S 2998 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPI?R"I'INO RU I LIONG-ELFC 1 RICA I. til211 r NO.
BUILDING DIVISION AI'I'LICATION/PERMIT PING PROG"MECHANICALIDEN IFIC
INILUING I•HOJECI'IDEN'1'It'ICA'1'[ON S 2998
BUILDING A 1)ORLSS. L ^'5a F1,,P/� SANITARY NO. APPLICAI'[ON
\SUBMITTAL DKIF
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,J-A 03IfjryNL ",' 1 : I'll( 1 CONT
ACTORS NA It /V-1112 / NIC LO`"TRUI,a
, t0l LIE niNGE ADDRESS: ❑ (_Jv'
/ OifA fS
CON'1'ACr: (/1�uONI^ BUILDhNG PIiRMIT INFO
t'(-�� O ❑ Consultant Pees[said by Applicant(Initial) D' ELIiCIPLI)MR ME it
LICENSED CONTRA(rOH'S DIiC1.AAION QTY ELECTRIC PERMIT FEE
I hereby aline till,trip Beenad ander provi'ma of C1..mar I ('I annealing JOB >ESCRIPTION
O�Z with Section 70(1B)arf Uivislon 3oflM1e Business unJ l'rofouionsCdr,ruh ylicense is r'I TI
W O I'ERAIIf ISSUANCE
F�LL� Licerellucu;nsJ clln's. �B/ SFDWI, ❑AL KITCHEN ftEMOIIIE
QUV Liccnsc Chis 8 Lice APPLIANCES-RESIDENTIAL ADDI'T'ION PLUMBING ftIiI'11'E
F Z W Dna Cmnracmr
m 6 aIRCO MULTI-UNIT []STRUCTURAL MOOJJ
A LCI"$DECLARA'110N -
Z O N Z I understate rnY plws shall be used as public mrnn]s s� I'ANEI ti MODII4CA'I'ION
OZ-an UP T02W AMPS OINTERIOR OCIi1MNIiY REPAIR
F v:Fµl LicenxJ Professional NII-INXIAMI'S IMPROVEMENT 0SWIMMING POOLS
OWNER-EU1LDER DECLARATION OVER IIXXIAMPS ❑HATH REMODP.IJREPAIR ❑DEMOLITION
C Q 1 hereby a1Rnn that 1 am exempt fruit the Colors License Law for site
K O L V lidl—u g lemon.Section.713 L.S.IL,sinme and Professianu Code:Any city nr county
SIGNS IiL1iC1'NICAI. E3 OTHER
W 3 LL ti which requites a permit to construct.alms insprove,JemnllsM1,or repair any structure
Q Pricermit,isnuntcc,also rryuim,the applicant for such Perini[o rile a signed.statement SYF.CIAI.CINCUI" SC.
Wy', this,he is licensed pu .a
rwnnn l,hc thcpresisl..nsoCentractor,Licc,ac hew(Ch,p,cr
µW00 (commencing with Section 7W))ofDivision 3 nrthe Business and Professions Code)or
'11iA1P.MLTIiR OH I'(lL. $" COMMERCIAL'
a c C ,[at hu is,x,my shcrcfnmt and,Ire haxis Ill,lits allcgcd uaoogn,on.Any violmion tib O NEW HI,DG/ADDITION O DEMOLITION
x—a- Scmion]I)3 LS by any applicam fora Penni,aulje<Is,M1c applicam macivil pcnal,y Lib IT)WIIH UIiVICF_S ❑TENANT OPOGDSERVICB
not more,hun live hundred dollars(85110). IMPROVEMENT
t-=QC](.as awncrof the prnpcnX nr myempbycm with wages a,her, olp compcnsatinn. SWIMM1I1NG Iq(Ih RIJiCI'R '
^m will do sup wurIt,and ill structure s not i mended or metal lienalc(See.Tall.Resins% OOTHER
µI3 and Professions Codi The Conena's License la does not apply to an owner a( OUTLETS-SWI'rClllis-PIX'rUREs
µ' property who builds or'roproves aharctn,and who does such work brunch-through
Ill,own cnspinymn prnvidvd,he suds intprovemenu are tun(mended or miller] or !I-
IIIE!RIRA
ECFR SQ PT.
,ale.il:however.the building or improvement is sold within tine year ofcomplmicul.he SQ.1'1'.FLOOR AIOT,A $/SQ,pal'.
