00020009ham ICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '+ V U 1,000 It
r CITY Or CUPERTI NO BUILDING - FI,FCI'RICAL
II1111,111NG DIVISION APPLICATION /PERMIT r PLUMBING - MECHANICAL
1{IBLDING PROJKC I'/IDEN'I'IFICA'1'ION
PIiRAIIT NO.
1 {IlILDING. \DS: /L .�/ / /� /,Y�/
II'1/1
tiM'IY'ARV NO.
PUCAI ION AL DATIi
NC
CON L ROp
El
RCIIITECI' /ILSGINHLR; LIC NO:
AI RBSS
LA
Co 'FACE: PHONE:
BUILDING PFRMTP INFO
BO ELI❑'"CI' PLUMB MFCIi "
Il ^ice/
/ f _
❑Consultant Frey 1'uiB by Applicant (Initial)
LICHN'SLD GGNTRACIY IR.S DECLARATION
1 hereby ofrlm tent l Lou licensed under pnwisinns of charter v (commencing
wish Srclion IlXXpof D, Oo onlofmc Hoimers amll'ndmsioms Code and my license is
io lull fomnand t
2 �3G 7!06A
Q'Iy
17LEC'TRICPERMIT
FEE
JOB DI?SCRIPTION
RESIDENTIAL:
❑SFDWI, ❑ KITCH17N REMODEL
-PIPfi
QAUDI ']TGN ❑SIRU
Is RMIT ISSUANCE!
AI'PE,IANCES- RI :SIUIiN'FIAI.
Dafe�cnmm% �r
DatecCss Conan
TURAIli
❑MULTI -I1NIT ❑ST' DIFICA IO
h10DIFICATION
❑INTFRIOR ❑CHIMNEYRI ?PAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH RHMODFURITAIR [I DI ;MOI.ITION
OTHER
ARCHITECTS DF.CLARRIION
I undetstnnd my plane shall he uses) as public rec,Ns
PANbI-S
UPT0200AVIPS
Liccnud Promwinnal
OWNER BUILDER DECLARATION
1 heron, affirm in., I Lou scmpt from the Contrdemal" Liceroc Law for the
R;Ilnwing ro...... (ticainn 711.31 S CIf -mrsa and put ..Tun, Cady Any c... ..'nobly
20 I000AMPS
OVER IIXXIAMPS
SIGNS HLFCTRICAL
which requires o pcnnil In con.. m4 ulie,, impnoc. dc,noasll, a ,cpni, any ,tmalure
SPEC] AL Cl RCUIDMISC.
prior to its : seance. also requires the applicant for such Permian file a signed statement
that he is licensed pursuant ao the provisinns of the Contmewr. License law IChapmr 9
(cmmnencing with Seen 171XXanfDI.lion babe ll usincrs and Prnl'csxinm Ctde)ar
de, he is asmnpl dalcln;, I rood the nusis t'or the alleycd csesnp,lnn. Any vinluli.n .I'
Section 7031,5byany applicant far alerted wblens lhcapplienm In acivil penalty of
'f ?TER OR I'OhEi INST.
COMMERCIAL:
❑ NF,W BLDG /ADDITION ❑ DI:MOLITION
E14pMRN'1' ❑FOOD SFRVICF
'O iVICES
not more than five hundred dollars (5500).
Ej Lal owner nftM pmleny, nr mYOnpluyecl with wugnmthcirsnle compcmmion,
IMPROVINENT
❑OTHI!R
SWINISH.. C .I!LFCIRIC
willdo the wnrk, and Inmmn:nule is bat iwe Ind tarolleed basalt, (tics. 7f 4, IWsineas
unA P ... fi- one C,dm The Cnnuacm,'s Lx ... c Law doer not apply In on owner' of
pmpeny who build% or improves thereon, and whit dies such work himself or through
his own employee%, provided that such improvements am nm intended or offered for
sale. If, however. the building or imp omnant i1 said within oneYmr of complcninn ,the
awn eohuildcr will have the hold'. of privity than he did not amid or Improve bar pur-
Out LILTS -SW -FIN I IRBS
N•HA, .. AL R El SQ PC
SQ. PI'. FLOOR AHFi\
EISU. IT.
'IY)'1'Ah:
pne of noisy
Cj h its r the p of the popery, . Business cxdusivdy cummcting wial linewd mmrannn i-
mema Ih. project (See. ]1HJ, snof and ray wh inn.v Gde:) I),e Commeton. nd
ac haw Jame not apply o-o tan owner ofprnpcny who builds or intpnrva thereon. and
QTY. PLUMBING IT
FEE
who ends fn-lidt pm,lr<n with a nom"ols) liecud PUr nunuathc Cunm;mur'a
License lax.
l am exempt under Sec .Ii@ 1' C hadiis reason
PLRAII'I ISSUANCE:
AETER - DRAIN X VIM' - W'AI'FR (1 :A)
wrier Dam
VALUATION
BACK ROW PR(fl'CCL DEVICE
WORKER'S COMPHNSATION DIiCLARRI]ON
�
1 hereby affirm under Penalty of Perjury one of the following declarations
❑ IhavcandwillmainfainaCenificamaf Consenuoself- insumfnr W'urkee%Compen-
sadnn, n % 'as ided Ibr ny Soon 3700 of the Lanni Code. Introit, ncri m use of 'he
Iii, pat Is hcd.
wnrk tort which rid m w
DRAINS - FLUOR. ROUE. AREA. COND.
