S 3358 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•11NO BUILDING-ElAu7i RACAL PEEprr NO 3358
BUILDING DIVISION APPLICATION/1-IORMIT PLUMBING-MECHANICAL lV
BUILDING PROJECT IDENTIFICATION
NIJILDING AUDItESS: NIC CON]ROLR SANITARY NO. AI'PLICA'1'ION SUNMISUBMITTALSUBMITTALDAT[
S 5 K!v( uJ�n/ E /G _/fo q�
OW tR" ME: PHONE: - CONTRACTOR' NAME LLC U:
•a M Wi o Crycof¢ �EGjY..1(, 1 IIfS'S
ANCIII'1'ECI'/I:NGINI:ER: LIC NO: ADR SS;q ir"OfVo Sr SJ qJ)2.� ❑
CONTACT: PHONE: z7!l7/ fill DING I'ERMI'f ENI°O
^ �� 2/ ❑ Consultant Fces Paid by Applicant(Initial) BO ELECl' PLUMB ME❑Cx
LICENSED CONTRACTOR'S DyECLARATION QTY ELF,CTRIC PIiRMfI' FEE - 1lrLl/'
n[reby nrrrn mw[art h[enagt Boder provLdata nfcntp[er 9 mmmneatoiatg JOB DESCRIPTION
0~ with
Se meund10) vinlnt3of In, Pml'Gaslu,Code,and my licanscis 4 rpm -RESIDEN'T'IAL:
with Sccalnn 70001 ser Dl J J �-/
O O_ YIiRMI'TISSUANCE
�UV hirenLCl <x Int �1 Lic.N ��it��^� - �SFDWI. ❑KITCHEN REMODEL
H W Daac D Contra 1 2 APPLIANCES-RESIDENGAL ❑ADDITION El PLUMBING RE-PIPE
E-M. A RCHITECT'S DECLARA I'ION PANES' ❑MULTI-UNIT ❑STRUCTURAL
z O r.z I under and my plans shall be used as public records I MODIFICATION
OZ=O UPT02MAMPS G7 OINTERIOR ❑CHIMNEY REPAIR
F41=Y1 Licensed Professional 201-11100AMPS IMPROVEMENT E]SWIMMING POOLS
C C Q I hereby affimt mv�ll nm BER- UILDEcxmnpt GomF he C mtrectora License law for the OVER 1000 AMPS DCLARATIO ❑BATH REMODEIIREPAIR DEMOLITION
xaxOdV following Tensile (Section]031.5,Business and Professinns Calc Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 U.y which requires a permit at conmmct,alter,improve,demolish,or mpair any stmeture
F�•O I prior to its issuance,also requires the applicant for such permit o file a signal malefactor SPECIAL CIRCUIT/M LSC.
> pursuant that he is licensed pursuano the prontrac
visions of the Contractors Liaw
Liana,Liss,(Chapter
�aC0 (commencing with Srwtion 7000)of DiviNon3 of the Businessand Pmfexsions Gsle)or TEMP.MITER OR POLE INST. T•
L 6 e that he is csempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W;y Section 71131.5 by any applicant for v permit subjects the applicantin a civil penalty of POWER DEVICES Ll TENANT ❑FOODSERVICE
not more than five hundred dollars($5000
y} IMPROVEMENT
❑-'Q
22CCL�� Losnwne mrut oyces with ustheirsnle eontpe , SWIMMING POOL IECrRIC❑wil ol,andtemuteresno,ironical armidfBusiness
El OTHER
and 11 cosCode hieC t ur,LacanseLwdoesmestudy
sou ye,,an,tnsulfar
tl (]l1TLLlS $WITCfII:S-IIXIUItLS
pulp Ty 1 '1 'or doemscS[h n,andwn U such l, unteell orThrothh
his Ely p 'Ld that,all it p t a are t 1 1 r O'cral for NEW RP,SIDEN'TIAL I'IX [if SQ IT.
;ale B,hwcvice the btllmgr' p emt " Idwthinnrr
ey I" rielion.fbo SQ.FI'.RAORAIt AREA $ISQ.PI'.
