S 2243 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT'INO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2243
BUILDING PROJECT IDENrIFICATIUN'
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTN.DAT
2 / 577-';'
UWNIJI'S NAME/��afA• 1�J I'110NI:: CONTRACTORS NAME E
M`��T ,..-r 5�� � N� C' -WI Rol.
/FN
ARCHTECT` GINEER: EJC NO ADDRESS
'I
466 7 �tTl/5 MaL+Wl�N V/;';o
CON`MC.: PHONE: BUILDING PERMIT INFO
!--\ � �£-�_ � �iO,o�� ❑ Con:nlLont Fees Paid by Appllcan((Initial) Blip; F Cr %.ustx � MF❑CIf
LICENSED CO NrRAUI ORIS DECLARATION7 QTy ELECTRIC PERMIT FEE �'�V/ `•`��/-'
I teretb'alrter Nm I am liecrivd order pr,.s,;ona of CTupce 9 comrrc e, JOB DESCRIPTION
OZ withS Oi«19( )),If Blisinn 3 of lM Bmi«.csetxl Pfffusiau Gdu,and!my licen.¢is PIiRMU ISSUANCE RPSIDENTIAI,
�V Liccl fo�c and<Rcct. UCN lM��� ❑SFDWL RCHLN REMODEL
QZ F Da�DJ[I SrQ APPLIANCES-RILSIUIiNI'IAL ❑ADDITION PLUMBING RF,-PIPIT
Q Ilmu Gmtrn
FVy ARCHI'LECPS DECLARATION PANELS ❑MUhTI-UNIT ❑STRUCUIRAL
vnz Iurale Plan.endln dull beusal e.'Hic oxd. MODIFICATION
�� ❑INTERIOR ER ❑CHIMNEY REPAIR
EP
O Z- UPT02W AMPS
F t?F"G W Hero"'!PolE.cavaml 201-1000AFIPS IMPROVEMENT C]SWIMMING POOLS
C C C'� 1 Mrchy Am.N��forEcaempl bon.IM.Cmlrumada Liccnrc Ww Lobe OVER INC AMPS ❑BATA RIiMODIiURHI'AIH ❑DEMOLITION
K 1 V following Lean.LSeclilm 7031.5.Bmimn and Prnfexdem Cale:Any city or countySIGNS ELECTRICAL
[I OTHER
which oefairu a Iemul m a,rtgmel,ohne inlprn C,Acnmlkh.«ywir any strvcmre
Prior o lu ivunrme.tow requires the appllcnl fccsuchpermit to rile a signd smaco nt SPECIALCIRCURMISC
thv he n licY cdpurorl the Proviaionc ofthe.CanvacuMa Licenw I,aw lCbapter9
a]L�GCO (muuwrei ng wil h ScmimiTO))W Or vision 3 ofbe ausioc"oul l'n,fc.inm C.10... I'EMR MUFFS OR POLIH INSI. COMMERCIAL:
a a e C Ihul Fe is exempt therefrom erd the ba ix for Nc alleged cxcllrplion.Any violetion of ❑NEW RUMADDIf10X ❑DEAIOLI
Section 70315 by any ar licam low a pemlit subjects the applicant to a civil Penally of POWER DEVICILS ❑'IINAN'I' ❑F "'VICE
notmom 111.1 rive hundrN olJl.(55410).
E20 ❑I,00wxr Mthc Proq,cny.«mYcmplryas with wages as lhcirmkmmprnwrim. SWEVIMLNGPOOLELI Ih/PROVEAfIAT
wilidmtrow.xk,cod the roik nn inlcnckdoroRcnJ fur salclSec.T(1W,Punincbs ❑OTHER
d3 w atd Prvfevaian.Ccdc:Tvc Gmlmemr'a Life—Law doe,nm apply w an owner of OIIILGIS-S W I'ICIIiS-FI%'IVR
peopcnY wM huid lof imlm.n therms,old who Ibes swh wart holmYlf m through
0
his awn c oplo,ecw,Ixmiokd Inns...h Imlxovcncnm arc nM inNmkxl ar alrcvd for NEW RESIDINrInL IiLEC!R S IT
sale.IL buwever.the Willing«itnpnwcmcnO,ted withinrloe Ycarofmmplewn,the .FL AR S.
xr-bit wit have Nrhiddenof Proving that hedid not Wild orimprove forpur-
" "f own SEP 2 81 98
❑I,mwnerof tie Sec.
7( a B cwlusivdy mntruting Cid,)Th lennlracmn to '1(TL\L:
ver.Il,the ,Oo Ml, ,,fro Hu.sinof and rty,h i bar Code:)The Comractur's I.i-
mlawdwfnmupplymwowmrorpn,pcny wlm huilJs orlmt tuRe Cclmn.ond QTY. PLUMBING PERMIT FEF.
wM,rnnuocu fa slob prajaa with v Cta11rrc1«fs)IiccnxJ punuanl la the Cmttrssror's
1Jccn¢Inw. IF PIiRMII'ISSUANCE, O By
❑ un exemq under Sec. .B&1'C for Nix Ieuwm
' ALTER-GRAIN&VENT-WATER(IIA) UATION
(Trn:r Talc / elk"O
. WORKER COMPENSATION DECLARATION HACK II,ON'IYt(TIECT.DEVICE
1 hereby affirm muter Penally of lerjury one M Je follwing dalaratiam.
