S 2972 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPRR'I'INO BUILDING-ELECTRICAL PERMI"1'NO.
IVOILDING DIVISION APPLICATION/PERMIT Ph11MBING-MECHAMCAL
ItUI1.DiNG PROUEC'F]DENI TFICATION
BUILDING,IDR : �� / �� SANITARY NO. APPLLLIIC�'ION SU....ITT DATE
et�c
GWNE 'SNAME: _ //\/-''K•. I'll0 ': CONTRACTOR'S NAME: LIC NO: v
/ � r/I��f� JI-44
r . r a
NIC CON'I'ItOL k
ARCHITF.CI'ENGINE.R./ /'( Jh1�/LIC NO', ADDRESS: ❑
COSGAC, PHONE: HUILDING PERMITINFO
Consultant Fees Paid by Applicant(Initial) BLDGi ELECT 7 PL 7lT4/ V+ r4rQ✓ f4r{'/ 14nq/
ford th
LICENSED ade,prRS IiC1.A RA TION QTY ELECTRIC PERMIT HEI?
1hereby0)of Ina)1a3fthesedander vtlPmfgne.fmope.,v(emmnendng AL, DESCRIPTION
OmZ with Section 7000)of Division 3.fthc l3unnens and l'rofessinns Calc,nnA mylicens iv RESIDENTIAL
ulpp 1 PERMIT ISSUANCIi
QF, LiceneClasnd,nine). �❑..ffS''FU\VL ❑KITCHEN kEMODEI.
UU Liccna Chien Linty APPLIANCES—RESIDENTIAL rySwDDITION ❑PLUMBING RE.PIPE
Na W Dan commclnr _
Fly ARCHITECTS DECLARATION PANELS
MUT:rI-UNrr ❑STRUCTURAL
ZOyZ 1mndcmm.dmy plansshall Ne meadas public recants MODIFICATION
O'y'IQ Q UP 1021)AMPS ❑INTERIOR El CHIMNEY REPAIR
F4tW Licensed Prnlersivnnl 2IId01)AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 11X10 AMPS El SAID RfiMODE1111EPA 11< ❑UIiMOLI'I'ION
W 1 hemby allir that aI am caved,roto the Comm"a's 1 accrue Low for the
iqqi((O L U following mason,(Section]11315.B-ines,and Profession,Code:Any city or county SIGNS FLECIRICAL ❑OTHIiR
Yl3 LLE' which reyaim,a permit to commruct,ife,impru ,demoli,h,or repair any eoulam
� prion.Its ls,monco,all.re'dual the applicant for such pmmit mNe a signed.shdemm�t SPECIAL CIRCUIT/MISC.
by that he is licensed pursuant the provisions(if the Commons Licenx Law(Chepter9
QO (cmm�tcnnng with Semi.n]dlXBof Diu'ision3uf lM1C llusincna and l'ndue,ion,C.Jc)or TEMR ME'117R Olt POLH INST.
d O.Qo that he is eemnpi therefrom and the basis Iia the alleged exemption Any violation of I,)G/ADI�1'/0 EMOIXI ION
AII
x^+� Section]031.5 by any applicant for a permit subjects the appllcanto n civil penalty of POWER DEVICES �� U
ID�m ❑TI3NAN1 f )OD SERVICE
nal mora mae five morn,,(it
ySon).
e 11)1 I'RQVIiM1iM'
_< wi Lo the the nwi nr my amPloyced.romwages a,their state compensation. SW MINING 1'001"ELECT'RIC I'W.�lht
will Prom"inrk.mod the she Conid,te not,Li,come Lave dowmal n sI a,ly 1.E wdereex TI
and I'rty who
b Ctnlc:The over t eredi Lind who dos such
mm apply t.un.encu of OU'1LETS-SW' LLIS-FIX'1'IJItES
4i his own who buile.s or improves thereon,and who ntsx much work himself m though
his own employeese pmvidad that such improvements within thin nm Imarof .r offend for NEIV R&til I' 1.EhIiCTR SQ fT.
sale i,bot. uwevcn ll have the bur en of phmcnl is sold (id t Wild rt mpm vctior or-the $Q.Fr.FLOOR A 8/SQ.lal'.
c'Nafdcr will have the burden of paving that M1c(lid not Wild nr impmvc for pur-
�po of sawn).
