S 2143 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO BUILDING-ELECTRICAL III. ITN., �I1 43
xUu,DING DfA'ISu1N AI'PLICATION/1'FHMIT PLUMBING-MECBANIC51•
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAR
idi3c f=j2wuv4) DMZ -�
OWNER'S NAME. PHONE: CONIAACTOR'S NAME LIC NO:
S yO t j r] u LL �p C 1 nIN,� NIC ONfR(II,N
•ARCHITECl/L'NGINEER: !` LIC NO: ADORESS: f ❑
CONE P
ALV'�
PHONE �� xUILPERMIT INFO
6 El ConsultaN Fees ail by AppliI
cant(nitial) BLDG ELECT
CT/Pyty-N�1H >11'CH
ElCJS LJ ❑
LICENSED CONTRACTORS UECLSRATION I QTY ELECTRIC PERMff FEE
1 hm-0y alBtnt that I am li«rva�amlcr pm ,mss ofcbaper i le„mrr<xing JOB DESCRIPTION
OZZ wentimvm]gp)of Division hdthc ba:ire�s eul Profcv.iom Cade.and mylicrnmis RESIDENTIAL:
WOO I'IiRM111'I'ISSUANCE,
Fz W.. in lull lace arW eRm r /-'I 'AU p� O ❑SPOW, ❑KITCHEN RF,SIODGL
U[- liars Clan�I A
Lie, !n Y (L
6 V AI'PLIANCIS-HISIDI 'IAI. OADDff10N ❑PLUMBING RE-PIPIT
F Z LL: Uatc Cnnha'Inr iMN
6 ARCHITECS'DECLANAT[ON OMI11.T1-UNIT ❑STHUCI'URAh
PANU S
-LOT-Z 1um1«tatd lay plea shall he u.Jav public ramL,
h
OZ-0 UITOqAMPS L [:1 INTERIOR El CHIMNEY REPAIR
F!Eu1 Licaud Proal md
CNII-(MAMFS IMPROVEMENT' (]SWIMMINGPOOS
F -f
UILDER DECLARstTION
OVER INCAMP,S O BATH REIVODEUREPAIR [I DEMOLITION
C C Q I hereby alrinn that I ant even frgn the C'onlllMun',Licutase hth
aw far e
X6X060 Inlloxitgassom(Section W31.5,Businnv end Profrnkm Gdc:Any city or county SIGNS ELECTRICAL 0OTIIFR
6 E' whish rcyuiruv a perndl n,answcL dnr,nnpon.Jcnlulivh,or repair vnY 9rvdurt 71
03 Priorm its iswnec,alwerv,mreslhe appliam torsuch p w to file a signedt vehement SI'IiCIAh CIHCUIT/MISC.
<�y ohm m
he is lka.sedpuanO"the .an, of lbc 0mazaurt hir:ns cLi.(Chyler9
II C, (arnmmetcingwitXSeaion7q ).fDa,mon Jofthe Bmite.oad Pmfakioh,Cade)m TEMP.METTER OR POLI?INST COMMERCIAL:
6 y o C that ha,exempt ox rot r,wW Pat Imvis for me elle,l exentpllm.Any vamtrion of ❑NEN'BLDG/ADDRION ❑DEMOLITION
uX1 n• Secrian]BJ LS by any applicant f«al'ermil subjxls the aplAirnm mvcivil penaky of POWER DEVICES [j TENANT ED FOOD SERVICE
«' m9 nem:that fico hitdml dollar,(SNXE,
(-Z'r OTIIFR IiMEYI'
Q 01,uwmtt of ole pmpcny.«my cmplyxe wio eredl tsale(w,70,W.Bwian. SWIMMING P(R)1,ELECTRIC
�Ca willdnthuwars muldmHmel.rciaehal tcmk0«ot.elves
fnr Wol-Ssz .. Buan.f ❑OTHEk
3 , NufevI h Coae:Tee cmltrxmr's IxrnK I�w d«.ur apply to on«vxr or otm_I>I's-SWrreHEs-FTxrukFs
pn,peny wm,Imdn,or,innwthe rl ashn,and eracIno ors. wee tintx died!or mal for
To,awn mnplyees,poik aro that Lech ash, rn W arc m immxlal«nRctrJ for NEW kESI AL EI,ECcIi SQ I'f.
w1alChnwevealhehui dm,ar illq,f memo iv sued wit mcI Wild or
prove for Else SQ,17,FI,(R)R AREA LSQ.14.
mrhuiMkr rill hare de huNcn of pmvin8 that he did nal h.iM«improve f«pea-
L,
m-
of wlc).
