30845 (2) 'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•PINO BUILDING'-ELECTRICAL PERMITNO.
BUILDING*DIVISION APPLICATION/PERMIT PLUMBING'•MECHANICAL 30845
RUILDING PROJECT IDENHIFICATION
BUILDING ADDRESS: T '�7 SO pI2 t G V f—R SANITARY NO. APPLICATION SUBMI'ITAI.DATE
PLL(✓►'16 N 6 y2 y E'. rewo ori
WNEN:S AMIDgg.$ PHON@ CONTRACTOR'SN ME: - LICNO: "
�0+1nJ E1v021C1c g(Q - 7oHr9 '. HENOKk C N/C CONTROLg
kCI1ObC7/LIJGINF.ER: - LIC NO: iLrDRE55: El
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MGCH
❑ ❑ �' ❑
LICENSED CONTRA CTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I nm licensed under provisions of Chapter 9(wmmenuin8 - JOB DESCRIPTION
X25 with 5 tin 11110)of Division 3 of the Business dProfessions Code,uul nyinan RESIDENTIAL'
00I'HRMIt ISSUANCE.
in full f andF f�f�t
1�OU ss . 01513 L.' ❑SFDWL ❑KI'1'CHIiN ftI:MODhI.
U V Llccn.c CI Co M - -
L.Za(y ' Cunt t '10� H 110RIGL APP(IANCP.S-RP.SIDF.NTIAL, ❑ADDITION: C1 PLUMBING RE-PITC
fn ARCHITEC'US DECLARATION - []MULTI-UNIT ❑STRUCTUIIAI.
1,=t¢es - PANELS
ZOyq• Iumbmmndmyplansshall be.elix,adlicrecords MODIFICATION
0'z.-' UPT02(01AMP5
O - ❑INTERIOR [I CHIMNEY ftEI'Alft
rrr&, ta] Licensed Prolbsxionol - 201'-I000AMP5 IMPROVEMENT
YY „a
OWNER-BUILDER DECLARATION
Conti ON OVER]"AMPS - ❑BATH REMODELiREPAIR C3 DEMOLITION
C W Q 1 hereby affirm that 1 vat exempt from the Contractor's C's License Low for the ❑OTHER
h-0SU which following reason, crinaa1 703 1.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL -� `
' to 3 0.rhj which requires o pcnnil In ronswct,niter,improve,demolish,or repair any mm�urc
I"�'0g prim to its is...are,ilm requires the applicant far such permit In fila.sigrad statement SPECIAL CIRCUIT/MISC.
that he is licensed pante,mune provisions of the Cmicacto/s License Laic(Chapter 9 ,
4�'p0y (commencing withSaction7")of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:
a o LL tam he is exempt thetefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ti
Section]031.5 by any applicant fm a permit subjects the applicant to a civil penalty of POWER DEVICES, ❑TENANT ❑FOOU SERVICE
FZ.} not more than Eva hundred dollars($500). IMPROVEMENT
Q ❑Lremoner ofnic property,or my employees with wages as theirsule compensation, SWIMMINGPOOLELECTRIC fes,
will do the work,and the structure is not intended oroffered for sale(Sec 71144,nosiness ❑OTHER
3 and Profesdons CWe:the Contractor's License Law does not supply to an owner of OUTLETS-SWITCHES-FIXTURES -
property who builds or improves thereon,and who does such work himself sur through
his own employees,provided that such improvements and,not intended or offered far NEW RESIDENTIAL ELECTS SQ F
sale.IL however,the building or improvement is sold within one year ofcompletion,the FLOOR AREA $/SQ.ff..
owner-builder will have the burden of proving that he did not build or improve for par- D I ,
p tsc f 17. T.
