S 3280 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
E_V'S
OFCUPRRTINO BUII,DING.ELECT RICA I• rEl n'No. 0
LDING DIVISION APPLICATION/PERMIT PING PROD CIADEN IF:C
IfI11LU1N1:I'211.11!CI'IDI:NI'IFICA'0ON
NG ADDRESS: SANITARY NO. APPhICA'IION SUIIMI'1'1'Ah DAH!
o Z �� .Qrr �NAME: PHONE: CONTRACTOR'S NAME. LIC NO.
N/C CONTROL.
G ❑ s
RCIII'I'ECI'/IiNGINEIiR: LIC NO ADDRESS
CONTACT: PIIONE: BUILDING PERMIT INTO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG F.LIH r PLUMB ME'll
/ V ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEE JOB DESCNIPTION
1 hereby affirm that 1 am IicenseJ under provisions of Chapter 9 mo n mending
M,ZZ won sedtion 7ak)µd Division Sonne Busines and Professions GNe.and,nylicenseks l �Q NF TI L:
Ia1 Q PERMIT ISSUANCE
Cwt- in full farbcand effect. ❑KricBE;REMODnI.
aUU Livedo Class lic'N AI'PLIANCIi.S-RIiS1UtiN'1'IAI. TION ❑PLUMBINGRE-PIPIT
FZW Dad Contractnr
❑MULFj-UNIT [I STRUCTURAL
FOw ARCHITECT'S DECIARATION PANELS
Z Ou,,Z I understand nryplanx shall nemed aepuh1w nxmLLs MODIFICATION
OZ� r UPTO NOAMPS L 2-� iRIOR ❑CIHMNEYREPAIR
Licen.mdl'rolk,,nnall 11WNFilt-11UILUIiR DI[CLARAl10N -NI I(SX)AMPS IMPROVEMENT SWIMMING POOLS
y+l4 .4 OVER lINX1AMlti ❑BATT{RE.MODEUREPA1R ❑DIiMOLITION
C C I bemM1 Minn tba I t exempt Inn the Contru,nu,Liamec Laws for the
CW,U following rens....15ecttom]1131.5.itu,incns and Pmlessinns Code:Any city a eeuu, SIGNS EI.ECI'ItICAI. ❑OTHER
m 31L y which mynimx a pernm m ennarnet,Beer,hnimve,demolish,or minor any swears
.F.I� pr m I_ II ,fin II 11 'It I I g d,awroenl SIT IALCIRCUIDMISC.
1z1yt thin l I 11 t the I t t1 C I 1 .1 I' (Chapter 9
c, (ton na ngw'Ib S,,uf ]IIfND fD x'n 1 fid B :' 's II t .' Cde)o, TEMP.MI:'1 I:R OR 1,011;INS 1'. COMMERCIAL:
L p o ry deal he In c.enpl Ihcrcfrnin nod II c bass Int tire alltgid Icon pl r,.Any v'olaeun nl DGIADDGGON ❑DEM01AMON
Sermon Nl3l5 by any nppflnnlfora pvnonil aobje,"te a,pficnm m a ,,,I Perot,,of POWER DEVICES �VONFWB
'T ❑FOOD SERVICE
e mom Ihmt live hundred collar,($500) IMPI OVEMENT
� O I,as owner of the proper,or my cntployce%w 1111 wageelirlhcir sole colnperemion. SWIMMING POOL I!I.ECI'RIC
F• will dolhcwnrk.and the,cf unc ix..(fair ieJanuffard Ga suld(See.7194.13nsinels ❑O'CHh
W 3 m and Profession%Code:'I'he Contractor',Licemv law does not apply n,an owner OUTLE'P.S-SW GCIG7 -FIXTURES
progeny who hardy ar improves Ihemm,and who does such work himself or 11,u ,
jo
his ownctn In ccs,providN thin such int,doonu ors are not Intended or offered for NEW RESIDENTIAL ELECFR SQ FI'.
P Y SQ.Ff.FLOOR AREA LSQ,171'.
