S 1670 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Ttv)_01 1 / _
CITY OF CUPF.RTINO BUILDING-ELECI RICA I. -1!IgalVl'I NO. O
BUILDING DIVISION APPLICNFION/PERMIT PLUMBING-MECHANICAL.
167
ItU1LIliNG PROJECT II)EN'TIICCA'1'ION
BUILDIN O&V7 4&0`9 t" SANI'IAKV NO. AI'1'I,ICA'r1UR SUliMI'I✓TAC DAT
OWNER'S NAM
I'HONU CONTRACTOR'S NAME: LIC NO.
N/C CONTROL
tCHITECI'/ENGINITR: LIC NO: ADDRESS: ❑ E' &
CONTACT: PHONE: BUILDING PERMIT INFO
1
V,/ a //�I^L1 •'t C q "UI 1(v 'HII, �ry ❑ Consultant Fees Paid by Applicant((Initial) Itl.l� IAA'❑.CT PL S1E�cH_
/ In Lt+- �.a 7f IJ
LICENSED CONTRACT OR:S DECIARAI'[ON QTY ELECTRIC PERMIT II?E
1 hereby arm.Thal 1 am hcaused under provision.ofchmtcr 9(commencing JOB DESCRIPTION
WC)Z with Sccdion]g0)of UivisionJOf the ltusinw,und Pofc..im,Codc.and my licensers PERMIT ISSUANCE $' IDP 'PI I'
F1=Qet� is full fora mad el@m. DW'1, ❑KITCHEN REMODEL.
V U Licenu Class I,Ic,p APPLIANCES-RESIDENTIAL DITION ❑PLUMBING RE-PIPE
F Z w Data Contractor
m6a ❑MULTI-UNIT. ❑STRUCTURAL
ARCHI D:CP$DECLARATION F p w PANELS MODIFICATION
OZ=Z lundcmand my plans shallbe uaN as public record,
UP T0210 AMPS ❑INTI!RIOR ❑CHIMNEY REPAIR
Fy'�F'a ]-trebled Purfewinral 301-1000AMPS IMI'ROVEMINT ❑SWINIMPIGPOOLS
C sj�a OWN17R-ISUILDEK DECLARATION OVER IOXAMPS ❑ IH RL'MSI:IJRI!PADIR`❑IJF.MOhII'ION
1 hereby all that I are exempt front the Contractor's license Law for atm
3 U following reason.(Section 7031.5,Business and I'mfessinns 6We:Any city or county SIGNS ELECTRICAL fYTHI!R
m which requires a pernnt n)construct,alter,improve.ilmoolish,or repair any slmcmre
.F„NON j Pnor1 t 'I 4 Ille I'ducandt Ii,sarankt IIe-oupwd:rt nem SPECIAL CIRCUI :C. %err(--AV,P1 ) '
i• Em h licensed l I I II P 11h ( I I :1 I lCh Per9 Q
m oo
(commencing with Section](ANT)IliD sioni l the Italia— f plofic,o...I,Cdc)rr TEMP METER RML COMMERCIAL.
M aye
W that he Is caempl Internal rnal and the boots Ini d e alleged eau opt lar A ay Ir dmlm ul" ❑NEW BLDG/ADD1110N ❑DEMOLITION
W Section]11315 by any uppllcanl lora Permit wtbiems the oPPlwan, ,,x c'rvll Penalty of POWER D. 1
��� nm mom than Eve hundred dol hot, 5900) ❑'IENAN'f ❑FOODSERVICE
6 L.Vevow,ufthe t IMI'ItOV13MEN'1'
Q Q prnlwt Y,onnY cntPlnyce,wlth Ipsco ar thele nslc unn,,cIII ur , SWIMMING POO, !I,' RIC
wad d A Ise• I I I me Ill d Uors (S .]IHV Iiltr a rs 00 I=
fit .ul T I C 1''11 C t I LI I I ml II1Y 1 m of OUTIJi1'S SWITCIII;S r
property hon hoild—,iu,uov,nation,u 1 such k olostrit ,, hurn to
his own "floyce,providtalfind soul'ocaniallualuill' I II orofterelll , NEWRLSIDCNHALPIIC'IR SVPI'.
u:Jc.l(.howcvcl the huilJing nr lntpmvensnt it weld wlthm oncyc:v oRrtmplclinn,the SQ,lel'.PLOUII AREA SISVIcI'.
