S 0641 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•rINOBUILDING-ELECFRICAL PERMITNO. %
DUILDINC DIVISION APPLICATIONA-ERMIT r PLUMBING-MECHANICAL S 0641
BUILDING PROJECT IDEMPIFICA'1'ION
PIILDING ADDRESS: SANITARY NO. APPLICA'HON[ I�
tiUBMTEAL DSTI3
/ U '_SJ � �AKVIZ-4 — Vc Q 2T�j
NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
JA E S AG.0 Z. —08 ZS NIC Is>rvruol.x
.RCHITECI'/ENGINEER: IJC NO: ADDRESS: ❑
CONTACT: PHONE:,: BUILDING PERMIT INFO
❑ Consultant Feu Paid by Applicant(Initial) BLDG [CECT Lp um't MECH
1$W.
LICENSED COMnsed under
p DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed%oast proviannN of Chapter v aommermine JOB DESCRIPTION
�d'Z with Section?000)afloinion 3 ofthe Dusioros and Professions Cale.and my license is RESIDENTIAL:
W O PERMIT ISSUANCE
in full force and ellen. - ❑SFDWL TCHIiN RIiMOUIiI.
QUU License Class I.it.a
RITSIDEN'1'AL [I ADDITION S UMCBfINUGRARIG.
I'11'1:
FZcw Date Convaclar APPLIANCES—
AHCHTTETS DECLARATION ❑MOLT[-UNIT
PANELS
ZQvsZ I understand my plana shall he used as public retards - MODIIICATION
OZ,O _ UP TO 200 AMPS C1 INTERIOR ❑CHININ17Y REPAIR
F�E"J u1 Licensed Professional 201-1000AMCS -JIM PROVEMENT El SWIMMING POOLS
�%j J OWNER"BUILDER DECLARATION OVER 1000 AMPS 7 � pTH REh10DE1lRIiPA1R ODE 01.1'1'ION
C=k) I hereby off est that an esempr s an the Contractors o Liceove. c Law for the F�
X L V which ire rumon.(Section 7031.5.Business and ove.deinn%Cole:Any tiny nrcouetY SIGNS ELECTRICAL 1 CJ OTIIF.R
W 3
Lch which it, ,tn u v.al.t ar cumtntct,apes Improve,h vernl%lb.to or repair ed swment
prion I oleo y 'J pplie It 9ps 'n tl signed SPECIAL CIRCUIT/MISC.
W`y�Y
but he Ip n tl til C I 'I .1 I '(Ch'pmr9
�aQQ (tom b "II S s' ]111X11 tl ' ' l ftp B ' 11 t 'C de)or rF.MI'.MFTIiN Olt POLIi INS'P. 'COMMF,RCIAI,'
ON
d unit I core than live hundred Aollurs ISSq x f tM1 .Jlegul exa pl on Any violation of [—INE W BLDG/AUDITION ❑FOODS RVI
Cthe b:s
iC•+:�• Secrian]031 5 by any npplicum lar a permit%ubjcca the vppllcam na o civil penally of
POWER HR DEVICES ❑TENANT ❑FOOD SERVICE
B� - IMPROVEMENT
S� Dl,muwncndthcpmpany.or ntycntpinyeeswilh wugexmlhcirvnlcmmpcnxotion. SWIMMING IY)01.13LEG'I RIC
will Jar the work,and the structure is not intended m offered for salt,(Sec.9044.Basi Tell ❑OTHER
F>:~+ )UTL13'L5—SWITCHES—Il%TITRES
04 and Prdas%ions Code:'rhe Cantexu r'x License Law doe%ern apply m an owner of
6'3 proNoy who builds or improve%Ihereen,and who Jtes such work himself or through
his own emphyce%,provided that such ingaovcmea%are not intended car offered for NEW RESIDEMHAI,F1 RUTH SQ 17L Fr.FLOOR ARBA VSQ.IT.
