,u pmvidcd fa by Sm on 3700 of the Tabu CMe,f«he perfmmae of the STORIES TYPIi NNSTRUCI'ION
work fa which Nice pemot u issued. FIXTURES-PER TRAP
❑1 cove and will maintain Workc/s Cmnlpe vaddon Irounmce,as o,,Pl by Satim
37Wofdatabos Ctdc.forlheper n¢oflhcwukfvwhichlhispcmulixiu . GAS-EA.SYSTE.M-IINCAOUT OCC.GROUP APN
My W"orL,Compmmim los mena camcraryl Policy number mm:
Carrier. Policy No.: OAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF ETIMU ION FROM WORKERS
COMPENSATION INSURANCE GREASEBNDUSTRU W'ASIE INIFRCEPIOR
(This anion recd not he emopla ed ifth femmit k for ort hundred!d.11us(SH)(I) InUktuo )mSION Mfi-S
lc")I GREASE TRAP PIANCHECKIE�
1 ay soy tit cedie any mormar Mlle soak ntwhich Nis permit is iv'Co l ball
runs,Law wypersm in any r®nrcrwuwhco�.wtyxlmde Wrckers'Canprn- SEWER-SANITARY-STORM EA MO FT. ENERGY FEB
Q z satins,Laws of Califam;. One WATER HEATER WNENf/ELEM
z 0 NO Tx'^nt GRADING PEG
N NOTICE! by APPLICANT.If,C. making tha Cikimi,of
IlscntpCod, tMwd WATER$V,STIiM/I'RFATING
b" becutrc acubjat to be WurkcYs Nmpmwtim pnwixims of the Iwlwr Code,yew must SOILS ME
faMwiN comply with such pmvssioneu Nis permit shill be deemed mvok�
4 Q WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO.PT. PAID
V 0 Dam etp#
O � ti note far which Nis pmdt u isxted(Sec.3091,Civ.C.)
F'V Lender's N. TOTAL
Lewlefac AdMss TOTAL:
1 comity that I have read this epplicatim W wm that tie above inrarmuim is BUILDIN
r7n c000e" I agrw to comply with all city sod comity mdinnnces ntd state laws rel iloi In i�
V w1- Wildin trunion.vtd hrcb tho. y Dma QTY. MECHANICAL PERMIT FEE
Y cons you nepracnmtivex of Nis til memeru the SEISMIC E
acbovc mrnucml topx formyecnm purposes. PERMIT ISSUANCE
(We)acpxw cost,indemnifyand keep may
in m the City Me asmim acgalw [LECT0.IC FEE
Ii cim ies,jW(nrcms,rnusind.f this w'hicb may in enY way rccrvc egalvtxadCity ALTER OR ADD TO MECH.
im mLICANT ofthe RS IANMthiopermit PLUMBING FFili 0-7
APPLICANT EUNDERS'1'ANDS NU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURS-y ION$/� MECHANICAL FEE
//` /� 3-2� — y� AIR HANDLING UNIT(OVER IO.000 CFM) CONSIRUCEIONT
gfialoo,mfAppl wC..mr Data EXHAUST HOOD(W/DUCT) HOUSING MI'TIOATI NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will doc epplicml or fuwm WilNngarupant9ucahvWlc haaaNcus mitcnal HEATING UNIT(TO 100.000 BTU)
as defined by We Cuprtim Municipal Code,Chit,n 9.12 acted the Had"Sumer,
Crile,Section 25533(,)1a-��� HEATING UNIT(OVER 100,000 BTID
❑Ya lzlyo PAID
VENTILATION I'AN(SINGLE RESID) Dae Rc
Nill Ne applicant m furore buiMEnII rc.vpwt use�uipmenl ur Jevica which BOILER-COMP OHP OR 100.000 BTU)
mit h_=a c a'u mruaMl-..es defined by the Bay Ann Aa Quality Mamgmcnt
istrinl BOILER-COMP(OVER 100,000 BTI!) TOTAL
❑Yes �J:o
I have rtaJ Oe n.,...uws matcriulx so mmtumts unlcr CEvper h95 of lh Cu,_ AIR CONDITIONER
ISSUANCE DATE
lamio H®IN&Safety Cwls Sccwnx 2]505,25531 w125]3J.1 urdernnrd Nu if Ik NEW RFSIDFNI'IALMECH. SO.FT
be
moo Ironcumwly hive•team.Noro ismyce N.CORymunifythehavpam
M de roqubrneaa whicM1 moa be met prig m issuene M•CmiOcale M Oa'm'a^cY.
6wrcror mete'ad vgcm Dere TOTAL: ISSUED BY:
OFFICE