99110184 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY If /
CITY OF CUPF.RTINO BUu.D1NC.-E1.EC I KICAh msRnuT ND.
PUILOING DIVISION APPLICATION/PERMIT wNG PROO.MN;CENRIC,M.
BUILDING PIM),II?CT IUI[NI'IN'ICATION
SANI'IAItYNO. AI'I'LICAFI NSI111MI1'1'N,UAIii
BUILDINGAUURESS:
15 ZuI rI bow bl- _2�-�
OWNF N PHONE: C RACfOR'S NAME: LIC NO: NIC CONTROLN
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CHELCDENGINEER: LIC N6. ADD E'S ��
crrSf�ns CCO
CONTACT: PF{ONE: BUILDING PERMIT INFO
ED Caa..hanl Fritts Paid by Applicant Initial) BW)G - ELECT' PLl1M{i MTCCH
VD d S 2S3 33Z [J El
uciENSI1D cONTRAcfOK'SDECLARATION QTY ELECTRIC PERMIT FEE JOE DESCRIPTION
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
Z9ZO with Section 911(IOpdDivi3)flhe Rhoincss and Prol'essimocode.lmd ntylicensc is RESIDENTIAL
y
in fill PERMI'I'i15UANCli ❑SFDWI, ❑KITCHEN REMODEL
aUV License C�a,s I.ic.N APPLIANCIES-RESIDLN'I IAL ❑ADD]'I]ON [_1 PLUMBING RE-PII'IE
yzw Datci _ Conlmmor ❑NIULTI-UNIT ❑SI'RUCI'URAL
ARCHITECTS DECLARATION PANELS MODIFICATION
OZ^IZ I understand my plansshvll be used as Public recads UPT0200AMP5
❑INTERIOR ❑SWCHIMNEY
NGREPAIR
F intw Licensed l•mfewionul 201.1000AMPS IMPROVI?MIENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVERI000AMPS 1;4nfliRIiMOUELR1El'AIR C1 DEMOLITION
C C Q I hercby aOiml Lha 1 am exempt farm the Comment's License Law for the El OTHER
O L U folhwing mason,(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 3 c.h which requires a permit to conswet.Ater improve,dentolkh,or repair any stricture
Od prions Ilan iamanec,all s..raluirestbe applicant fnr such permit to Fila it xignrd sone.,., SPECI AL CIRCUI1/MISC.
A•.]l malh,istianswpmsuann UcempLio,(Chapera) roMMFRCIAL
u1�00 (commencing with Sterna 7(X10)of Division3 of We Business caption.
Professions Cod0or TEMP.MISTER OR POLI;INST.
ON
a a e ,hal be is ecc.pt ilmrefmm and the basis far the alleged cacmption.Any violation of ❑NEW BLDG/AUDITION ❑DEh1OhITIVI
Way Section 9031.5 by any applicant for a panni,subjects the applicant,to a civil pewlryd POWER DEVICES -]TENANT ❑FOODSERVICE,
tut Inorc their Eve hundred dollaa.(S500). IMPROVEMENT
2GE]I,rsowncndthe propeny.or my vin111,ve,with wages us their mlccuntpcnsmlnn, SWIMM ING POOL VI.IEC'TRIC
H
[D OTHER
will do the work.add Ihc,loo ure is not Intended or nipered for sole(see.9140,Business
63 m and Pmfcssions Ga1C:The CommmoYs Law,Indoes not apply m an nx'ner of OU'1'LIffS-SWIlLl11!S-FIXTURES
property who builds or improves Iherenn,and who does such work himself or dwugh NEW RESIDENTIAL 12 his own employee.,provided Ina,such improvemen l am nm MenJeJ nr oRereJ for SQ.I'I'.PLOOH ARf\ S/SQ.F4.
