S 1544 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEwrINO BUH.DINf.-ELF:(71 RICA], pLl{I�IT ND. 1544
BUILDING DIVISION APPLICA'I'ION/IaI?RMIT rhuhunnc-MECHANICAL \!
BUILDING PRIIJ I?C'I'IDh:N'I'IN'ICA"LION
BUILDING ADDRESS: SANT I'ARY NO. AVPLICA'l1UN SUBMIFI'ALDAI'
16ld-3 Wooll ooZ Cut ;r �-Ielyp ''Y Lc xiiv l
(IWNF.S NAME: PHONa: ;NMA r5X 11%/70'/ NIC CIINI'ROLN
Ick A ET NTnRACIYIR'�N' _
nRCI11TUC'r/I:NGINlilik; LIC NO: <J-CJq-
CON'IAC'r: THOSE. J J rJ • `BUIhDINC P13Rh1IT INFO
❑ Consultant rets Paid by Applicant(Initial) BLFG IR,ECI PLUMB MECII
LICENSED CON'nsed ander,DECLARATION,HA Chapter
ELECTRIC PERMIT IEE
1 nercby mrml dmf].it,B,enwa ander nrn.ieimn arcnnpmr 9(uam.memc;ng .10B DESCRIPTION
OWQz with Seeion700(aid Division Sof the Businessand Pmfessions G+Je,andery licensers PERMIT ISSUANCE RESIDENTIAL'
FWO in full)lorcc,'n y97 ao 7 ❑SI:DWL El KITCHEN R'EPI E
�UU I_iare �' LiaN API'LIANCILS-RESIDIiN OAT. ❑ADDITION C]PLUMBING kI PII'li
FF-Zyl Dam Convuchn
NG1 ARCHITECPS DECLARAI ION ❑MULTI-UNIT ❑STRUCI'UkAI.
Z O`an z 1 underumd my plam,nall he used u.public accord., PANELS MODIFLCSTION
oz,- lP10IIOAMVS [I INTERIOR C]CHIMNEY REPAIR
P-I-, Liccnsul l'ndesuo..I 1_071000AMPS IMPROVEMIN'f E]SWIMMING POOLS
OWNER-BUILDER DIiCLARA'I ION _ OVER UMEASIPS ❑BATH REMODF,IIREPAIR ❑DEMOLITION
C 6 I hereby aflimt that I am exempt Inns the Cantmcmr.v License Law or the
W
[]OFFER
c,F joboa e,mason.($,union 7031,5,Bmimc,x asst Podeloku,Ctnlr!Air,city or....all SIGNS ELECT RICA],
y
which a perms er amume,alter.intit demolish,nr repuia any nlmewre
I.. C) priorm it, u 1. "mineshe ppl t for suchpermit t Cite a signeduatemenl SPECIAL CIRCUIT/M ISC.
W9999 ty 7+ Ihnh .I' Ip to th p at Contractors t L (Chapter COMMERCIAL:
aQO (tnnm,aIng with Sari on 7000)d D:voter.;t1 the 13titr,:ndl 1 too,Cedc)or I I:MI'MI:I'ER OR POLE INS'f.
a ax e¢ that he i,exempt thcmlin.n and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUUIIION ❑UEMOLI'I'ION
Www Section 70315 Tian
not any applicant far a.. edwbjecb m the applicant a civil penally of POWER DEVICES ❑'ITNANT ❑FOODSERVICE
nal nmrc Than Svc hundred dollar,($51X1). IMPROVEMENT
1- an
of the propcny,ar.ny cmpinycc,wilb wu6"-v u,lhcinnlcumgwitoatinn, SWIMMING I'),L ❑U'I'llliR
IiLIIC'f
F. will do the work.and the sumeum n not intended orodcad for sale(Sec.
G 3 m and Professions Coda:TW Corsi License Law does not apply to an Owner of OUIl.EfS-SWITCIiI!5-F RC
property who build.,or impnrvex themou.mid who doe,each wad himself or nhnmgM1
hi,own employee,,prmvidwl dear each Intpmwnmne,are nal intended ar ullercd for NI!W RESIIIEN'FIAL 171.1!CPR P I'.
xale.If.however.the building or improvement is sold within one year of completion.'he
SQ.PI'.FLOOR AREA AISQ.FI'.
