S 1970 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEKEINO HullDINI I-ELECTRICAL I'I!y\�I'r rvo.
I BUILDING DIVISION APPLICATWERMIT PLUMBING-NIF.CIIANIC.M' 1970
BUILDING PROJECT IBEN P6TCA'C
BUHMINGADJURESS: //.� / �A� (/y,( SANITARY NO, AWLIICAU NSU�/1tMITi'AL.1lNIF.
�/�81 GwnaI / w. 1� lit\ / L �V
OWNL!H'S NAht[: cJ PILUNIi: 3- CONfMCfOR'S NAME LIC NO: L
MG TAI q - NIC CDYI'NDL.
�n1cclDrECTnsNGIN1!EH; uc ND: ADDRPSS:,sy F S� CQgfl.neo '�1�9 ❑
CONTACT: I'IIONB: B ILDING PERMITINFO
Cmtsa tont Fees Paid by Applicant(Initial) Bit%; rtFCf PLUMB MECII
y/2-07 OA / <6s 31 a s ❑ ❑ ❑
LICENSED CONTRACf(lRlS DECLARAI'[ON QTY ELECTRIC PERMIT FEE
1 hereby affirm Thu I vo lieen.val oder Irocisisua of Chaper 9lcommercm.. JOB DESCRIPTION
Z with Srebro TXXltof Division JolOre Beirensand Prolsainm Code.mrd myliccmc if RFSIDENTIAI:
l =W o 4---3 7 ��� 1'I:HA11'1'ISSUANCE
F full tor-arib p ❑SFOWI. ❑KITCHENS REMODEL
aUU Gel Clava U IJc.g APPLIANCES-HESIDEFGAL C1 ADDITION ❑PLUMBING RE PIPE
II--ZZ W Omc C..'c
NQ2 ❑MULTI-UNIP ❑STRUCIURAI.
!NCI II'IECPS UECLARAI'ION
r p.7m PANELS MODIFICATION
'ZornZ lundermwd mypwsshall he usN as'N.rteads
OZNO UPTO200AMP.i El INTERIOR El CHIMNEY REPAIR
W 4mond Prufus"mal 2111-1000AMPS PAPROVEb11'eNT SWIMMING I'(KIIS
OWNER-BUILDER DECL.ARAHON OVER IIXMANIS ❑RATH REXIODELLREPAIR ❑DF1s101.R1ON
_ 5{y�WQ I heahy infirm Illel 1 am exrem
emp from the Cunlcr's Limen+:Lew for tM
K %U fo lowing maw n.(Section 91).31 s,basin.,and Pn!'caa s,Coda:Any psiicy or...umIGN
y SS ELECTRICAL ❑OTI IIiR
1+13 4 y which onluima a permit to cmmmwh der,improve.Jcmolixh,or repair any mrumure l
'Hog prior In its issuarcn re
e,don uilthe,sppieanl for w .sch permit to file asolved statement SPECIALCIRCUIUN11SC.
}7 That be is ll er,dIpormawo the Pm....moot the Cinnamon-Licumn Ww(Clmpc+r)
, a'O (nwnwmingwithection S700pefOivision 3ofdm Businessord Pmfcadaa Ca1,d ce TEMP.MITER OR POLE LIS, QGMMERCIAI:
d a e n d m M is cmmptIhaefmm raderr basis for IM1e a11egM cscal fm.Any virWMm of ❑NEW BLMADDITION ❑DEMOLITION
K m_LL. sic, 70311 by any.,Iran,or nI'annitsubjoi,the appliamn to u",it 1111Y of POWER DEVICES [I TENANT FOOD SERVICE
W nn more thw dive handled dollar pi!K(L.
<=0I.mswner of Ups pmPcny.amy empkyecn with xngcsmlhcir sok rnnpcnwiou SWIMMING 1 ' si O_]C IMPROVENtI'M
will do Oc avork,wed thnumemre xmN intended orotic d fmwle(-See.70TI,Busincbs ❑OTTIFR
W and Pmfrainnr Commm'lo
Coe The Cors I.'acmc Larsdoes not menwrc
apply milliner of earn-C I;-SWI'to I ES' XTURES
L his am mho huiMa or oiler!that
I...In i aha scan docs sucfi wale himmelf a IM1mugh
1
his own cmplvyeo,pnmdal that wch impmvnmms art m imadeJ tic olfertJ for NEW RCSID[MI LiCfR SQ FI',
t sail.Il.however.the humidinptr antool loran it lid within III.ye,,,L cmnpldinn,IM: SV.FI'.I�hOOR ANI!! I�L
5/SV�
orworr bil will have he burden of proving Not the did not buil!or inyrtmx fm pm-
wk.).
