S 1531 (2) I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'I'INO BDII.DINc-ELECTRICAL PB CI'No
BUILDING DIVISION APIsLICATION/PERMIT TING PRNG.MECIL\NIFIC 1531
BI111.IJING 1'ROJF:CI'IUN.N'I'IF'ICA'1'ION
HUILDINGADURESS: SANITARY NO. APPIICA'IION SUBMI'PIAL DATE
2 ;z L-41.-1-0 4
OWNI!It'S NA PIION17 �D ('ON'IRACI OR'S NAME. LIC NO'.
WC CONTHOLa
AliClll'I"ECT/IiNGINIiEIt'. .IC NO AIlIlR1iSS ❑
CONTACT. PHONE: 13UILDING PIiRMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) . LB MOHLOO
LICENSED CONI RAC'I OR:9 I1CLARA'IION ly, ELECTRIC PERMIT ITE
I hereby dd—foal lain loeruct made,pro,d,mns or chapter 9 aommencing JOB DESCRIPTION
�xZ with Seelimn700(yof Division 3uf the lboines,and Pn fv,slonv Code.,odnry liceis RESIDENTIAL'
O OPERMI IISSISSUANCEh W in full bola and cff«I. ❑SITIWI. ❑KITCHEN REMODELQ,UV License Class Lick APPLIANCES-RESIDENTIAL [I AUDIT C1 PLUMBING BE.PIPE
y Q 6 Date Contrmair
ARCHI'TIi(TS DRCLARA'1'ION ❑MULTI-UNIT ❑STITECTURA1.
PANELS
z O,,Z- I undemmul my plan„hall he aced as public record, MOUIPICA'I'ION
OL-n OF TO 200 AMPS C1 INTERIOR IMNEY REPAIR
1-�F'nl Licenaed Profe,vional 201-1000AMIS IMPROVEMENT SWIMMING POOLS
,^t,-1 OWNER-IIIIILDHIR DECLAItA1'ION OVER IOIIIIAMPS ❑BATH REMODEUREPAIR ❑DEMOLTCION
S C¢W.d I hereby affirm that 1 am ewmpt from the Cuntrumur's License Law lar Inc
4..5 a V following reason.IS,xfmn]031 S,Business anJ Prnf,,,inns Code:AnY coy or coumY 9GNS EI.ECI'HICAI. ❑OTHER
LL]
C,y which mqn in,u permit nm"at u'l,alert,arinmvr,(mnelish.(11 repair Iury vinlcmm
Od prior to its iouame.al.,onnuire,Ine applicant R,,,.,b .it I,)file asignedntvtenem SPECIAL CIRCUIT/MISC.
that he is licensed pursuant it)the provision,of the Comments license larw(Chapmr9
n1�C0gwI' COMMERCIAL:
C (conuncnein h$m:nnn]gHO of Division3n(OCltmmrms:mA l'mfmsrnm Cdc)or "TEMP.METI?R OR I'ULI$INS'I'.
d dC that he k e,cmpl Ihernfnml and the bavis or the alleged emmpuon.Any violwian III ❑NEW BLDGIADDITION El DEMOLITION
Xn Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
1- In n 1 nc than live hundred,]d1ws(5500). ❑'1"TSNANT ❑FOOI3 SERVICE
I✓Sd ,mwnen I ffic,alatny.or nayenyaloyce,wilh wngm at,lire',sulennnpenulinn, SWIMMING POOL ELECTRIC IMPR(IVEMF.N'I'
SFO viiiJo.he tuna.and the sweat,,is not Intended oroffered for sale(See0W3.Busine,. ❑ THER
t�ia 3 m MIT Code:The Contraanr%License Law does not apply Ina omaar of OUTLEI:S-SWITCHES-FIXTURES
p' Piwho hn'dds I impm c,Ib—....and wbu Ince web work n...i,lf ar 11hnigb
bis own employees,provided that,ucb Impnrvcmeav are nut imanoled cr offered lin NIT RESIDENTIAL ELEC,R SQ IT. D
vlc.IL however,the building o,immunchncnt is mid within one year of completion.the I•T. RARF,A 5/SQ FT.