STORIES T YPB CONSFRUCION
J71 X'l IIIUiS - PER 'fk AP
GAS -EA. SYSTBM- I INC. J OOILE.°IS
❑ 1 have and will maintain Worker's Colo ensalion Insurance, as required by Senior
1701 ofthe Labor Code. for the of work for which this permit is issued.
OCC. GROUP a, 7S1N
GAS- BA.SYS'I'I!MUVERJ[fiA)
X,performance
My Wnrly9'p [p,ppe'smi n(P (11il Palmy Nqy nu y�ryrPr._�q.jl
Caner: ��W if /C% JO(f
CFRTIFICAI'17 OFL'X710FDON FROM WORKERS'
COMPENSATION INSURANCE
OO
GRFASbJ INDUS" I' BI. WASTE IN'IIBCEITOR
BUILDING DPVISION FLITS
GRE:ASHIRAP
I'LANCIIIiCK FEE
(Thisxction aced nut hecompleted: tabs pmnit is fnr one hundreddoll:us (51(X1)
or lets)
Icenilylh,,,a nityonnamvnf,hIworkfnewhich this Ill
the Worker, ISM,)
nut soaping any prsnn unity ,banner m as In Iceone sonjrat m the Wnrkcd C.mpm
SBWIat- SANI'I'AItV- S'101<M PA. 21)U PI',
I1NL'NGV I:IJi
WAITR 11P.ATER W/VENT /BLCCI R
%drum Wes Of Califnmia. Dale
,GRADING FEIN ("1
t a
Appkcanl
NOfICH 10 APPLICANI.11;.1mr,nuking this Cianficmc of 17songnion, you nI III
bee .... re abFU m the Worker's Cnmpen%ntion pro,kiun. of the Labor Code. You onsl
Emhwithannply with such ptnvisi ... our this pmtil shun he deemod revoked.
WAD!R SYSTEM /IBHATING
,}OILS ITiI:'�� Lj
it
W'Al'I7R SERVICE:
'
CONSTRUCT ]ON ],ENDING AGENCY
"' \I part Reccip, x
. PLB. SQ. FT.
Is RCSIDENTbM M
I h...tw ollirn, shut lwm.,;I" ngnmlion lending agency be the Perlin on.unce of
the work Ina which this pcnnil is issued (Sm. 3097. Cie C.)
I'OIAL:
'IDEAL:
•
Lender's Nance
Lrnder's Address
I elily tam 1 have,cad 11,11 apinh,;n;.n nn I stain thin the above infmtold I is
s llItiger. to comply with all dtyundcoumy nrdlnanemI datate1mvsm1:dingtn
building cnmtrre ion. add herehy amhnri're reprexnmtives of this city at enter upnt the
ILDIN(i FHF
-Q. - �-._�.
Q'I'Y. MECHANICAL PERMIT
IIiH
SEISMIC FFF
PERMIT ISSUANCE
IiLECI'R1C PEE
ah,rve- mentioned property [or imp,cnion purposes.
(We) agree m save, indm may and keep hunts... the City of Cupninn.,guinea
liuhili,ie...... bau,m h, cn.1,; 1rxpcnms whlch,nuy ill ;Illy way uccue ag:ains, s:dd City
ACf1dRORADD'FOMF 1I.
PhUMIfINO PI?E
in nmquence of gaining of this permit.
APPLICANT UNDLRSIANDS AND WILI. COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10.00007M)
MILCHANICAL ITH
5 1 CB kFGUI„
n M/I.a
d�
AIR HANDLING UNI'I'(OVER III,IXI() CFM)
CONSTRUCFION TAX
L e6�R
S,gnmurco A p n omrucnr D
HAZARDOUS MATERIALS DISCLOSURE:
Will the 11"Pl:an to finure blukh ,w,meun Itum or handle h—ohm, mOeritil
as defined by ,he Cuperr nn Municipal Coic, Ch:ynur 9.12, and the Ilcaldn mad Safety
Ode. Section 2551200'!
EXIIAUST HGDD (W /DUCI'1
IIOUSING \IITIGAT]ON 193E
HBA'1'1NG UNIT (TO 100.000 BTU)
HEATING UNIT IOV I!R 100.I00 It 'I V )
VEN'FELATION PAN (SINGLE; RfuSID)
E3 Yes ❑No
PAID Date Receipt e
'
Wrdou,at,el:fu tar h,u,re building by lie Buy Area Air nllly Elicuwhich
mil huu,rdnn% ter eonuuniwne m A'lincd by ]ht, Itny Arcu Air Qualhy Mtmugcnenl
pOIhIHt- COMP111 {TOR I(NI,lX10 BTU)
BOILER- CONINOVBR 100.000 BTOI
District!
C3 Ye, ONo
Ih 'ill I' tl 't 'I q ' � ads (III (JS IdcCa.
tote Distill ,VSIr Cd S t S 525533 )255'1)1 J r 11411 little
nut Illy ha I I It yy te. /upI'sihftyt if)the .scuptnt
mm t f<U.upuncY
ns�
/
APR CONDITIONI!R
ISSUANCE DATE
/ .•. -�^ a 0
SIM RUSIDIM'IAh MECIL SQ. Fr
'TOFAL;
�Ovg�'mu� c- �C�N /1���f
ISSl11iO 11 V:
UYt-lut