n owner r II in,property, exclusivelycontracting-with licensed co oar 1 t -. ,� 'r TOTAL:
construct tlep 15 ]014 li tJ ProfessionsC Je'1 The Comructo 11 Np�.�' �
s I J :m t apply w f p p oy h lamich,c u,n,as thenno, d (y FY PLUMBING PERMIT FHL' R f t
his onintricsfar such prnlcutx with a contmuar(s)licensed pipwauFto the C...nnctors - _
License law. PERMIT ISSUANCE. y Ur
❑ emVUre I�O
I exempt under Sec. ,A&PCfnr this rwsnn H�
Owner n.te ALTER-DRAIN&VENT-WATEE(EA) -� - VALUATION
-
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing decimations:
•Ulh.ve and will maintain aCedificme of Coosem toulGinsure for Workers Compcn- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCT ION
sauion,as provided for by Section 3700 of the labor Code,for the noncontract,of the - -
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,in required by Section
3100 of the lsbor Coale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC J OUTLETS OCC.GROUP AI'N
My Workcre(.'mT� nn lnsumna.vmer vnd Policy nu � �e
'er. Y Nn�r Policy No.: n�2D 9(.N'I}R GAS-FA.SYSTEM-OVER 11
CEKfIPIC OMPE EXEMPTION FROM WORKERS'
COMI'ENSATIONINSURANCB � GREAFPJINDUSTRL WASTE INTERCEPTOR
(Thissection need not hecomple.red ifthe u is formabundred Jnllsis($100) BUILDING DIVISION FEES GRF.ASEI'RAP'
or less.) PLANCtIECK FF.F.
Io,mri,hat in l be mcrfumumcenfine bermarwhich Nie permit is issueJ,lshnll SEWER- Y-STORM EA.200 PT.
not 2mploy any person in enymmmneradds to become subjecuo the Workern'Cordwo ENERGY FEE i
0 Applicant
Laws of Cnlil'urnia.Data m
1'IiR HEATP /VENT/ELECTR -
0 Applicmn GRADING FEF.
y NOTICE TO APPLICANP If,after making this Cenificme al Eientpuion,you shouldSYSTEMITREATING -
I-•' �5^
become object m the Worker's Compensation provisions of the Labor CWe,you must SOILS FEE
' W G.S forthwith comply with such provisions or this permit shall be deemed revoked.
WATER _
LL o
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,IT, PAID Date ReceiptM
U 0 (hereby affirm that there is a construction lending agency for the performance of
14 - the walk far which this permit is issued(Sec.3097,Cih,C.)
0 Lender's Name TOTAL:
IUiI Lenders Address T( f
(r•' y 1 codify that 1 have road his application and state lhanhe above information is BUBAING FEE
fA cancer,I agrte to compty with all city mul d....y mer iar noes snd smea lms,adming m QTY. MECHANICAL PERMIT FEE -
U Z building construction:arts herebymahodxe representatives of Nis city to enter upon the SEISMIC FEE
above-memioned property for inspection puHnus.
(We)agree to save,indemnify and keep harmless the Cirym Captains,against PERMIT ISSUANCE. ELECTRIC FEE
liabiliuics,judgments,miti and expenses which may in any way acerae against said City ALTER OR ADD TO MECIL !
in consequence of the grunting ofthis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCErULATIONs. q
0.� AIR HANDLING UNIT(OVER 10.100)CFM) CONSTRUCTIONTAX
Signaturer'pPNicant/Cornrnmor Date EXHAUST HOOD IW/DUCT? HOUSING MITIGATION PER
HAZARDOUS MATERI LS DISCLOSURE ,
Will the applies, sur from,builJiammer pnnia c7miundlohumrdnus atmerial FIRMING UNIT G 0 100,000 BTU) _
as Defined by the Cupenim Mnnicilial Coda,Chapter 9.12,and the II calf tr l Surety
Code,Sccliun 25532(a01 - IIBATINO UNI'T(OVER 100,000 BTU) -
❑Yn _ C]No VEN'I'I LATION'FAN(SINGLE RESID) PAID
Dam 'I Receipt
Will the applicant m future building occupant use ea Air u of devices which
emittransactions air nmmminumssdefisued by the Bay Arca Air Quality Management - BOILER-COMP(JHP OR I(q,fi(q BTU)
TOTAL:
District? 1
❑Yen 7 N BOILER-COMP(OVER 100,000 BTU)
EA
(have read rhe hvarduus mamrials ra{uiremems under Chaptcrfi95 of the Cnli- AIR CONDITIONER - - ISSUANCE DATE
fmnia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.fT.
building Joes nm currently have a mranLlhat it is my responsibility to notify the r ocupanr
oftherequircmcnts which must be nat prioruo issumrce ofd Certificate of Occupancy.
Owncrormahoricad.,a., - - Data TOTAL: ISSUED BY:
OFFICE