S 0859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF(:UPF.RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLIIAIRINCMECHANICAL S 0859
BUILDINI;PROJECT IDENTIFICATION
BUILDING ADDRESS: �� , SANITARY Na. APPLICATION SUBMITTAL DATE
Ow . NAME: ra6jHON}::/-/ - CO A O.
/,�./'1s//) NIC CONTROL
ARCHffECf/INGINEER: LIC NRA D S ❑
COKfACT: �iw J PH NE. /_ BUILDING PERMIT INFO
- '!�/ — 1/ ��/(� ❑ Consults nt Fees Paid by Applicant(ItIt xllw E cl' PLUMB M
LICENSED CONTRACTORS DECLARAI'[ON QT y ELECTRIC PERMIT FEE ❑ JOB SCRI0-
I thereby affirm that 1 am licensed cacti,Ism"inns M Ct",9(canmrncing
ON
QZZO with ScclMm](XM1)01'Dlvoion]Ofthe Busircr_< acil'ol, au Ci ,undm licaVie PERMI'i'ISSUANCE R SIDENE TIAL.:
FWp-;�F in full fm,e ante(pg/r"a/��J^� ❑SEDWI, ❑KITCHEN REMODEL.
6ZU Lltt"1p� -J�'Ta7� Lw'� APPLIANCES-HI!SIUUNHAL ❑AUDITION [I PLUMBING RF.-i'IPE
r z w UU`�CTS fJECI ❑MULTI-UNIT ❑STRUCTURAL
Z p✓=j Z L un&rrmtd rmy'plum shall he ural m per ' retards PANELS MODIFICATION
O UPT0200 AMPS ❑1NIERIOR ❑CHIMNEY REPAIR
OZ
E.4 A IJcrnscd Podk,,.owl 201-INX)AMPS IMI'NOVIiMEN'1' SWIMMING%X)IS
C Y7; OWNER-BUILDER DECLAHAIION OVER IWAMP5 [IBATH RE-MODELIREPA ❑DLVOLRION
5 Q I herchy Alio that I am c,cmpt from the Cantmctor'v Licenm Low fnr Ne
k 06 e
L V rnllowia,�'n.(Sect csa]1315.Biennia.,As,!Pmfem Calc:uinCaAny city or cwnlY SIGNS ELECTRICAL OTHER
34.� whicM1 require,a permit to camtruct,alter,im ,imrs dcar iM,or rgWr,ny strvnure
'i
C� prnxwiu luuarcc.ulro r,quitos the Applicmt Bmswh Nrmit to l ilc ao,oadsmmntcnt S I'ECIALCIHCUTI'/MISC.
'� Y that the is limned pursuant to de Povnioro of Nc Cmtracrdsixrnu Lzw(Chatvrr9
R� COMMERCIAL
,L man ,,irci oamn S,,bPon(gl of lh c,,for
o(NC Busineu andoa.An,iCNgor TEMP.MSCIeR OR IrohI?INST.
a L e rhm he is e,emP Ney.,Ai and rhe bmu ler dra AIkgN pPicriim.Any violuion of ❑NEW BLDG/ADDITION ❑FOOD SERVICE
^,y ain mo,dorm by enyapplinmfor apcmdt wAjm.uhe vpplicem tov civil perwty of M)W'IiR DEVICES ❑IMPROV C]FOOD SERVICIi
n mete chin Eve e,hirrinad
Empa Jrdlan ya. ;1. IMPROVEMENT
F?Q QI.0cacti
so,L,Jle ixapeny.«my em eorle with xAedfortic(Sicero .Bt ion. tiWIMMING POOL ELECTRIC
jd lG`. svill"dothuw«1,Coit rk, Th,
is nmmtoMNa I..sjlrar soleppm,]UW.Husirw�. [I OTHER
W � aul Profevka„Cn4:TM Contracmr's licmte I<w Jues ru aPdY ro on mvrcr of OIIU.ETS-SWITCHES-FIXTURES
pnlpmy who builds or im"ces ffie, ,aM who does-ch woA h m.wlf or Umogh
hLs own emploYCR pr idBl thin torch impmvenena me not ime M w nRcrAl fnr NEW RESIDENTIAL EI —I'R Q FT SQ.FT.FLUOR AREA S/SQ.IT.
craft.If,howeser.be Wiliingw imla Aa,mcnt is sold within acre In ofc.PMim,the
ncrb ldmr will hava the hurelcn of pnn'mg that M1edid red hudd or improve for For-
P,se of salcJ. TOTAL:
❑ 1,m owner of the propeny,an,escicovely uomraefmg wish Iisxnscd lorm"Inu to
c.t Ne pmjat(.Sac.](114,Husirww and Pmfil siau Code:)Tim CoNrscror's I.i-
cros,L,w does odaplly tomowrerof PreanywM huiilsor imPrwcs Nermn,and QTY PLUMBING PERMIT FEE
who eotraets for weh pmjecis wilt a conwctMs)licensed pennant to tha Contractor's
IJcauc L.w. -ERMIT ISSUANCE
❑I ant excmP racier Sm. .11&1'C for this rcav
ALTER-DRAIN&VENT-WATER IIA) VALUATION
Owrcr Da(c
WORKER COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICP.