:u owner of the prtperry,.B exclusively enntmedtig with IitameeC onset ors i- A
construct thedoes
not apply.9W ovearrof,,li dyPriwho bei Com,:)The Cs Ino on,Li-
m Law doesnmapplyjcun with
arotpmpens whoheedsorimproves Contrn,am QTY. PLU PER PEP, a
who amtmcts Ibnuch Fmjecu'with u canuucuu(s)Ilcunmd pursuant the Cnnnamor's
Lieensc law. PERMIT ISSUANCH
❑ lam ex 1' .w. ,H&I'C fnrdl'n rcnsnu
,L ALTER-DRAINN VENT-AT. ii VALUATION
imam�wncr - Dam
WORKER'S COMPP.NSA'I'ION DHCLARA'FION RACK PLOW PROTECT.DEViii
I hereby alHrm under pvnahy of perJury one n!the fnlhwmg Jeclar tions:
I have mrd wil load mai no CaninaaeofChu.conn af-imam for Worker,Compel- DRAINS-FLOOR,ROOF ,COND. STORIES 'I'YPC CONSTRUCT ION
action,its provided for by Section 3901 of,h.Lid-Cale,for the parfah a of the
work for which this permit is issued. FIXTURES-PERTRAP /
E] I have and will maintain Workers Compunmha,nn Insurnnee, myuim d by Satalon
3700 of the labor Case,far the performance of the work for which this ii is issmad, GAS-EA.SYSTEM-I INC.4Oil I'LL OCC.GROUP APN
My Workers Compensation In,ommce carrier and Policy numhei um:
Conic,: Policy No GAS-EA.SYS'I :M-OVER 4(13A)
CER'I'117ICNI If OF EXEMPTION FROM WORKERS' re3•� / Y�
COMPENSATION INSURANCE GREASE/INDUSTRI.WAST17 INTERCEPTOR
OlJI1,1IINO DIVISION la1&S
ITM1Ls.mainn note rel 1,a.ntpkletl tfrM1e pcnnit isf rmtedn'
huneddollurs($100) GREASETRAP
or Icsn.l I'LANCIIIiCK ITE
leendythatiothe performance ofthawuzkfarwhichthis permit isissamd,l shall SEWER-SANITARY-STORM EA.20()17E
not employ any person in any manner so as to become subject m the Workers'Compete ENERGY FEE
0Z sation laws of California.Date WATER HEATER W/VENI'11i1.ECl'R
C Applicant GRADING FEE
�=
NOTICE TO APPLICANT:HL alter nmNng)iris Cerilicme nl'Exempaion,yon sM1.Wd WATER SYSTENVIREATING
F , beano,subject to the Worker's Cnmpcn.ation F.AW..ms of the Wort Code,you mus) SUITS FEE
a Q forthwith comply with such prnviaion,n,this permit xh;Jl be dcomed revoked. WA'T'ER SERVICE
U O CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL.PLMB. SQ.P. PAID
I hereby afllnn that lhe'c is a ctmswction lending agency for lire perfnmmnce uI oat Re "#
Hthe wok far which this pe.,it is t,ted(Sea.3(19],civ,C.)
Lender's Na V TOTAL,!
O Leade-AJdre.as 'I OTAL:
1.... I certify that I have mad this application and state that the above infomtennn is BUILDING FEP
rn4h mrred.l agree mcoanpy with middy one coonry ondinanmsand state lmwxrahaing u, Q'I'Y. MECHANICAL.PERMIT PEE
C.) ,Z building rnmwai.n,unJ hcrehy authorize representatives nl thi,cirymennuapm,la, SEISMICFF.F.
abrve.mmhti ned property for inspection purpaaes. PERMIT ISSUANCE
(We)agree In save indcnardy and keep hamdu,s the City of CuPerwnn against ELECfRI I
liabllities,judgnnenu,costs and expenses which may in any way came against%aid City ALTHR OR ADDIO MSCI I.
mzcnuence.fyre gruandg of this permit. PIDMRI GFIiE
API'I.I' "'a DI'.It STA ND.S ANU WII,I.COMPLY WITH ALL NON-POI N' AIR HANDLING UNIT CFO 10,000 CPM) MECHANICA PRE
SOl' 'P.'R ULA'110N5
X91 ; AIR HANDLINGUNI'1rOVER I(fBIN)CPM) CONSI'RUC ONTAX
l
Signmmeof ApplicaMCantmctnr Date r:XHAUSTIIOODOVIDUCT) HOUSING ITIGAGONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building tscupunt nacre nr handle ba`nudousmamriol HEATING UNIT(TO 10(1.01)BTI)
as def red by the Ce'rom.Munici al Cade,Chapter 9.12,and the health and Safety
is A-
Code Section 25532(:0', HEAI'INC UNIT(OVER I"I t )BTC)
❑Yee Nn
VENO'11.A'I'ION FAN SINGLE RF_SID) PAID t
Will thea applicant ar fnture building I use c[ni,menl nr devices which Dow Hee 1pl
401 pp gnctheB 11 BOILER-COMP(3HP OR IW.000 BTU)
emit dm>ab.us air nmmmiwnuas dfi ed by the Bay Area Air Quality Manngemem TOTAL:
ni.mn9
p Yes � 1)OILIIR-COMP(OVER IlX),OW 13'1'U)
I have m c hozandoun matcriaws regnireramm,under Chapmr 6.95 of the Cali- AIR CONOH'IONEIt ISSIJAN DATE
tomio Ile,t th afety Code.Section,25505,255)3 and 25534.1 unJcts lord that if the NEW RESIDENTIAL MECH. SQ.F1.
he 6d of currently M1ave;tenant that it is myhenrymsihilirymnmifyt occupant
orate is whlc met phi.,at nwanaofaenhrcZ
plan
�
Ownenu amthoriad agcm VOLoc TOTAL: ISSUED Ii Y:
OFFICE