S 1574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OI'CUPER'PINO Bt.LDf:NG.ELECI RICAL PEIgi I No.
IIUIIvDING DIVISION APPLICATION/PERDIIT DING PROG-MP.Cl1AN'IFIC {J 1574
mnl,Dlrvc rrso,nacr,l HtNrD'Icnnnry
a
BUILDINGAPLARF • , SANI'I'AItY NO. AI'YLICAI']ON SIIBMI'I'IAh UIi
AT
Q1�1��
� ��
OWNER NAM1 " �(�
P110NH: CONI'12ACT(lIfS NAME: LIC NO:
f ` NIC CO1N/l'IL
ROM
*' dHl'IECIIIiNGINfaig: LIC NO: ADDRESS. ❑ ��1 �{V t
CON'IACI': HONE: - BUILDING PERMIT INFO
�� `- A�Z` ❑ Consultant Pees Pair)by Applicant(Initial) BLDG HLCCIPLUMB MECH
.ICENSI D CONN FACTOR 5 DECI ARAI ION QTY. IiLGCTRIC PERMIT PBC
n In by n fon t1 f sed d p ' .sof charm"9 aa: ..L mon, . - JOB DESCRIPTION
Oq'Z wtl S i nXI(PofDoi,rarn l of,lim Iftoincomel Net..has Qde.and my fireftSe Is - —7 'ID° "[
"100 n I'hRMILISSGANCE
FUe" full J effect. 'I'DWI, ❑KI'I CIIEN REMODEL
Q,UU License Cass Lirp APPLIANCES RIiSIDEN'UAL ]AUDITION ❑PLUMBING RE-PIPE
m Date Comfort.,
ARCHITECTS DECLARATION ❑h1UL'I'I-UNIT ❑STRUCTURAL.
D y PANELS MODIFICATION
zZ,z ImWorsandniyplinidall he real m,uhh,",oils
y_ UP 10 ALL AMPS ❑INI ERMIR ❑Cl I IMNEY REPAIR
-
;eI.Licensed i'.fessinnal 201-I10Aq AMPS IMPROVEMENT SWIMMING POOLS
OWNFIUBUILDIIR DECLARAIION
q q G 1 hereby n0i.m Stmt I on eaanpt Braniff,Cammnuh License Law for the OVER IIL)OAMI'S El RATIO RIih10DEURIiPAIk EI DEMOLITION
d06U
following Sertiot7031.5,Rasmus,and foams.ions Code An t ❑OtPER
x g reason.(, y ei y lir rvamY SIGNS ELEC'IRICAh
ul a W y wltich rvnulrus u perm"h vma de uh,c,improve,h permaM1,o,repair nay sm�ment
F.RiO� pia,he its censeeprsantto thetheahsapplicant forthe Chracterunfileasignel statement SPECIAL.CIHCtIIr/MISC.
mIy� thalhcislon, .dpurauau h.lhepmviaiinnfinecomrvelm's License Law fC Code)
ea I1Op1e is exgwhh Sxtfrom and the basis for the al aged cl.und Pn.Any vi Cnde)or TCMP.ABirER OR POLL INST. COMMERCIAL:
a q o q Sham he is 31.5 by
therefrom and the en for the alleged exemant to Any violation til' - ❑TEN BLDG/ADDITION ❑FOOD LII ION
SERVICE
11. Section 91q L5 by any uppliram tom permit suhjreu the applicant to n evil pen.Jmy ul POWER DEVICES
� rn ne t ht..five hundreddollars SMV). ❑IMPROV ❑FOODSERVICE
FZY """n' OFHIHRVIiMV:N9'
=060Lazowoenduddir,eny.or mYempinyccswithwageaaz Wcinole cannPrnxation, SWIMMING I'OI1LIihLCi'RIC F. isiland Jolhc wons C le; he Carr ,irs nor,License Law
dow,hot apply
owner of
❑D'rHHR
ae
tuml I'rnfu.inns Gmle:'fhe Conwe.ra Limns,Law dons nam apply fon vn owner u[ OU'iLEIS-SWITCHES-PIXTUItES
proper,who build,or improve,thereon,and uha does such.,,,it himselfor thai
his own employees,provided the s."h impnnxnmms toe nom intended or offered tar NEW RESIDENTIAL BLECVR SQ IT.
sale.It.however,dabuilding or improvement is sold within one year oerandeiam the SQ.FI.FLOOR ARIiA� 5/SQ.lel'.
owner builder will have the humanofpmving that he did not hand or improve torpor-
1,
m it named.
I,its owner of the property,am exclusively contracting with licensed common.