ce"builder will have fire hurdcn of proving that he did not build or improve for pnr-
ofIdc, TOTAL APR 2 0 ANSig
L]1.as owner of the prnpens dna e.clavively contracting with ranted Orm rmtor.to
nn,trmct me proles,(sr,]Baa.Ba,Inc..,III prof,„ion,em-,Thr CooTmnoraI.i-
se Law doev not apply lm an owner of property who build,or improves Theme ,and Q'TY. PLUMBING PERMIT FEE
whocommas forsuch projects withacommcton,)Imenvedpursa,mm the Commemr', I4. Vf VWf'C,',1IIrt,
License Law' PERh11'I'ISSUANCE`\❑
In eaenaIn under, .11&P C I...Tbn rea,on
Panor IAty ACI'ER-GRAIN&VENT-WAGER IBn) VAI.UAI ION'
WOR MIT It'S COM PENS A 1'ION DIECIARAfION - BACK FLOW['BUTIzC'I'.DEVICE
I herchy affirm under penally of perjury one of the fallowing declarations
❑ I nave and will maintain a Cenifcate of Consent o self-inmm for Woul.er's Compen- DRAINS-FLOOR.R00EAREA,CONO STORIES TYPE CONS,RUCTION
.:tion,a,provides for by Section 370D of The Laborade,for the perfoma;mce of the
work to which Ni,permit i,iamcol. Il X'I'URES-PER I'RAI'
❑I have and will maintain worker's Compensation Inwmnce,as required by Section
3700ofmc LO-or Code,for lbe perfmanccol hework forwhi,hchis Or, I, iii GAS-EA.SYSTEM-1 INC.a OUTLMS OCG GROUP AI'N
My Workar's Cmnlmmutlma Insurance carrier'anti Policy number arc
Cartier. Policy No: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMVIiNSAON INSURANCE GREASPJINDUSTRL WAS'Tli IN'1'ERCI!PCOR
H
BUILDING DIVISION IlilS
(T'hi,mcaian need nal beromplad if the pemnil Lv baronchundred dolluo(51 W) GREASE'I'RAP
nr Ica,) PLANCHECK FEE
I lenity Phut inlhcperforn,ume oleic work for iflaodhis pcnnit I,In nod,I,hall SE\VER-SANI'PARY-S'I ORM EA.21111 PI.
not employ any pun al in any manner so as m.bemna,ubject m the Wn kc,i Con.pea- ENERGY FEE;
oz scion laws of California.Dam %VAT ITR HEAT ITR W/VENT/ELECR GRAVING Ielili
z O Appr,alal -
y NOT ICIT'10 APPLICANT IL alter linkinglhi,Cvnhi,a,uI l isumpuon,you should WAILR SYS IENI/TNUAl1NG
become subject to the Worker's Compensation pmvisionv of the Ichor Code,you mast SOILS FEE.
foahwith comply with ouch provisions or this pcnnit shall IN deemed revoked. WATER SERVICE
aQ
UO CONEIatthe is
constENDING ruction
lending
NEW RESIDENTL\L PI-MB. SQ.FT. PAID Date Roar'
I hereby affirm that mere i,a ennamnion Ienamg ag,ner rot mepemarmanea or
Ibaiv,nrk To,which IT Ixmnif i,i,siad(Sen.3097,Civ.C)
CL U I.cri Name 'TOfA1.:
ULender',Address TOTAL:
} i I crody thin I have mail Phis appliaaio,and slum that ov
The abe information i, BUILDING 122E l
j-
F-th amen.l agree to comply wah all e'ny and comaynol ane,,I I,fate la--,pang In QTY. MECHANICAL PERMIT FEE
U z building consminion.and hereby authurim mprianative,of lhischym enmrugm the SEISMIC FET
,neve-amour nd mapeny for im'pcctinn p,upnecs' PERM IT ISS1ANCL
(We),grca m sus,Iadcmmty and Ave,lot nnle,Inc Carol Cuperlinu again, ELECCRIC ITP
Ilabilide,judgments.aras and espemes which may in any way acerae agaiml said City AUHR OR ADD TO MECH,
in n, uence of The grating of his pemah. PLUMBING IIJi
ry
APPLICANT UNDERSTANDS AND WILL COMPLY Wl3'll ALI.NON-POINT Alit HANDLING UNIT T(TO IU.W(ICPM)
SOURCE REGULMHONS. MECIIANICAI.FEE
AIR HANDLING UNIT(OVER TO.”CENT) CONST RUCHON'TAX
Signature of AppllcanPCrouniOn Time EXHAUST HOOD I WIDUCPI HOUSING MT ITGAT10N FEE
HAZARDOUS MATERIAIS DISCLOSIJR17
Will the,pphe,mor l umm haddingoccncimmane,handle ha,zad material BEATING UNIT(TO I01,00)It I LE
defined by The Chlorine,Municipal Cod,Chapter 0.12,and the Henllh and Sudety
Crdc.Sector.25532LdU HEATING ON]'I'(OVER K0AXm BTU)
E3 Yet
El No VENTILATI(IN IAN(SINGLE RESID) PAID
Date Re,cipt a
e
Will the applicant or future building occupant use equipnanl or Device,which
tie bwm ardoair ennmminomn an J,RneA by the Boy Area Air Quality Management BOILER-COMP(31111OR 100.000 RTU)
DisOin,f
❑Yes 0 N HOT LIiR-COMP(OV IiR ITAI,IHN)BTU)
I
have and fire haninlous naterink rcquirenrenl,under Cbupler n 95 nl The CIAi- AIR CONDHJ ONER ISSUANCE DATE
f mid 11eakh&Su el,Oil,Sculuns 25505,25533; Tl 25534.1 undemand that a the NEW RESIDENTIAL MECH. SQ.ME
building dons not currently have a tenant.That it is my tespomaibilay to notify the occupant / I
of The n'tircmem,whichmlia M tan paa,mi„uana ora cenircahe of Occupuncy. \�1— ��/
Owana,infloarsD agent Date TOTAL: ISSUED BY:
OFFICE