tas er-builder will have the burden of proving that he did not build Or improve for par-
PAID las ret nl suk.l "rIYI A P A
❑1,a owne,of dee ra,pert,an,rxdmiscly a...(acting with r,co al vammllal to
conquacl ale p 1 I Sac.76bl Bri,inev,and Ik f s Cat )IN,Correctors I I- a�
,a Lawdoes tapply l of linearity who builds or p s Raman,and QTY. PLUMBING PERMIT
who, na "cf eltpr n,."It 1.loonalon(l)1' d im-1.1111 Toth C .maral'x
Ijeetac Law. PERMIT ISSUANCE Gil
1 am exampl under lice. .B.@ P C for nd,reason Cp
. Owner Dare AI:1'IiR-DRAIN.F V[iNT-lVA1TiR[EA) /'CnVAI(YU
'. ION
WORKER'S COMI-ENSAI'ION DECLARATION HACK FLOW I'RGII-CDEVICE ��
1 hembv allium under Penalty of perjury mac 01 Ne Billowing declar itione
I hocnd will maintain aCcnificntc of COnwnuowll-inxure for Workds Compcn- DRAINS-FLOOR.R(R)P.AREA,COND. SIORDES TYPE CONS'IRUCTIO
.,atlas,us......idea be by Suction 37000 the Lnho,Cn 1,,to,the pe,tor a,c at the
work far which this peril is iuucd. FIX'I'U RES-1'17R TRAP
1 have and will minimum workds Compensation Insurance.as required by Section
3700 of the Lalwr Code.fear the arbaftence of the work fur which this permit i,issued. GAS-EA.SYSTEM-I INCA Oil FLE[S OCC.GROUP MIS
My Worker'x Compcnxution lnsamncccnicr and I-obey nuntha,ear: GAS-EA,SYSTEM OV17R 4(RA)
mar. Tal icy No,
CF.RI'IFICATEOF EXEMPHON FROM WORKERS' GREASFIINDUSIRI.WASTE INTERCEPTOR
Cl 1117,NSAHON INSURANCE BUILDING DIVISION TEES
IT howeietnced not W,onn,lcmd l On,panni l,ha o.tett irNdolmts(Sle(ft GREASE'I'RAP
1'hANCIIECK hili
or Iexs.)
Ittrtiny.hut in the aparny
of the becameeek fee
does,at
Pertare Wasiasuc ownhall.
$IiN'F,R-SANITARY-STORh11iA.2IX1 t1'.
net employ any person in a y manner ro as m hecunm xuhjen nt rhe Workerd Cn.npery ENERGY IEE
Z Zinn Law-C/li2rNi 19 WAI ER EVA I'UR W/VHN'I'/HLIiCI'H
r••� - Xu , l GRADING II?li
]f.GLeapliCE; _
-"""NOT ICE; A (CANT:IL soca making Ibis Cenifcme mf IisemPlton,You should N'ATER SVSTEM/1'RIiATING SOLUS FEE
f-a becamo,uhlca Earn,Wink"',Cu.nitemmton Pnw'i,ionx of the Lnhnr Rolm,You most
aiQGimhwilB,nmpywilbxcJ reeWA'rl3k SERVICE
rn >`OiSlRVCI'ION LENDINGAGE:CY NIiNRESIDENTIAL ILMB. SU.FL
herehy anion lhat thorn is a con.,an,Iion letting agency bar perhmamce of Ilam M
ipt
LUL F the work lar which do,permit is issued(Sic.9097,Civ,Cd
O Lenders Name TOTAL:
GI'AI,:
V Lendch Addrc ' '
�•'' 0. cr,.py`ih'nl I have read obi,application and nwro That the abno,iafonnerror i., BUILDING Glib
F ( , eomed.l agree to comply wilhah clly and county onllnnnccx and,inns law,mining to QTY. MECHANICAL PERMIT FEE SEISMIC IEE
V Z building conswclion.and hereby amhorim mprewnlalives oflhis city ..vita upon the
nMrve-Remained property far inspection fano,. P17RMIT ISSUANCE. ELECTRIC tai Ci
(We)ubrcc m xavc,inJuu.nlfy anA kiwi hmnduv the City of Cupcninn ugui nal
Ilabilitiex,judgmentx,c..ax asst expvn,e,whicM1.nay in any woY:'txmc ugninw.,aid City A:IER OR AGO IGMF:CH. PLUMBING IT.
in consequence of the granting of this pennil.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING ON]]TO 1h(XX)CFM) MECHANICAL,a
SOUR NE REG .AI'1(1"
�` AIR HANDLING UNI'I'(OVER 14IX0CFM) CONS'IRUC'HO TAX
&A A..gnaum:of Applic:mtlCommnor D EST,
S XHAtEsrHOCD(W/DUC`1 HOUSINGMl1' iATIONFEE
HAZARDOUS MATERIALS DISCLOSURI3
Will the applicant or fmnre building rccupanl nmrc Or handle hamrdnux mmmriol II EATI NO ON fl(TO 100.100 It I'U)
its defined by the Cupcninn Municipal CMc.Chapter 9.12.and the Health and Safety
Code,Section 25532(x)f HEATING UNIT(OVER I00.0n)IITU)
Yes 1-1 No VENTILATION FAN(SINGLE RESID) ('AID Date or#
Will the applicant or future building occupant use equipment at devices which IR)11 ER-GOAIP(3111'OR 100.000 BTU)
.nil kvurdonx air cnmaminunl,To Jelinnl by the I{uy Arca Air Quality Management UTAI
Uhtri°tl
Yes NO
BOILER-COME'(OVER 11HIWil BTU)
❑ ❑
I nave rend Inc O-adaux nrvwrinl.x re tt anter Chn ler fi!15 ul the Calm AIR CONDITIONER ISSUANCE DATE
25533' li:miu Ilcolth h Sash,Cerra.$satires,255115,25533 and 25514.I undecaunA lbw it IL° NIiW kIiSIFIiNTIAh MUCH. SV Irl'l
of the re duce rte is which Love a tenant,that it is ua rc,pmab111ty mteo fy the occupant
' of the requirements which mum tic mi Prior In issuance olaCeniOcme of Occupancy.
Owneraranthmriealagenl Dale {••V� y� ��y�l ISSUED BY:
OFFICE