nate.If,bowaom llihbuddingur rn
nproveml iwithin oane yeof completion,the
rye
cr-0uilJcr will have the burden tit
til proving thin he did not buil)or improve for pury
WF.olsu
le.). 'AI.: �33 (�
ax owner of the propq contractingcny,am with licensed contractors to /
Carl the protect(Sec.7194,nosiness and Prolessiom Coal The Contractor's Li-
melawd„es on,apply aw
+an owner of propdny, proes whit hudds or imvthereon.and QTY PLUMBING PERMIT FEE
who cummcts for such projects with a tounalrLM Iieen«d pit I.the Conwaors
Limnm law. PERMIT ISSUANCE
�Iamesemp uMer See. ,BAPCfn�Ws myon
"zle,47V ALTER-GRAIN&VI!M'-N'ATIiR(1!A) VALUATION
!;Rs C(1 ' ',ATION DFCLAR6DO BACK FLOW PRCTI ECC DEVICE: O U IJ
I hereby affirm under penalty of perjury,one o(ehc follman,f Walker,
❑ Thaveeno will for by naCcnifcmcof he LatuoCode far'be Workers Compen- DRAINS-PhOOR.RIX)Ii AR1iA.CONO STORIL.S '1'YI.13 C(INSTRUCIION
mein,,az hick thi for by$storm 3]1X1 of the Luton C,dc.Por the perfonnanm of the l
wink for which in permit is issued FDTURI:S-PRTRAP
1 have and will ode ton Worker's Compensation work
hicke. his reqper by Scai
J7UIl of the laMn Code tor performance nl the work for which this permit is inured. YSTEMI C.40 S (KC.GROUT' 9APN
My Worker's Compensationam
lnsnce curia and Policy number am: GAS "fEM( :R 41F 3S- 7 ,,,0
/O
Cnmec Policy No,
CF R'I'IFICAT1:Or 13XI3MI9lON FROM WORKERS' GREASO NO(1S'FRI. FN"I iPrOR
CONN iNSA'I'ION INSURANCE 1UILDING DIVISION FINS
('I'h'nscctionnceJ nut hu can.plelell,dolmnmi.i,fornnc moded dollar;($11111) CI 4r RO 7 r
nt Ibex.) I'LANCHP' �iP sl
l,r,if,,u,0n0beperlbmrenceunbd work for which tM1ls tmnnit is insudJ.l,hall ShWI!R-SANI'IARy-STUKMF/,21M FE
nI"u'loy anypennon In any manner soa,lm bee n...xubject,o the Workenl Cnmpen- ENTER, Dili O r L/
Z suht hawxoi Culilomia.Dan: WATER[]EATERW/ ' OR GI iii
NUNCHTUN'1'LICAN'P.Ignllernr.IkinglM1is Ccrtillcnteat Esen,pGon,yon should ;(S'IENVI'RHAl'ING
nobject b,the Workers Cont mnmoon t the Luton Code,you must 5011.' E
becme
J Pfmisinnnu
(k � Rmhwil,comply volt of prnviti...o,a n,putok hall be deeovelmvoked. WA'I ER SERVICE
WQ
a' CONSI'RUCION LENDINGAGENCY NEW RESH)EI1'IALPI.MB SO IT. F'AN
henhy:dlirtn that rhere xnenneltnctinn lending.loew,forme perfnrtnuneenr nate Rectinp
P. F the ,,,it Rn which this lmrmit is IXsncd(Sec.3107.Clv,C.)
TAT:
C) Lender's Name
V Lcndcr'x Address AL:
>� LLI BUILDING FEA
1 cenily that I have mad this applicallno and seam that the above iofnnnmion is
6 TY MECIIANICALPERMIT FEB
r) Z building 1 onsi el comply with all city and county oNtive—f and smut laws a mining m Q SEISM C i Q
V Z building emntmnlon,and hereby authorize mprexmtmives nnhis city menmr upon We X
Ilmvammeional property for ireapcetion purposes. PERMIT ISSUANCE El..7 P'. 0
(Wo ag ee a+s�ve,indemnify and keep harmless the City of Cupcnino against
Iiabiluies.,m mms,cnem,nd ev,srews which may in any way accmc against said City ALTER OR ADD'TU MECII. PLU FEE 0
in comcyuenc of the granting of lhix permil.
APPLICAN" UNDERSTANDS AND WILL COMPLY W'IT114LL NON-POINT AIR HANDLING UNIT('f)10.000 CI'M) MECH, ]CAL FEE
)URCE 'GO TIONS.
AIR HANDLING UNIT(OVER 111.1X0 CFM) CONBI'R TION TAX
awrcoo^ mcu,r ¢ EXHAUSTHOOD IW/DUC17 HOUSING MITIGATION FEE
F ZARDOUS ; SUISCLOS U RE
Will the applicant or future buildingoecupam store of handle hverdou .inumal HEATING UNI'T(To 111100X)131'U)
as defined by the Cupertim+Municipal Code,Chapter 9.12.and the Ilnhh and Safely HEATING UNIT(OVER I IXI.IXX111'1'ID
Cole.Section 25532(1)]
Yds No V GNI'11AHON FAN IS INGLE R 1510) PAID Umc Receipt
Will the applicant or future building occupant use cyuipnmnl or devices which BOILER-COMP 011POR I(Xit)(M If GB
:mil haturrin s air cl nlmninauts as dcfacd by the Bay Arca Air Quality Marugemcnt
Diadcf' HOILUR-COMPIO1I31 1a1,IXXIB'TU)
Yes
Inirentun sumer per AIH CUNIII'TI(1NIiR ISSUANCE DATE
"�he havenminun ntnteriuls m 1 I Cbn t G.95of the Culi-als;Sections 25511.5,255)3 and 255)4.I end,,,, ul(an,it the NEW 1<IISIDI3N'I IAI,MECI I. SQ.Frlybuvean,nanl.fro irw my ruspmsiMlitya , oy l'yor'apamail M1e mdt hn, ororcrin
I)nm 'IUI'AL: ISSUED BY:
OFFICE