.owrcr ul ILC Pmlzny,air exclusively mnnocting wI1N IlccnrcU mnlnlihrx um IOD
l Ibe Project(Sec.71W.Husircsa std Plofelaiuns Ctde:)The Conwclor's Li
-
melnwducsmXepplymanownerorpropcnywhatbuildorimproves,thereon.and QTY. PLUM BING PERMIT' FEE
who,femursfmsoohpmjccns wilt aconuonnlx)keneciplooluand to IIs,ComostrS
Licenm Lew PERMIT ISSUANCE
C3 I em exemp under Sec. .B A,P C for dik reason
Owrcr s .Ume AUER-ORAIN k VL'N'I'-WATER IEA) VALUATION
KP C 1PF.NSN'I 'DC:CIARATION BACK FLOW PR(YfECT.DEVICE 000
Iherehyulfrmmuk:rpenxlly afpnjury nc of Oc fullmving dcdataumf:
❑ Ihavc wJwillnwinminaCmifrwcofGmsrnnnsdf-inwrcfor W'nikcr's Compeer- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
action.m Irovidcd fa by Section 17M of the labor Code.for the PrHsrrrarce of the
wad for which this permit is issued. FIXTURES-PER IVAP
1 hall and will maimnio Workers Clarp,mmim Ins. —.ss real lend by kerion
37W4 the Lehr Code.for llrpetiorma a the work for which Ibis 1.1 i.loin!. GAS-EL SYSTEM-I INC.J OUTI.ITS OCC.GROUP APN
byWorker's CompClWlimm Imumrcc eters,and Policy number on,
Carrico Pniky No.. GAS-IBA.SYSI EM-OVI!R LILA)
CERTIFICATE OP EXEMPTION IROM WORKERS' C,RPASFIINDUSTRh N'ASTF.INTERCEPTOR
COMPENSATION INSURANCE, ItU1l.O1NG DR'i$ION FEIS
ITh,section ncni nor becmuplead Ifthe pcnnil is formic hundred dollen p$100) - t
a ka�d GRIASE'CRAP PLNNCHECK FEE
Ittnify bar in UwpMormmlrm of the alt fmwhich thispermit islasued,Lshell SEWER-SANITARY-STORM EA.2EB FI'.
norstaidlyxstaidly any M1'm army r m as ro lnnme fnberl to the Wlmkc-'Ctxnpen- IIJERGY IIiE
O Z 'tiro Wwa of California.Dam 11teacvWATER I[RATER WNEW(!LECTR FEE
Z Appliezu GRADING-
y NOTICE'CO AI'IX.ICAM:If,after mek'm.this Certificate of Ilxemlmon,you Ideal J WAFER SYS'IENVIRGTING
a > bceonr wbjed m Un WorkcYs Cooperstown pmvLsitms of Ile lobo Cork,you mora 'SOILS IId7
rit
head.ith comply withs do Provisions or this permit JWl berrc
e dedm
reted. WATER SERVICE
Q
L C(lN$CRUCfION Li'NOING AGPACY NL!W RP_SIDENTIn1,PW111. SQ,17, PAID
U OL hereby mTlrm Heat hurt is construction lording ageay for the Perfmrence or 1 Receipt.
ale wruk for which thio pemr,ie issued(Sec.3197,civ.C)
0 Lenders Nano 'fUTAL:
UIrMer'aAdmbeaa TOTAL: BUILDINGFFk L O
I ernify that I base mad m and this amlicalistale Ilial the ehove information is
rF-r rn mmID
nn.l agree to comply with all city and cmnly ordlnwa.and same laws relating to QTY. MECHANICAL PERM IT
U z Wiling csmlruclion.wd hereby wrhonee mepresenutivesdthis cnYmemer upon Jr SEISN
aM.nmcationed fortmy for impectimm particle, PERMIT ISSUANCE
(We).......save.indemnify and kcas th
up haonke Cny of Culrmm� I....... !1.1!CT :Si
IR
Iwbiliaies.judemenu,moa erd IPA
expenses which may in any way wcmeugainst saidG, ALTER OR AUDIT)MECII. Ali^ UNIBING IT
in marc,.of the.merrier.of Ihia permit. Mvu
APPLICANT UNDERSTANDS ANI)still LI,COM PI,Y WITH AL1,NON-POINT AIR IIA N OILING UN IT(TO IIhIX)U CPM) !C L !
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I o.aXI CFM) CON'STHUCT(. '
Signam re of Aptri csna/Cmauct r Dam EXHAUST I IO(A)OL UCI'1 (. ) G htll'IGAT N IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the aWlicam tic future huildiag occupant floor or handle bwwdnvx rnnerial IIFATING UNIT TO I0a%XXD BTU)
as debfwd by the CupIcnim Man kipal Code.Corpse,9.12,und the HCWO and Safety
Cala.Scaim 255J2(a)T HEATING UNIT(OVER 100.000 BTU) 1 �N O
Vee No -/ —
VI':NTILATIIINPAN(51NGh1?RCSIU) PAID
Dare Receipt
Will the applm art or Name huiding mrmpanl use ry.ip..or devicel which
rnm hvudms air mnwdnamse,Jefincd by be)lay Area Air Quality Nlaru.emenm IllIIhFJt-COMPIJHP OR IIXLOOOHN) f h:
h an°7 BOILER-COMP(OVER 100.000 BI'U)
C]Y" ❑No
I have and the lmmnlous nuucdnln mater Chapter 695n411w Cull AIR CONDITIONER
ISSUANCE UATF,
forma Health N Smmy Calc,Section,25505,25533 and 25S:U,1 mvlmxwrd teat it be NEW RESIDENTIAL.MECII. SQ.IT. ( O O
building docs ml cmrrnlyMex amen,data is no,rcyvnihilily to NXify the...to ( o
I nolle rot rirermmswM1ich rnurben vpnmmi.auarcc nfa Cenifrarenf ny.
Owruror rnl Dao TYJfAL: ISSUED BY: -7—` 1
lL OFFICE