sola If,however,the building or improvement is sold within one year u!completion.the
,,an,,milder will have the burden v1 proving that he did our
build or improve for par-
Ease of salcd. TOTAL: PAID
I] I.as owner of the property,an,exclusively Contracting with LccnaE coaleamr,to
consract the project(Sec 7814.Rusbas%and ProfieWmns Ctdey The cammocrou s Li- - OC
'r Law does not apply u)an owner of pouNry was builds or improves Neuron.and QTY. ` PLUMBING PERMIT FEE � 2O ���
who contras for such projecm mn
with a contm(s)licensed Pursuant to the Contranoh O
License low. PERMIT ISSUANCE /%
I am exempt under Sec. .H&P C fonhiN reawn CIT��I T "'F
_ AUTER—DRAIN&VIiNT—WATER 07A) • NAu TION
Date
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
400 I hereby affirm under Penally of perjury one of the following declmmions: �N
I havernl will maintain a CcTfate of Comaoun self-insum for Worker'%Compm DRAINS—FLOOR.ROOR AREA.CONE). STORIES 'FYPH CONST RUCTION
Nation,a%provided for by Section 37W of the Labor Code.for the performance of the
work for which this permit is issued FIXTURES—PER TRAP -
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
TBXl of the Labs Cole,for the perlimnance of the work for which this stand's issued. GAS—EA.SYS'TEM.I INC.4 OUT'1.11 S OCC.GROUP APN
My Workers Compensation Inmeacc carrier and Policy number are:
Camier. Policy No,: GAS—EA.SYSTIda OVER 4(EAI
CERTIPICA'1'F OP I:%IiMF'fIDN IgtOM WORKERS' GRHASFIINDUSTRI.WAS 117 INTERCEPTOR
COMPI!NSAIION INSURANCE - BUILDING DIVISION FENS
Thi",eGion tealool bxtnnpleted if the pcnad,,rnnmchnnJreJ JnlWcs 1411X)) GRCASEIRAP
car less) PLANCHECK FEE
I certify that In the perfornenwo,of the work liar which this permit is issued.I shall 'SEWER—SANITARY—STORM HA,200171.
bol employ any action in any Too c,sons to beenmc xubjoll m the Workery'Co:open- ENERGY FEE
Z sxtion Laws o(Calilinniu.Date WATER HFA'IFR W/VIiNT/FLECI'N
z Applicua l - GRADING PHE
NOI'ICETOAI'I'LICAN'I:11;nficr looking thl%Ccnilicnrc nr F seultion,you should WATER SYS'H!M/IBEAI INC,
y SOILS 19:I.
(••' hecto:ih comp ut ILC Worker's C i...is par,permit
steal of the Inbar Code,you mus
Wlonhwith comply with'such prnvixiun.a mar,pemtil ehnll he AcemeJ revoked WAI'1iR SERVICIi
Q
p• CON�,S'I'RUCION LENDING AGENCY N13W kF.51DL'N1 IAL PLMIi. � SQ.PL INID pare emiplx
U OI hercby off an that there i.a aomtmcdan lending agency for the perhmaamee of
F-t the work far wbidt this t is isond(Scat 3097,Co.C.)
Q TOI'A h:
Fiancees Name -
Wlender's AJdresa TU'IAh:
0. 1 eerily bar I have real Ihi%apPlicainn and state that the above information is BUILDING 1'EF
f•' N correct.I agree to comply with all city and nmmyorcinances and sate laws relating to QTY. MECHANICAL PERMIT FEE IMECHANICAL
SMIC FF
U Z building construction.and hereby authorize mpmxnmtives of this city m enter uponne
aMve-mentioned property for insertion"vcs. PERMIT ISSUANCE ECTRO EE
(Wel agree In lave.indemnify and keep'armless the City
of Cupcnino against __
liabilities,judgment%,costs and espensec which may in any way accrue againnsa�ld City' ALTER OR ADD TO MECH. UMRINGF '
in consequence of the granting of this Permit. _
ot
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFkH FE'
SOURCE iGU1.AT10N5.
^%Y � 57_Z.1-97 AIRf1ANDLINGUNITIOVIiR10.(XpCPM) NSTRUCfIONTA.gnawm ofApplamulConnmctor Date EXHAUST HCKD(W/UUCD USING MITIGATION EE
HAZARDOUS MATERIALS DISCLOSURE
Wiliffic.plicamarfumre bolding ottupanumre nr handle hazardous material HEATING UNIT(TO 100.000 BTU)
as delin al by the Cont iso Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)Y ` HEATING UNIT(OVER l0a NN)BTU)
❑Yen Fl No VF.NTILAI'ION FAN ISI NGLE RES ID) PAID --
Date Ruccip M
Will the applicant or future building occupier use equipment or devices which BOILER—COMP(31111 OR 100.00C,HTI3)
tit hammm
rdous air cnami Turns an defined by the tiny Area Air Quality Management Tl Al.:
District? BOILER—COMP(OVER u),N)OI I'U1
❑Yes No
I boV rend the ltm,unlnnsmarcrias rcquimmmnt%under Chvptcr 695 of rbc Cali- AIR CONDITIONER ISSUANCE DATE
fmas Health&Salcly Ctdc Sections 25505,25533 and 25534,1 understand that if the NFW RPS I DEN'I'IAL MSCI I. SQ.Irl'.
building llW%nm cmremly have a to,.am.Ihal it i,ay mxpmnibilay,,easily the mcupum
M ft he rcquiremcnts which must b'it"prior to ixxnunce ern CMilicllc orf Occulcor". ^JQ s
Uwne,oi—tahmiXcd agent Date - 'I'UI'AL: ISSUED BY.
OFFICE •• ,