,cree L t d project(Sec.]IPJ,Busso,r el and ny It,,nn+d—,in.he Comment's Li- �k
w oel.aracis nmapply.mn itharafpnq.mny aha build..,unto.,,.Chianti,and QTY. PL BNG PERMIT 1 f•EF Zoo
whocommnsfornuchprnjrc0.withncomracnmis)IicanseA pnrsuammthe Commonrs -
License law. I'ERhf"1SSUA
❑ Iamexempt fouler Sec. .B&PCfar i on
ALTS - R &VF. A ill MAI VALUATION
No,, Data
n WOIdK.k;SCOMP9NSA 1'I DECI,ARATION I{ACK lie W P IPIi .DIA`IC
1 mirymE.nn order penally or perinp tieorrbefdmwingdeaamtmn-
]I have and will maintain aCciilicateof Comma.sell-insnrclin Worker's Camper- DRAINS-IIAOR,tafl Ali' C11NI1. S'PORIES 9'YPE CONS'1'RUCTION
..tion,as provided for by Seat on 3900 of the Luhnr Code,tin the performance of Lha
work for which this permit Is issued. PIXTU It1LS-PER T
❑I have vad will maintain Wnrkors Cntnlwnot ion Inauma e.ua.dflred by Section
3]Wafmhe Labor Cnde.forth"lnrGmnance oftbc work tbrwhattfea profit is issued. GAS-EA.S I- I '4OIL'LH IS OCC.GROUP APN
My Workers Compensation Insurance carver and Policy namher am:
Cameo: Pot icy No.: GAS 'Y :M OVF.RA
CItRTIFICATIi OF 9XEM I'PION FROM Wf1RKCR5'
COMPIiNSAIION INSURANCE .RIiASIJINIID'"R I. ':It QFOR
PUBS
(I hiasectina lived not becon.plmeditdarpernnitisfif ofnn 15
c limited tu100) BU VISION
VA- ?TRAI
lir Icsn) iZ> V PLANCHECK P'
Iccnify the inthe perfnrmance of Wework firtwhich Nialermit iliasueJ.l.hall SE R-SANITAR-CPSTORM EA.
nmemplay any person in aoymammr.omn,bacnmcaah3l,m set h,Workrri Compen- EN9RGY PI?I_ r-
aatil Lav,of Culifa nil,.Date WAIF. EATER WN.T it E
z0 Applicant GRADING FEE
N NOTICE TO APPLICAN'E IL after making do,Cermifinaen1'Exenkame,yon should WATERS Eton REAL I
vat i .b ,.t he Workers Cam tsminn fthe labor Cade, must SUIL$PEI!
ju pat praviaronan rvn
4L Q
hmhwith amply with such ProaWair-o hi, .it shill be deemed revoked. WATER SP.R
UO
CONSTRUCTION AGENCY NEW RIiS1UENT PLMR. SQ.P1: PAID .tc Rami,a#
1 hemhynfimithe there I,a anmmedon lending agency for the porfontin of
u the work for which this permit is issued Sec,3097,Cie C)I)
LL '�-' Lender's Nutue 'IOTA h:
U LenJds AJJrexn 1
A9 I cenify that I have read this.ppGemion and sate than ie above information is BU EE
4 (A "morel.I natal,to comply with u11 city and county nrdinanccs tand.mm le.,ra acing m Q'rY. ' MECHANICAL-PBRMIT FBF
U,Z builJingcon.a.ctimn,and hercby'vmharize representatives at thiscity tenter uM'n the SF.IS. 'EE
above ratified property for ins,actinn purpu.o.
(We)xgnc m save,indemnify xnd keep harmless the City of Cnpeninn agnimt PI?RMI'I'ISSUANCE F:LIiC tic I PC
IIalahlice.judgments,costs and exprnma x0ich may in any way acme,against said City AIT ER OR ADD 10 MIiCH.
in consequence ofine granting of this permit.. PLU HIND PI?li
APPLICAN'P LINTERS ANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,0II0 CFM)
SOURCE REGULATIONS. MECi NICAL FEE
AIR HANDLING UNIT(OVER IO,fNq CFM) CONST ICfION"i'AX 4
Slgmawmof Applirvnt/C,mI.i Doc EXHAUST'HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE NI
MI'I'IGA'fION P139
Will thenppli,ma lir term.buildiagoecupnmmnc or handle Inaallom,mmarial H17ATING UNIT(10 II),(NIO 1{'IU)
as defined by the Co,ninn 6lunicip:d Code.Chapter 9.12,and the Ihealth.nd Salt,
Cnde.""."I'm
"."I'n 25532(v)'/ HEATING UNI'i'(OVER 100,000 B'FIJ)
❑Yea ❑Na PAID
VLNTILATION FAN(SINGhE RF_SID) Dote Rcell".
Wlllnueus applieantorlanre budded bythe Btymea Air mmlity a,iou,whichManagement
BOIL17R-COMP(3HP OR IINI,O�NIllU)
Court hamnlouv air tt.mntninums nv defined by the Bay Area Air Quality Mvnagement 'VIITAh
�Diari<tn.
❑Yrs E]No BOILER-COMP(OVER IW.000 BTU)
I have read the k:tudous manreds renuiremem.under Chapter 6.95 of the Cnlb ALR CONUII'IONIiR ISSUANCE DATE
famin Ilealth de S,M,C dc,Sections 25505,25513 au125534.I understand that if me N17W RESIDENTIAL.MUCH. SQ.IT.
ntilding doenm .molly hnvanannnS,Sheat po ibil'y f.notif', aeeup t
`did it , ywhich. yet t t ta ' ithm of lk
I`rIr Qn7i,,, .>Y 1e. 9F
I�wn zed ugrm I - Dm T I'O Is ISSUED By.
e OFFICE