Las,therofde ,Pchry. contracting with 1, 1_ elm..... w lIIf
mstma 1protea(,A•c.]Wd,Hoarr of wdtay&N,buiCnde'.1TeCommanr'aIJ-
melawdlerm,ach ymanowner ofplup nywhxlbuild.nr..I,, he Chtttm,aM Ql'Y. PLUMBING P. IT FEF,
who manvta Gr such prnj«nwlthvnintmduq,)liacnnlpurtuanuu the Cnnavetur's
Iseen'e Law. PERMIT ISSUANCE
❑ 1:0o a.antpt miler See. .B,a P C f«mi.mason
Ohhar Data ALTER-DRAIN&VENI-WATER(EA) VALUATION
WORKER'SCOMPINSATIONDECIARATION BACK FLOW PROIECI'.DEVICE
I hereby a ino miler penalty of,der,amt M the ILlllwing k daraflmv:
n Ihavcarx Imam naCmihlcofConrctntorclf-insurtlm W«kcr'a Cmt n DRAINS-FLOOR,ROOF,AREA,CONDSTORIES TYPEC(1NSIRUCIION
ovation,a.In,idcd for h,Section 37(Mof the ILhn Clad,or the perfon:anec of the
wwI,for which Nis Terata is i..ued. FIXTURES-PER'DU P
13 1 have amt will maintain Wnk.T,Con,arsahion lu,amhwa,:t.«.rvimd by suction
3]00 of dtclahr Code,le,the pcHlrmmee of the w«Y fur which this Permit is owed. GAS-1:5.SYSTF'.M-I INC.J OUTLETS OCC.CROUP AI'N
M1y Wn.tkcr:�, 'TFn.w%'tin�n lnw�mmrcr✓ci)r+MKy No:Ind
CiRT11ICPlIfNrk(M naW
GAS- a.SYSTEM OVER JEA)
S
t COMPENSATION INSURANCE: GRIASFJINIIUSTRL WASTE INTERCEPTOR - —
'Miss
raion acid N Ie cmnl8chad if the penhil is hrmc hunllmd calms(51 TIO) BUILDING DIVISION FEIiS
GkEASF TRAP ---
or -le".l PI I CK FEE
lanify rant in the pro-fuemmer-Ohcwmkfnewhich thio Use Wavivwmd.L,hdl SEWER-SANITARY-S'IDRM I. _ FT
not cnlploy arty pclam is any rmmnawas to b¢orrc wbjcct to tXC Wahcrs Contlen-
ZZ .tion law of C.lifomia.Lea, W'NFERIIEAI'ERWNINT/ LF
Q ApplicantA I FT:
NOTICETO APPLICANT.If.after making thin Ccnificam of P amputm,y«i should WAIERSYS'I'ENUTREATING
FK hecone wbjea to he Worker.Cnntfem oma pr,vkrilm M Ile Isar Cade,rho me., SOLI 5 E
4nhwitX comply with wch pmvisians«tai.Iwrnit shall ha dccmW mvnkcd. WAI'HRSERVICE
CONSfRUCIIONLENDINGAGIiNCY NEW RESIDENTAI.PLMB, SQ.ET PAID
U O IMxby dhnn Nm tMrtlsa«mstrvctian krding.grncY lm the perflmwKe of D < Reeip,#
the w«k tort which this Tomb,is i—c,[Sac.JIH].tie.C.)
OI,adm,Name TOTAL:
LUL7 Lc %Adthc,a TOTAL:
I termly that I have read do,ap,AiaWi,,n and awte that the above information is BUIIDI 'FTE
IZI y.l agree uo comply kill,all city and calm,mdinaes,and Nam law.«Iming to QTY. MECHANICAL PERMIT FEE
U Z huilding cartvmction,andhratty amhnriae reprasenwtivu of rhis city to enter upon the SEISI, 'FELE
aMve-nenti«ed lNopeny for i nq,¢me pugakcs. PER.mri ISSUANCE
we).prec m wee,iisearo ify aril keep hermless IM City of Cu,crioo against ELE IC FEE
liabiliti¢judgmrntx.cmastd cxpcnscs wElch may in any way x<rvc against wkl City ALTER OR ADDTOMF.CII,
in c
onseyucncc of the gramma Mthat Permit. PL MBING FEE".
APPLICANT UN 'ERSI )S AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT('H)PETw C'FM)
SOURCL'NI:Cq All S MEC I LAICAL FF.E
J/ AIR HANDLING UNIT(OVER 10.1X91 CFM) CONSAUCTION TAX
Siptature ofA Dam EXHAII,STHOODIW/DUCT) HOUSING MITIGA'T'ION IIiE
HA%ARII0US h1ATERIN ti Usionco handl
S Wilkie appliantmfmurt huiding,ecupwt unrt«handk hnrardnus material HISTING DNIT(TD Ig1,1M91 b'N)
C' te'Sc in 115 32(.)?nu Municipal Cudr.Clwgcr 9.12 aril the HcaIN and SafGy
Gd<.Scctim 255R(a)P FiMT1NG UNIT LOVER IDUXp RTU)
L]Y" f-1 No PAID
VENDIATION FAN(SINGLE RI3IIp Ume R.-,ipl N
Will the ep con. «Iumm &ffintlaceupanlu¢e.AirtenlnrdMiee,miiam BOILER-COMP CJHP OR IM,(XM RTU)
D 1,l hvnNres air cunbmnwra as lkhml by de Bay Arta Air Quality M1fanaBcmcnt
DlvriaF
E]Y, ❑Na BOILER-COMP(OVER IW.W)BID)
I have rad the Warr lour rwmidL, - Cher or AIR CONDITIONER rtyunenen..lxler n95 of Cali- ISSUANCE
LATE
f«nia l Icahh h Safety Cldu..kvYinn.3N15.25913 and 255 W.I uNcr tr d TRV II the NEW RRSIDFMIAI.MF,CH, SQ.FT.
but",dux m rmmuly haveaI..lair it is my mpansieility to miry de lecupvx 1T r 1/
a(tlw yuirrnrnts whkit lnuvthnel prim to is,uvna ufa Ccnil'x-Wcnl(ktuPw.g
Ownenr authuvul moat Data TOTAL ISSUED BY,N/ e4 ' `l
OFFICE