29136 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT71NO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLI CATION/PERMIT PhuMBING-MF.CHANICAI. 29136
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: — SANITARY NO. APPLICATION SURNI TIAL UATI
M'_'4_,
OWNER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO.
NIC CONTROL
•%RCHfTE-C1'rENGINEER, LIC NO: ADDRESS:
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Inillal)
ELECT
v).UMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 Iteteny tile Ilett 1 M ricemN ower provisioes of Chapter 9(commencing JOB DESCRIPTION
ZZ wilhSmtion]OW)of Divisinnl of the Budnns ofd l'n,Teaion.vCNeand my liccasek RESIDENTIAL,in full face east effect. PERMIT ISSUANCE
G,— Lianss Chu+ Lre.Y ❑SFDWL ❑KITCHEN RFlfODFL
F.Zaa Dam Conloacm APPLIANCES-RMIDENDAL ❑ADDITION 13PLUMBINGRE-PIPE
AR(:UH ECTS DECLARATION PANELS ULTI-UNIT ❑STRUCTURAL
z O�2Zj Iundaoluid."bass shall beurcd u public rernds MODIFICATION
OZ-1 UPTO200AMPS ❑INTERIOR C]CHIMNEY REPAIR
5=�� licensed Podeuionvl 301-I(1k)AMPS IMPROVEMENT -
gi •.1 OWNER-BUILDER exenaUERDECLA RATION OVER IM AMPg ❑BATH RFMODEUREPAIR 0DEMOLffION
y U I Fsreby affirm on 1 I vet exempt fwm the Cowfactar a License law far the 1
x O U following wawa ernot to m19lo,Buelrcas arW Pr^fc1c ism Crit:Any dry armunry SIGNS IH.F.CTIIICAL ❑OTHER
la1 a w�j which ayui s v permit In mmnucL eller,nt focsc,Jcmolish, fi¢pair any swcture
thanr,itI'lvua«a alman,1.ze Nei'usxaemf«such pmut tufleesiaos,(Caremrnt SPECIAL.CIRCURIMISC
H2
than be, ecus, itpumant toJ).f IT iom Ofae Cwuranss lieneclaw(Cbynn9 _ �e
4j�0�0 (mmrocrlciog wuth Scctim]^IX))ofUviviim3d'Nc Nosiness lust Pmfesions Cotic)nr 'IEMH MBIER UN POLE IN.ST. I ,q([]�
6 q a pL that he is exempt f,mroms and the Iasis f«the alleged exmin ire.Any violation of ❑NEW�BLDG/ADDITION ❑DEMOLITION
uXl 1+• Sectim]OJIS by any a,,licw f«a prnvlt wbjeeu See tip Rxina to a civil pmally of POWER DEVICES V(-
tiIdinurethanfivehurdredmllar,S5M). ❑TENANT L(Jr[gI ❑FOODSERVICE
� ❑ I,uowncr of the lnpcnY.nnny employee.with wugou Ncir.mk nmtpcn.wtion, SWIMMINGFIX)LEI.ECTR IMPROVEMENT IHrV
y willdo the w«k.ends: he,C ie RclLice Luo,
rwlcltr,1..,Businef ❑OTHER
LLI and erry h.br Code:The,Columnres Lkeme law don tow apply oif owner of OVTLEfS-SWRCHES-FIXTURE
a 3— hit owy woo bullas«impc^vO t such and who tha rano writ Morse,of thmegn
his awn ewpver.the
pr^vided Out web impmvemm�u art fm i,uaared nr pletion,Tri NEW RESIDENTIAL EhECTR
uk.ILltoweve,Ihcbui the bur imp f proving
withinorcildoricvrove for the SQ.FT FLOOR AREA LSO.FT.
owrL its0 o,-cc wir theve,sm,,irnof Proving lMthe distort Wild«i mrsarfmpm- - .Iqo� T�a�� j .��
of sale,J. // IITT�
1,u owner of de property, H exclusively contracting with:)'meed mNrxlax to
the pmjc0(See.]1314.tluri•...aryl Pm(eui«a Code:)The Contractor's Li-
velawdocs nu apply to an nwrlcrof lenleny who huiWn«impmvu tlrrmrt efd QTy. PLUMBING PERMIT FEE
who ccvr wsfsrslmb pmJecne with v contruatm(s)liccmedp roanl to the Cowracmr'a
Lianee Law. PERMIT ISSUANCE
Ism exempt ufdn See. .B A P C f ar his rc.