sole II',however,the building or intpf proving
is at h within ono year or completion,put-
,so
will have the harden of proving that he did not build or impn,ve for p�r-
,scol wk.), TOTAL:
❑1,an.ow net of Inc pmpeny,am exclusively contracting with licensed contractors to
construct he project(See.704-1.Business and Professions Code:)The Com.emts I.i-
xeLow dCunot apply aaanOwner olproperty who huilds or impnrves,hemair and QTY. PLUMBING PERMIT' FEE
who eonirrO4 for such prnicOts will,a,.... moot(')IlItowd pit o..out to the Conimcor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for this mason
ACI'F:R-DRAIN&VENT-WATER(Fust VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PRIIfEC'f DEVICE �O
1 hereby affirm under penalty in perjury one al the tollnwing declaraaiuns:
I havcundwill mainlainaCsnifc.,cof C....cnuomll-insure fnr Workers Compere DRAINS-FLOOR.ROOF.AREA.CONE). STORIES TY PE CONSTR UCIION
73700ol
ion,as provided for by Section 3704 of the Labor Calc,for,he perfmannoce of the
rk for which,his permit is issued FI1s-1'URIS-PER TRAP
1 have and will maintain Workers Compensation Imurance,as required by Section
'the LaborCode,lar the pertianonc'mf the stock lie which Ibis permit is issued. GAS-HA.SYSIl.M-I INCAOUILETSy Workers Compensation Insurance Carrier and Policy number are GAS-1 EA.SYSTEM OVER 4 IRA)rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE%INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION(TES
Tissccrannecd not be completed flhepcnnillr franc hundred dollar,SIXB GREASE'IRAP I'hANCIII!CK ITE
I certify that in the performanaeol the work for which this permit isissued,lshall SEWER-SANITANY-STORM IIA.2INIIT. ENIiRGVl9ili
Ili employ any n any man r us as become subject n the Workers'Compen-
Z scion lA a of 1 !h nrnia.Dale WATER HEATLR W/V[:NT/ELECI'H GRADING 19Ai
C APPllcam �
fn NOfICH 'O LICANT:If,ulicr nmking ihle CenJlenic of ExcnTonn,you ahonkl WATER SYSTEM/1'RI:ATING SOILS piEli
i~ hcco.,e subjac,m the Work,,',Cnmpens.,ion pmvlsiou,if 0c Labor Code.you mutt
forthwith comply with such provisions or this permit shall he deemed rcvokd. WADER SERVICE
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.fT.
Dad iRei' p,par,7Z
I arrear aroma Incl mem is a a,n.Imamn lending agency for the perElminn«of U
L2. N-I Lha work for which(his pernol is issued(Sce.3097,Co.C,) II 1'OI'AI:
O V Le'nder's Name TOTAL:
0 U Lender's Address B ,D GP
1 certify that I have rand this application and sure,ht,the above information is
F' A contact.I agree to comply with all city and county ordinance`and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC RBE
U Z haildog,onomOinag stillhereby' 0 P . li el ofthocillt enter rPnIn.
all In....pod p pcnYl imI t I P PERMI I'ISSUANCE EI�LCI'RIC FEE
(We)agree t c indemnify W A ep h 1 a IIIc Cry 1 Capetian against
Iiabllnies.judgments,costs and"Prows wh hmy in anywyxcc 6 nsts JCnY ALTER OR ADD TO NIECH. PLUMBING I In
in consequence of the Printing of this p,nnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR DAN DLIN .UNIT(TO 10.0NI CFM) MECHAN ICAL FEE
SOUR I 'aULAI'IU'
a /�
loop, Dole
HANDLING UNI'I'(OVER III,IXXICF M) CON5gRUCfION TAX
J
nfAppl n omrucmr Da¢ EXHAUST HOOD(W/DUCT) IIOUSWG MITIGATION PI]i
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orintme building Occupant moleor handle hanardoes material HESONGUNIT('1010090001TG)
vs ddincJ nY Ire Cul'Lninn Municipal Gnlr.Chvplcr 9.12,and thr 1{nJlh nnJ S:dcty HEAIING UNI I(OVER I00900K)11'1'U)
Code Section 25532PC
p Yes El No VENTILATION PAN(SINGLE RISID) PAID -
Dale Receipt a
Will the applicant a future holding acupa d use egripmcn,or devices which BOILER OHP OR IW LXX)BTU)
Iii hanardous air conluntinints a,drtind by the Ibay At"Air Qual'ny Managenmm TOIA.:
Dishier? BOILER-COMP(OVIER 100.000111U)
C)YO, 0 N
1 have real the Code Illamr255 5,2553 an under Chapter rou 0l the if the
AIRCONDITIONER ISSUANCE DATE
tomb Plc ov &Su1iry i Starton l,thei 25573 and 25534.1 undclsmnf that If the NEW RESIDENT Al.MEGH, SQ.i'I'. Z 9-
M1ui1Ji not cwand', von aunt,Thal 11 is nlyrcnpnnslnilly In nmil'y(fencer,mt
oft mqul meals wh,i lu' nleipdt)rinlssuancetiiaCeniliclnc of(kcvpancy.
ruulnonn
Doc TOTAL ISSUED BY
agent :
OFFICE