sf
er.nahn,r,sunt Ilene nee nara,n ni 1,1nd,,,g roes b,did,an Hudd ser„mrove tier par- � /i���er
0;of sale) of Ole properly,a s1111,vO,comrucil with licre,ed c ropes,ms m (Al (�Gb
constructI p j 'tp oair vase 'a IY s . sCtd TIT C ,'snot,- � / _/
ucn,e I ,apply to fpr pcnY h builds(it P m on and QTYPLUMBINGG PI3RAIIT FEE (—/J/T�
whosnonus forsach prdca "b o: t OI sed plc [()tireC oat, r
IJ,vec Luw. SSU41111 JI an,excnq+t under Sec. ,It Pa i'C ba tills rmsonRANI'-w'ATEk VAI,UA'1'IUN' Ownaf DuroWOHKEN:SCUAIITNSAIIONOECLAHA'1IUN UIN 1'.DIiVICH�O herebyafnnunder p,nuby seri perjnry ane tilthe follnwing dcelarutinro:(has,and will maintain a CrnificatcofCnnxad in self-insure fr Worker's Cosnpon- I a. A It BA.COND. SIORIIIS TYPE CONSTRUCI]ON
,titian,us prs,ad"IfarM1y Section 371X1 of she LaMn Cade for the parental of ahs ' `wod far whch this perosis ix issued. S-PI' vO 1 M1me and will asainnum Walker's Compcnsminn Iwmnce.ev sequircl by Section
3700oftheLsaa Core.for thcitcrhnn.;umwd''Ill sunk liar which,itis pcnna Is issued. .SYINC.4 OU AOX OCC,GROUP 2 PiaMy Worker's Compensation Insurance carrier and Policy number art: .SYVIiR 41EA) \/•\4/�//� /
-! Currier. policy No.:
CERI'IPICATIi UI'If.XEMIrIION FROM WORKERS' GRGASP/INIIUSTJU..WASTtilNrf.RCE
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need nos he consp]mnl if the permit is bosun,hundred dollar,($list))
or Ices., GRIiASE TRAP PLANCIIIiCK FEE
I clay that in lhel'eAnmekeeftle work torwhich dui peri,isissunl.I dell SEW(?R-SAN]'1' RYI-STORM I?A.2(X1 Fr.
not employ any parson in any nsanner so m m become subject or he Workers Compen- ENERGY PEB h
aT
Z Applicant Laws of Culifinnin.O:nv N'ATI:R HIiATEIt NIINTIEB.EG'IR
� O O Appbcam ,.- � Iy Ganmmc lana
Still ICE 10APPLICANT](',N1cr,nukin,dis Cmiti,nmof llscmptinn,you should WNI'1!R SYS'I EMr' EA'IING
SOILS Il?I?
a > f twillu,I ply is Worker's ComPcn.this pmvisi bel Ill the Latin Ctoke.. antis
W ti tnnhwisM1,unsply wish such Pnwisinnn or this perosinhall hcJcemed invoked. WAI'IiH SERVICE �
Y 'AID
CONSTRUCTION LENDINGAGENCY NEW RESIDEMI'IAbPI MB. , .IT. pile Reccip,p
VQ Ihereby aff ism lisp,des,is a emswnien loainga,,n,Y for,lie perEomm�cv of
(~(] he work for which this permit is issued(Sce.3097.Cru.C.) TOTAL:V benders Nene
hendds Address 1 \ r'
r G I unify ilia I b:r'c mad dais apPhacinn:nd sone that ties above inLnma,ion is It1111.UINC Plel ,
F' N correct.l agree vs asmply with all city and sonny oNinanccs and state law's rcladngm QTY. MECHANICAL PERMIT FEE SEISMK Ili �•
U z h:dldingamswcion,and hereby nutritive representatives ofthis city as enter uponthe ^�.s
aMrvcmentioned property lin impec,ion purposes. I'ERMII'ISSUANCE ,illi RIC I Hi
(We)agree as save,indemnify and I.ccp handless the City of Cuper ins against a
Iiabilhies judgmmP
� ,caw w
and copetiles hny ich may in awa,accruAl
d)alit Isaid City ALI'FR OR AD'TO MSCI I. PLUMB iFld! "it It
in cit ^ �
nscgncnce of the granting of this perm,,.
AN NT IINDEIISTANDB ANTI WILL COM WI'1'li ALIIN(1N-P(11NT AIR IIANIl1.IN(I 11N1'I'(TO It.IXp CPM( MI!GII (CAL FEIi
SOUR L.Je�
SOURCEE HEGULAI'
/O q AIR HANDLING UNIT(OVER IR,IXp CIM) CONST UCI'ION TAX
Sign;nurenf APPlien rots' Oaf, EXIIAUS'1'I3WD(W/DUCT) IIOUSIN( MITIGATION IsIiE
IIA' )USMAIERIAI XICLOSORE
Will the applicam fnmmbuildin upam sesrc or M1anJk hrzanlnus macdal HINTING UNIT(To 1X1001 RTU)
m defined M1y the Cnperfmn unapt Code,Chapter 0.11,and the lcalth and Safety
Cade.Section 25532(a)1 HIi TING UNIT(OVER 100,1%00 B IU)
[DYcs C]No VI?N'I'l1,ATION FAN(SING 1.11 RIiS I D) PAID Das, Rcccip,p
Will theappllenna Lir future huddingoaupunt use cquipmena or devices which 1101I,ER-COMP(111POR HXI,gX)HTU)
mit haaallons air contaminants as dclincJ by site Bay Are,Air Quality Manag"na"n _ O
Finalist BOILER-COMP(OVER I(MJ")BTU)
E3 In, ONo
IJeveledmeh,eardons.necrlalsreui,cmcn ....,s er Charter(.o5 of till Cah- AIR CONDI'T'IONER ISSEJANC17 DATE
hualdflub,, Safety Chair,Anions 255..5,15533 and SSW.p un.cmonJ that it site NEW HESIDIiN11AL MECII. SQ.IT.
huil:ing Jrxs nm uur,'nnly hove a anent,role h May rcsP"nsdaddy m nn,ify oho moamnm
ofthemquirt sit sic,snyybe n2 rmissuvnce'Ifu Ce�lxt til( vIt
Uw agent ! :J Dam ISSURII I;Y.ZT
OFFICE