owrrrftrildrr will have Ian btmdcn of provin,,hal hu did nal 1, It],,,impose for Pur-
prsc 1.-I ) 11
,��J/��` I tileproperty, lycontracting will, 1contractors ur I X -•R=L. .—a O .O7
c4 Nl ,l P l '1(S' ]0.W It J I C d D91 C t sLi- L/ / I
cause,Law mea not,pply to In owner of property who hu'Ids or roproves thereon,and QTY. PI BIN .P :MIT FEE
who emlmcts Iib such Pmjcas with a cantrauo ns)licensed Purwanuo the Contractors
License Low. PERMIT ISSUANCE
❑ 111,cxem t under Sce, .B&1'C for Ihis reason
ALTER-DRAIN& EN '11 R(EA) VAI.GATION
Ow Dale O U
WORKER'S COMPENSADON DECLARATION BACK FLOW PROTECT. EVIC /eq a,yO
I Mrtby affirm under penalty of perjury one of the following declarations: L-V
]I have and wit l mountain.Certificate of Conserv el sl f-insure lin Worker's Compen- DRAINS-Il OO R.ROOF.AK D. S'10 A LS TYPE CONST'RUCfl0
cation,as prov idea for by Sermon 3901 of the Labor Code,for the perfuromnce oRhy
ork for which this Permit is issued. FIX
wTURES-PER TRAP r `•1 R❑I have and will maintain Worker's Comixtion m Insurance,as required by Scaion e�
3700 of the Ltbex Code.for the Porfnnnanecul the work(or which this perp is routed GAS-EA.SYRIEM-I INC J OUTLETS OCC.GROUT' MIN
My Worker's Compensation Insurance rapier and Policy number arc:
Carriee Policy No.: GAS-I:A.SYSTLM"OVF.R4(F.A)
CEN I'IFICATE 01:EXEMPI[ON FROM WORKERS' GREASP/INDUSTRL WAS TE ISHTRCEPIOR J
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be<rnnplemd irthepenlil isfornnehundreddolhor,B1gq GREASETRAP
or less) I'LANCIIIfCK Rili 7311 y
lecrifylltm inthe Pcrfontinevod lhewmA fnrwhichthispennilin issued,l shall SEWER-SANITARY-STORM E\.210 Fr.
not employ any Penns in any manner ser us to bee on,subject to the Worker.'Cnmpen- ENERGY 1'171: 2 6�0`, 2,
Z satin.I",ofCaliform. Dme WATER HEATER WNENT/ELECT
z O Applicant GRADING P t" rr�
z .,i NOIICI!TO APPLICANT:If,after making this C-eniftcae of E vision,you should WATER SYSTENE RF,ATING SOILS PER 3 Gtr
F•' become subject to the W^rkar's Cmnlnnsmine Pnrvisions of file Labor Calle,you must
> forthwith eamPly with Inch anew sinm m diis Nin(dell bed,....tat resulted WATER SERVICE t�
CONST HlICIION LENDING AGENCY NEW RISIDGNTIAh PLMN. SQ.I'I'. ' PAID ' � � /
79
U ZIhereb ffrnt thanhcrc in acunstmtlinn leadinga,vue,for the Pedianam�eof a Dove HecdPtX
U O 1
V. F ser and,for warm,lata per.dt is mnnen(Sue.3(x».ca.c.)
O 1'Lender's Name IY) TOTAL:
LUPI Lcodcr's Address ' ' r
f�.•.•' 1'eptly don I bave re:ul this applr.alwn:sed aurae Ilan due above lottmn:nlon is it2JIIMNG IqA: 9 P/•00
fr h Gomel.I agree u)rou'lliv Is Ill city unit county onllnunccs unA lam law.mlminB to QTY. MECHANICAL PERMIT UC HI?rd
U Zf holAing coma nation.Ind lately I'll' tepmsnnlaliven of stir,rry 'I cnerugm the .11 g.1ZCIICC Z / Z'UR
abut ocallnandploIllyfurinpuxrinnPnrP^e PERMITISSUANCIi ❑LI!CI'RICII_I; 3J
c (We)agnv m save,indam...'and keep hurudcss the City of Cupcninn against
t-t headinca.indgroadI..oasanduspcoscIllicit any all anyIvoryaacn.mlgurs,lxaidCity ALTER OR ADD'IO MHC H, PLUMBING FEE 3t
' ns
0cqucnm of due go ling of I...permit. r
API'IACAN'I UNDERSTANDS AND Will.COMPLY Wi'I If AL1.NON-POINTAIR HANDLING UNI'IF('1010,0X0 CPM) MECHANICALlelili
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CFM) CONS'I'RHC['ION'LAX
Signume,of APPli,ma/Commaor [).to EX UAUST HOOD(W/DUCT) HOUSING M I'I'IGAIION FEE
HAYARDOUS MRIERIA1S DISCLOSURE
Will the applicant or future building"a'clpcnt store orhandlc bwurdous material HEATING UNI"r(TO 100.001 BTU)
49
ac defined by the Culat Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532oft! HEATING UNIT(OVER 00.000 B'1'U)
❑Yes E)No V ENIILATION FANS INGLE RUST U) PAID
Uac Receipt a
Will the applicant or fuser,building occupant use equipment or device,which BOILER-COMP @IIPOR IIXI.(A0 BTU)
mit hazardous air contaminants as dcGned by the Buy Area Air Quality Management U A
17"ans? Its ❑No BOILER-COMPO100.0pill
❑Y
I have pad the hadminkn materials requirements under Chapter 6.95 of the Cali" AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade•.Sections 255115,25533 unit 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PI'. ,/�•^ � 2 _ y
bridal as currently have a imaral,lhal it ism,resrymsibility mmnifytbe sccupam
of the mluircnrnts which most he net Prior br issuance of a Cenifcat,of Occupul
Owner or authorized agent Dale Alt ISSUED iryc
OFFICE