owner budder will hose the harden of proving thio he car an hull']or Improve for pur-
r+se.1 e1c.) Ili
❑ 1,as owner of the pru in,am exclusively commning with licensed conlrecmn to ItYTAI.: V _
mswct the project(See 70W4,Business and Professions Cmr,:)Ib,Co urnetors I.i-
nselawLinesnotapplytoanownerofpmpenywhobuildsorimproves(hereon,and QTY. PLUMBINGPIERMI'T FEE
who contracts for such projects with a conTmetwes)licensed punuannn the Cnmmctor's
IJcena:law. PERMIT ISSUANCE
0 I oro esempt ander Sce. .B&P C for Ibis recon I
Owner DoleALTER-DRAEN&VIiM'-WATEF 1 VALUATION
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT DEVICE / �)
I hereby vffirm under fully of perjury one nr the fol having declarations
• ❑ IhaveanJwillmninminaCenifcam of Cnnsenvo selGinmarc for Workers Cnmpen- DRAINS-FLOOR,ROOEARE QpNDI_ SIORIES TYPE CONSTRUCTION
sation,as provided far by Section 37M of the Lator Cnde,for the pectinnance mine C
work for which Tbi.v permit is i.mued. ' FIXTURES-PER TRAP
I 1 hove and will maintain Worker's Compensatinn lo,ownw,us requircJ by Section
NO of the Lwor Code,for the performance of[tic work for which this pernit is issued. GAS-FA.SYS'I'EMd IS ( 'I'LETS 9 OCC GROUP APN
My Wnrk"'CmytB nsyyfLInsurance Gaolerimd Policyn p
C'larim: S71'F 1`t/A I) Policy No, r
7- /8 GAS-EA.SYS'TEM-OVIiR4'OlA1„
CEit'I IFICA'I'1;OF EXFMPUON FROM WORK I iRS' '+.
COMPENSATION INSURANCE GREASHIINDUSTRI,WAS'1'li IN'I IiltClil"I i7 BUILDING DIVISION RIES
phis sceloom ia,dw Tate completed ifahe permit is firnne nodrarldelluts($ITT)) GREASETRAP
nr lay.) ANCHECK FEL!
I ociify[flat in the Performance afthe work forwhich this permit is i.,owd,],hill SEWER-SANITARY-STORM HA.200 FI'.
Boo empe
ploy any rson in any moaner so as to become subject to the workers'Colican- ENERGY PER
-
0 z Laino Laws of California.Date WATER HEATER W/VENT/ELECIR GRADING FEE
z Applicant
NOLCE TO APPLICANT.If.after making This Cenificete of liumprior.you should WATER SYSTEM/TREATING
become subject to The Workers CompenLtion provisions of the Larvae Cnde,you mus[ SOILS PER
W rnnhwith nsmPly with such pmnsinnsmthis permit shullMd[romed rcvokeJ. WATER SERVICE
0. 0
z CONSTRUCTIONI1.ON LENDING AGENCY NEW RESIDENTIAL PL,MSQ.EU PAID m Receipt a
UU O I
F ffmuM1m ais elending agency home,perfnmmnec of
'he work for which this Tarrant is issued(Se30X].
Civ.CJ
Lenders Name TOTAL:
V Isnder's AJJmse '10'1'A L:
)' I certify alma I have read this application and state it,., he wave inromadion is BUILDING F E
.F-aNcoma.I agrcem comply with all city and coutnyomimutocs and Lame laws renting no QTY. MECHANICAL.PERMIT PEE
7
U G builJaric,o truetinn.and hereby amnorize reprnemativ[v of Wis clay aoenmngam The a SEISMICR ?
ahnvnanenainnal prnlwray Int invpcc[ice putpo,ce.
(We)agree in savc,indemnify and keep harmless The City rf Cuprrainu against
I'T;ItMI9'.ISSUANCIi. ELECTRIC ill
s
Ilxhilities,jndgancn[x,atsTx anJ expenses which may many way accnmngainsa laid City ACT ER OR ADDTO MIiCIL
m...muce al the granting of this permil. PLUMBING Iq:'
API'I %N'IUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]]'('TO 10,000 CFM)
MECHANICAL P
ULATINS. L'
j� ) A /1r-ik/-/�I1 AIR HANDLING UNLP(OVER 10.gMI CFM) CONSTRUCDON'TAX `
Sagman of Applicmi/CommcmT Dme Y EXIIAIIST HOOT) W/DUCT) HOUSING MI'I IGATION FEE
IIAP.AR LOUS MATERIALS DISCLOSURE
Will the applicant or future building orcurent store or handle hmardnus mamrial HEATING UNIT(TO 100,000 SITU
as defined by the CuNnino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(m)'I IDEATING UNIT(OVER 100,010 BTU)
❑Yes -1 No VENIRAT10N VAN(SINGLE BE SI DI PAID• pate ReceiptM Will The applicant or future building occupant use equipment m devices which BOILERCOMP(7IIP OR 100,003 R'fU)
anal hu dorsus'air cowmi
nnam -
s as defined by the Bay Area Air Quality detainment '10 1
Distdc@ BOILER-COMP LOVE 1(kHXl HI'U)
❑Yc, ON.
Ln' Ian 1 J t AIR CONDITIONER.
qu t. MCI-pt r.is faha C.I'- ISSUANCIi DA'L'E
fornia Ihold,&sJlyC It.See a,15505,25533 and 25534 1 ....ii-sli f0 a fob[ NEW RESIDENTIAL MHCI I. SET.Er r/
boil'] y I ' lyl Ilntl ye]Xmbllyl Iffy 11 valtanl / / / '�
nn1 I r.mema wb bnms[ne net pro t „aa t,e traeen l[me rn'fx[apanay .
Owner or canonical egeno Date TO'T'AL: ISSUED BY:
OFFICE