S 1964APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPRKI'INO BUILDING.-F,LEC I'RICA I.
BUILDING DIVISION APPLICATIONIPERMIT 1'LIIMIII81:-M1IECHANICAI'
IllIIhUING PItOAEcr IDEN'I' IN'ICATION
PE IT NO
S 1964
]WELDING ADDRESS:
SANITARY NO,
APPLICATION SIJNMI'1'IAI. HATE
CC St Seo 1 D DA- C'uPERT/na CA. 9J-014
.OWNER'S NAME: PH =NE:
sill
All
CON TRACTOR'S NAME LIC NO:
`//_�
N/C
❑ —7
CONTROL#
ARCHIT'IiCDENG 'EER: LIC NO:
ADDRESS:
eD:vrncE PHONE:
BUILDING PF.RMI9' INFO
❑ Consultant Fres Paid by Applicant (initial)
BLDG ELECT LOMB Mlicu
LICENSED CONTRACTT OR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 bamcmeaing
QTY ELECTRIC PERMIT FI?E
JOB DESCRIPI'ION
PERMITISSUANCE
with Section 00(10)oRlivi ina3ofthe Rtomessand Pmfiradans Cade, andlny license is
I in full force and effect.
' License Class I.it,N
Dam Cnnnaame
RESIDENTIAL:
❑SPDWI. El KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑S'I'RUCPURAL
MODIFICATION
❑INTERIOR F1 CHIMNEY REPAIR
IMPROVEMENT' SWIMMIN01•(IOLS
APPLIANCES -RESIDENTIAL
j ARCHITECI'S DECLARATION
1 uullow nd my duration he usidles public omard,
i Licensed It c,sirml
PANELS
UP TO NO AMPS
211-ISMAMPS
OWNER-HOILDER UBCLARA'PION
I heresy .farm lter I am exempt from the Commcmr's License I.aw far the
following reason. (Section 7831.5. Business and Profesinne Gvlc Any city for county
j which requires a permit in construct, alter, improve, demo inh, or repair any snucore
❑ IIA'T1 RF i JREPAIR ❑ DEMOLITION
R
OVER 11100 AMPS
SIGNS ELECTRICAL
SPECIAL CI RCUIT/MISE,
jprior In illie,aahce, list' requires the applicant for such penniuo file.aagned statement
n1aahr,,1imtsul,vuo (olboprnvisiunx it ' Ilia Conl nmmrs Useme Law (Clmpmr9
(rmnmenein, with Sayinn 9lKKpof Division 3nrlbe BuxinsxsunJ Proffeiit'nx Code)...TFMP
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
MEl HR OR POE' ST.
R L,
O NEW BLDG/ADDITION [IAlii lzx-1 4—
LITION
POWBR DEVICE
• Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of
of more than five hundred dollars (S500).
• ❑ I, asownerof treenail ., at, engtlaym, with waged eiflairmic,onpenacion,
1 'Aldo Ill, urk,lind lhesnnnure is nm int ended molocred inside (Stw.7()4
and Pmfcssions Coda: Tl,c Commcmr's License Low docs not apply m an owner of
❑'fLNANT ❑FOOD SERVICE
IMPROVEMENT
1:1 OTHER
SWIMMIN CIOL ELECTRIC
OUT . Y-SWI'I'CI1E5-FIXTI 3S
pmpcny who builds or improves thereon, unJ who does such xvrk himscll or through
his awn employees, provided thin mch improvements are nal intended nr afferes$ for
sale. If. however, the building or improvement is sold within one year efcnmpletion,dbe
W RGMI11iNT1AL Ii1.liLTR SQ FT.
SQ. FT. FLOOR AREA A
Y P1
$/SQ. EL
erholder will lave Ihs burden of proving dhar hedid nal hail] or improve for par-
"wal mlc.1.
❑I. mownerofine propery,.,a exelasivclYeamraamg will, licensed eannaclart In
ammo the project (Sm. 0044. Business and Profession% G.odeq The Cn lmordo's Li-
AUG 06
#D
A
muselawdocxhatapplymonuwncrofpropcnywhonnildv nr improves nuclear, ad
QTY. PLUMBING PERMIT 14!E
whoenrnrms forsucl,n inch walbacentractool)licensed parsu:mtto the Cnnboetor's
License Law.