❑ Ihuvcund will nuinvin aCcmricmaef Cnnwnnomll-inwm lar Worker'¢Cmnlem DETAINS-FLOOR.ROOF.AREA.COND. STORES TYPFC ION'
vaunts,as provided fou by Section 3'1110 of the L aWr Codc.for the Perf.of be
wixl fu which This pcnnit is i�sucd. FIXTURES-PER TRAP
❑ I have aid will nwinlain W«lch Campmsation lnsumrcc,as teyuiml by Section
3700aflle lab«Cork.for the per6orr cY Mthe wod:for which this Permit u issued. GAS-M.SYSIENUI INC-4 OUTLETS OCC.GROUP
MyW«lyy
L «}y,cpsymv n�ecanivPoky Nor: � GAS-EA.SYS91Af-OVER 4IRA)
CERTIFICATE OF[AbPIION FROM WORKERS
COMPENSATION INSURANCE GRRASIONDUSTRI,WASTE:INTF,RCEPI'OH
BUILDING DIVISION P3F5
('Thi.aYtimt ii not 4 c«npktal if Beperna is fee aur hundred JalbabrS 100) GREASETRAP
or kax7 PIANCHECK FFG
I acnifylhul inlhe puravitao-ol the wokl ar whirl.do.......0,iund,l.Lull SEWER-SAN[LARY-STORM M.2W FT.
Eat employ any Pervn in any tlmnler wj M�`a, rat to the W'or�n'Comlm ENERGY FE I.
zZ satl,n fans of C yy{{yya1 a/2^ WANR II;ATIiN W/VI;Nr/I:I,I:(.TR
Applicant GRADING LLE
N NOTICE TO APPLICANT:IL aria realm,Nis Cectif to of E ern Pion.You should WATER SYSTE HEATING
a ; become subject m Nu Wodcr'e C o,envamin Pro'kims or IM I.Wr Code,you Inuu SOILS FEE
(Il fobhwithc«nply with such pruvi,ions for Ni.s pmmilil 11 he JeeNnl levAec. WATER SERVICE
uZ bar HerUGIIONI.IliDIendoAGENCY NEW NISSIDIiNI'IAL 1'IMB. SQ.Pr. PAID
V� Ihcrcby aaimrllur them iaacunaruction krding agency for Ube penorcvurce of arc ReaiptN
c wt f«which Nis Permit Permit is inued(Sec.30009.Gv.C.)
LS. f' ill
I<nllefx N:tlic 'I OPAL:
W t<nJcf.Adhcca TOTAL _ ^/�
r 0. I rectify that I have mo-1 Nix.,I"I on and sum dw the above inL,matian is BUILDING 103E r w�
.F'.c rn <omct.l ugncacNnply wlm allcity andcounty«Jimtcoa'and,aaro law.mlmingm QTY. MECHANICAL PERMIT FEE J.U Z builmmd
ongnstruclion. halebyaulllanra lepre,erietoveaaftbis oily to enter upm the SLTSMICFEL
above menticoc tel pnreny f«inspcaion rorty .
(We)agree to rave,irdemnify and Imp harnlas thin Cory of Coponlno against PERMIT'ISSUANCE ELECTRIC FEE 8 -r Q
Ii lilics,jWgmrnls,emts ardexPenses which nmy in vny waY s«ue against sail City ALTERORADDTOMECH. !`O
Iaylen'cof an
thegrt'mgof dox,Pcnoil. %.IJMHINO FEE aJ J
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNITCI010.000 CEM) O
MECHANICAL SEI?
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sigwmre of A,hc.nWonlrnar hale EXHAUST HOOD(WNUCTI HOUSING MI'rIGA'rl(lN ITE
MATERIALS'DISCLOSURE
WiR the applicant-bare huidingoccupatg sr«e«herdk baaadous nutrriil E fEATHIG UNU'(TO I(OPOT BTU)
as refined by the Culenitx,MunlciPJ C(de,Clxpler 9.12 and lite Health ad Salmy t
CWc.Seclion 25532(.)4 `l HEATING UNT(GVCR IW.UMI HTUI
-I
❑Yrs No VIiNIT1,AfION I'nN ISINGLE BESIDE PNU A O
Wit I Ne applicant or future Wilding occvrynt ate tyui,ol a devices which hate Receipt N
emit M®rd,usni,unuminanlz u defired hylhe If.,Area Au Qual ity Management BOILER-COME•(3HI'OR I W."BTU) Q
'IYI'PA L: �
IliNriaf.' No
E)Yea BOILER-COMP(OVER I W."BTU)
�
AIR CONDITIONER
I have rtaJ the hvanlrua nuterialr reydrtnetlL utakr C1vUa 1.95 of the Cdi- ISSUANCE DATE
forma 11.1th&Safely Co dc.SeeiWna 25505.25533 and 3534.1 unlvumd Jut if Je NEW RI_SIDFNUAI.MI;CH, SQ.IT.
binding&cs nN CummJy love a mwn4 NUI it t.my n�ryin.ibil'ny Iu n«i(y tMrccurymt
ot1' h ma.he tM
Owncroruulo,ri'usl6ebl��PryN In I�swINY d u Cerllllt`Jtc/PZr(k�ru/plu��ey.Y-
TOTAL LSSUFDBY:
OFFICE 10,