IIhachy e,m,urdn .try Mperjury ore o(the milmvinghave mJ will maroon.CeniGcmcul Comm to,11-inwrn(ar WIAa's Compcn- DRAINS-PLOOH:RWP.AREA.CONII. STORK} TYI,U CONSTRUc1nOh
n,u P,viriad for bySemon 3]00 of the IAbor Coda,fox rhe pedtxrrerrce ofole fnr whieh this pcmut is i.atrN. FINIURPS-1'I?N'fHAP
have and will mlnrvn Workeh Coallrowiun Itauwx,as requir t by SenimGAS-EA.SYSTEM-I INC.4 OU LETSf rhe Lehr Cn efarthe artormm ofthetAfnrwhimNnpe TniuN. f1CC.GROUP AIN
Wor tore 1 c d folic ,,!2:y'� /.Y.�.J�/4PolityNnyn_, a7`u' GAS-PA.SYSTEM-OVER 4(EA)
CERI'11IC Tli 01'CXEMP`HON FROM WORKERS' GHEASf%INDUSI'RL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEESGREASIiTRAPs.) YLANCIIECK FEIi
I cmify that in the parfermai ofthe work for which this permit is imocJ.I dull SEWER-SANITARY-STT)RM P.A.200 FT
nnploy any Darvon in any nunncr,so un m Itccwrc subja,m the Wo4crs'(:.In- ENERGY FEE
Z avian taws rR California.DAA WATER HEATER WNFNUFlECfR
ZD APNi.ant 1 GNADING FF:Ii
NOTICE TO APPLICANT:If,After making this Cenifcate M E adrr it n you should WATER SYSTE 1O`REATTNG PEA
F [n h,omc subjmr to ole WoAcrs Ctxrtprnution pmvisionx of the labrrc CNc,You must SOIUs PE F1
frnhwiNctmplY wilh welt Pnvisxms err Nis permit 0h 11 hedermcd nvokm. wA'IEH SERVICE
C+. CONSTRUCTION LENDING AGENCY NF.W RESIUIiNTIAL PLM O. SQ.(T PAL t F
UO Ibcreby ellirm nut there is,emwoctim letdiog agrrcY fav Ne perfrxrmrrce of
ole ,fu whi,M1 Nix Dcnnir is i.crtN(sec.AYJ],civ.CJ
OF larder's Name t
LUTI 1.cNn',Addreu TOl'A I;
a I ttnlfy nwt I Eta maJ this upplircWim vol rate that If.Above iarmank.,it BUILDING TTI?
Z2 ,meet.l agrccm comply with all city and coungoNimcce and xoom
nmws miming to QW. MECHANICAL PERMIT FEE SEISMIC FLS
V Z building ronstrvnio,uod herchy auNanm rtprawinetvc.n(rhis nrywrn¢ruP'n tom
W ,,,rcntimed pm crry for inyccamr,pu,xsa, PERMIT ISSUANCE �O ELECTRIC FEE
(We)agree in save,indemnify and imp hamJex,Ne Cry M Cupeniro ngainr
Wbil'niu.jWgmrnu.emu erd expenses whicM1 navy in anY w'eY ucervc AgdntxuiO Clry' ALTER OR ADD TO MUCH. PLUMBING IIT
in caosarluertcc of the Partial of it Neled.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(11)ITSXI CFM)
MECHANICALTE
SOURCE REGULATIONS.
AIR HANDLING UNIT LOVER III,IXXI CITI) CONST'RUCT'ION TAX
Sigrurvrc of ApplinrulCmtrenu Data EXHAUST HOOD(W/DUCTT HOUSING MUTGATTON IIT
IIA4ARIJOUS MATEIUAI S DISCLOSURE
Will tle,pplieerx or from,attaching wcawd Sime or handle hii N nureriel HEAD NG UNIT(TO I(A."BTU) a,
vs okfnN by the Cupcni no Mmnicnp tdc.Chi 9.12,ami he Ilculth arc!Sul cry
Code.Section 266321a)Y HEATING UNIT(OVER 100.000 BTU)
�Yes PAID
VIiNT'IIATION PAN(SINGLE RISID) Date RcttiP e'
Will d,applicant w formeWi,mg occupwr use equipmem or de,ic,%wthich HOLLER-COM P(311P OR I II)JXXI BTU)
nit lumrdie,:ur,nnwmitwnts rn I by the Buy Arca Air Quality Mnnagen rm 'HTIAh:
Dlurict^ s No BOILER-COMP(OVER I0(LO00BTUI
I ❑Yee
I have read dtc lwarNus materials requirtrrmu.M Chapter 6.95 M the Cdi- AIR CONDITIONER ISSUANCE DATE
I tnnir Ilculth&Safety Gds.Sections 25515,15533 artd 25534.1 coder% Nati rhe NEW RESIDENTIAL METH, SQ.IT.
Mriwirio ayho,ti em t.dutitinmY@P'resibilitY to 'f (O
orrhmuu ncnmr prermivwumwdu COcu Y. ^
������r thtxir���cx///llAgrnt Ilam TOTAL' ISSUED BY: I��r-� 1 `•w
OFFICE