❑Ism cx npinnder See �_,B& PC far this reason
CiIY LIr ll
I INU
PERMIT' ISSUANCE
cr lam
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
HACK FLOW I•ROTLCI'. DEVICE
' WORKERS COMPRNSAr10N DECLARATION
hmalwalarmunder penaltynt perjuryoneofthefellnwingdeakia's ne:
Inuits and willforby Section 37wu at Corlett I,abin Colsellic, for the erfoolrs'Cnmpery
provided for $ethos 3981 nr Ise Labor Calc, for the perform:mce of the
DRAINS - FIAOR, ROOF, AREA, COND'
STORIES
TYPE 'ITNUCI'ION
mi
work for which Nis permit is issued.
work(r
FlXTUIt1iS -1'ER TRAP
❑ I and will maintain chi required by Section
oafs Earc
he ftte w rk far h
of
3]fl(lafdl,e Labor Cale,far dhsurancrmunecrfthework for which this permit is issued.
of the
GAS-IiA.SYSTEM-I INC.JUUIT.I!fb
pCC.GRl1Ul'
AI'N
My Worker's Cnmpensminn Insurance currier o li Polity further are:
Carrier: � Policy Nn.:
�
CAS -En. SYS 'IRM-OVER J (CA)
CERTIFICATE OP CXEMI'1'ION FROM WORKERS'
COMPENSATION INSURANCE
(This union need not be completed if permit is for one hundred ]altars ($I W)
nr It (This
GREASUINDUSTRE. WAS 117 INT ERCITI OR
BUILDING DIVISION FIiFC
GREASIi TRAP
Flili
SFWFR- S ANITARY_Sr, BRM EA. 211111'1'.
Ic,Nirybar In dheper0omunce of the wol'kfor which l hisperall ivkoned, Is1u11
not employ any pers'tm In ally manned su nit In bsennm cabled 10 the Wmkcra' Camper-
cation Laws of Colifnrnio. (late\NATER
Applicant
ENERGY FEE
❑M'I'CR W/VI?NTNiYiilaQ III
FEE
NOTICE TO APPLICANT: If, i mr making this Cenificite of Exemption, you should
becmnc subject to the Worker's Compensation provisions of the Inbar Colo, you muss
WATER SYSTEM/BEATING
SOBS FEE
WATER S17RVIC17
holotill. cuntply will, xncn nawkiers nr Il,is permit shut bs docans revoked.
CONSTRUCTION LENDING AGENCY
I herebyalTnn thud there i,arnnpmetian forth.gogency hadhe pafornammof
NEW RECIDEN'I IAL PLMIL SQ, IT
PAID
Il:n Recciptp
the work for which this pcmtil is issued (Sec. 3097, Crit. C.)
LenJsrs Name
'rf3TA L:
Lendu's Address
TOTAL:
BUILDING FEB
I certify Ihn( 1 have read this application and state dandle move Ini'ormmloa i,
corral. l agree lr mainly with all city uad emntyoudinanecs a radsonclovoondmingo,
building construction, and hemby i nthuriee representatives of this city m eater upon lire
QTY, ITFCHANICAL PERMIT ITC
SEISMIC FEE
PBRMI'I' ISSUANCP.
ELECTRIC FEE
abovennemioned pmpcny for inspection puffaes.
(We) agree m cove, indemnify and keep harmless the City of Calwnino against
Iiehilllics.jndgmenlacoasmad expuucs whi,h mayin any wiry ocean agr....fluid City
in cnn.sequence of the granting of this penin
AL'fliR OR AUD'I'O MHC! I.
PLUMBING IgiH 4. Fli
AIR HANDLING UNIT(]O 30.000 CPM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRGCTION'LAX
Signmum or Applicurr Conlmcmr hale
HAZARDOUS MAITiRJAI.S DISCLOSIJRE
RXHAUS'I' i IOOD(W/DUC) I Zoo,
HOUSING MITIGA'DON FEE
HE A'rING UNI'1'(TO IIX1,INq )
Will the applicant or future building occupant store or handle hazardous numrial
as defined by the Cupenino Municipal Code, Chapter 9.12, and 1— Heelln and Safety
Code, Semien 25532(u)'f
HEATING UNIT (OVER nlp6 B'III
��
❑Yax E] No
VEMILn'I'ION P (SINGI.Ii ItESlll)
PAID
Dem Recciplp
BOILER- ,IP (3HI'OH IW,(gO BTU)
Will she applicant or future building occupant use component Qu or do -ices which
emit hambdous airconominams as defined by the Bay Area Air Quality Management
District'!
Yes L]No
TOTAL: ivssu
ROI-EQMP(GYBR 1116,8!16 B'rU)
I&CON VI'I'I ONER
I have read the hazardousa l:dsre,riremems nod,r Chapter 6.95 of the Cali-
V HANCE DAA'
NEW RISIDENTIAL MUCH. SQ. ET.
(untie Meath & Safety Col Seednos 25505, 25533 and 25534. I understand this if the
building Atesandctim, ty, have a banner, that it is my respmsihilidy to milify the cecupant
oftbe 9Jyeemcaova nra W dp' .. cafa Cenifiel cot( cupuncy.
'f0'1'AL:
aalhorivedlagent 7 in
ISSUCD It Y: is
/ OFFICE