ALTER I DRAIN R VENT-WATER(EA) VALUATION
V
WORKER'SCOMPENSATIONDGCLARATION--�%- BACK FLOW MOTECT.DEVICE
I heeby effort under penally of Perjury are of the following locluviwu: (JU `
(have std will mainmin vCmifcwe ofGm.mmtu.mlf-ivum for W,rkcr's Comlcn- DRAINS-ILOOR.ROOT,AREA,COND. STORIES TYPE CONSTRUCTIONmotion.a pmvidW f«M1Y Serino J]000l Ile labor Cion, or the perfnmlanced the
wmk for which thir pcmu,u issuers. FIXTURES-PER TRAP
❑ 1 have tits will mainain Workeh Compenmtim In..as rt9vired by Section
37(X)of the LOor Cache,for the pnrGmwwc nfNe work For which this permit is ismd. GAS-EA.SYSIHM-I INC.4 OUTLLTS
OCC GROUP APN
My Wartc'r Campcnwtion lrteawtce carrier tired Policy number art:
Cartier. Policy No.: GAS-FA.SYSTEM-0VER J(EA)
CERTI IICATE Olt EXEMPTION FROM WOR KERS
COMPENSATION INSURANCE GREASIIINDUSI'RL WAS3'li INTERCEPTOR
(This rsum nml rot be compleud if Inc pendt is f^care hundred dollen(SIM) BUILDfNG DIVISION FEES
«ren) GRE.ASETRAP PLANCHECK ME r
I emify that in Ile pertbrmarwe ofthe wmh f«which this permit vi issued.Ishan SEWER-SANITARY-STORM EA.201)FT.
not employ any heron in any manner w u m
to becte a6*1 to the Workeri Cornpen- ENERGY ITE /—tt
2 sation Iowa of Caia.lifornDae /V
O WATER HEATER WENT/ELECfR
O Applicant GRADING FF,F. �
y NOTICE TO APPLICANT:IL ufcr making to Cenifatc M Wcmption,you should WATER SYSTENUTREATING
become subject[c the Vvi"ll C«open ation pmvuionr M the labor Cede,Y.must SOILS FEE
forthwith rnmply with such pmvi:.of Nis l itshell he Famed rtvuked. WATER SERVICE
Q
CONSTRICTION LENDING AGENCY NEW RESIDENTIAL PLMR, SQ.FT. PAID
I onRrm eby aJur u af«there' awmaucum reading 6ency the perfmrce
ared Due Receipt.
[J' p F toe work f«which ur thi,pemis iswM(Sec.Nrl7,Civ.C.)
Q Unsb&,Nave _ r
L9L[oJersAldreva A
CL I certify that 1 have red thu application aid sate that Bre above infmmwim is BUILDING FEE
to emrennlagmemmmMY w'iN all city and aunty«dlnaree tied awe Lw.rtlwin8m QTY. MECHANICAL-PERMIT FEE
V bulldingconuroto,tied hereby uuN«ize re orsentatives ofthis city[center upon be, SEISMICFEE 2 �+
above-medimW Era ery for inspection purposes. PERMIT LSSUANCE Q
(We)agree to rave,irdeofd nnify keep hnrtnlos Bre City of Cupcniro agvnst ELE(-TRIC FBB
livhllitics,judgmrnu,w..v wd exlema which naymany way aLv.agpinw said City ALTER OR ADD TO MECH, L�
ansegwnce of the,ru fir,of Nie permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G O U."CFM)
SOURCE REGULATIONS. MECHANICAL ME
AIR HANDLING UNIT(OVER 10.0017)CFM) CONSTRUCTIONTAX
Siglutweof Applicant/Cowxt« Due EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the eppliunt orfwurt building occupantarie orhardk haruduus macular HEATING UNIT(TO 100.00r)HTU)
u def nd by the Cup ifo ManiciM Cade.Cheper 9.12,tied IM HW N and Safay
Code,Smion 255321a1] HEATING UNT(OVER 100Th )0 BTI)
Y. F7 No
VENTILATION FAN(SINGLE RFSID) PMD
Will the applicant or fwure buiWieg^nvp:nn arc eyuignernt«devke which Dao Raapt 4
,mit hernMwa are cortin nimnu m defined by de Bay Area Air Quality Mmaecmcnl BOILER-COMP(JIfP OR 100,000 BTU)
•Diener? - TOI 3
a
El Yes Fl Na BOILER-COMP(OVER LW,"BTU)
1 have reed 0c hvard,us mamrials AIR CONDITIONER ISSUANCE DATE
rryulrtmcnu undo C I unci 6.93 of the Ca0-
f«nu Health d.Safer Code.cocoons 355(1.5,25533 arxl 25511.1 uMurard Ihat if 0e NEW RESIDENTIAL.MECH. SQ.PT.
bolding due fin can hlove•tare,,Nato i myr of.CJitymhe ofytheaanr,.
n(de rtgvircrmus whkh mutts eel pimmiuuam'c MaCrnifnve of(heupvey.
Owrcr«wlbrilacd agcy Dao A ISSUED BY:
OFFICE