B 0361 (3) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIT$�F CUPERTJNO BUIL)ING-ELECTRICAL TERM I'1'No
BUILDING DIVISION APPI,IcA•PION/PERMIT PLUMBING IDENTIFICATION
SOOOI ff 0361
BUILDING PROJECT IDF,NTIhICATION
BUILDING ADDRESS: SANI I'ARY NO, APPIACNI]ON SUBMi'['[A[.UNI
3 0 0 hci, r L r ftcl
� e+-�no C4 9;0 — Q
W lik'S
NAMEy' 'IIUNIi: WkCi( t'S NAM LICNO',
S V1 U.N 'II NIC C(IN'I lll.p
'CHITECAIENGINF.ER: LIC NO: ADI 1 S ❑
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CONFACY PHONE: (/.LL BUILIJING PIil2MITINPO
❑ Consultant Fees Paid by Applicant(Initial) BLDGIiIECT ill U.MB ME 11
SUSflnI Folu.'Z 06 S?3- 7 E3 � ❑
LICENSED CON'IBACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby dm ohm ru1 am licensed,odor proNdons of chapter v mnmmencing JOB DESCRIPTION
"Z with Section J000)ofllivision 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
FU� mfrmse lass _ B Lic.X `� ❑SPDWh ITCHIiN REMODEL
aVU License Claw lJ APPLIANCLS-RESIDENTIAL [I ADDITION [I PLUMBING k1:P1Yli
p-.Z m Dale Cnmmct
yQy ❑b111Cf1-UNIT ❑SfkUCfURAI.
F=y ARCHITECTS DE 1 TUN PANELS
w Z I understand m plans shall be used as public mzmds MODIFICATION
OZ`"- y pu UI'T02W AM11PS
❑INTEk10R [I CHIMNEY REPAIR
[=�Lw Licensed Professional 201-1010AMPS IMPROVEMBNI' SWIMMING POOLS
%.j S-1 OWNER BUILDER DECLARATION OVER IM)AMPS ❑BATH REMODEIIREPAIR DEMOLITION
C d'Q 1 family o0irm that 1 am,tempt from the Cmdor is License Low for the
a V following mason.(Section 7031.5.Business and Profession,Code:Any city or errntY SIGNS ELECTRICAL ❑OTIIER
H"y which requires a permit m vomorct,almr,improve,demolish,or repair any sanctum
F 4•0�' prior m its issuance.also requires the applicant for such pnniunlilcv signedstmcmem SPECIAL CIRCUITIMISC.
� y that he is licensed pursuant to the provisions of the Contractor'sLicenee1-aw(Chapter9 COMMERCIAL:
u)�00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)of TEMP METER OR POLE INST.
a a e C that he is exempt therefrom and the Iasis for the alleged exemption.Any violation of ❑NEW BLDG/ADUI'f10N ❑119h101.IT10N
W,mSection 7131.5 by any applicant((it a proal subjects the applicant h+a civil penalty of POW)?R DEVICES 0 FNANT ❑FOOD SERVICE
at more than five hundred dollars($510). IMPROVIiMLNT
=Q n1,as owner of the property or my employees with wagee as their sole ct ce n SW1l ELECTRIC
F willdo the work.ndmestmcmre isnot intended mattered rormic(Sim.71Jq,B ❑Ol'HF:H
eo
W and Professions Code:The Clamberer',License Law diva not apply to an a ,IIT. 'WI I'
property who builds or improves thi and who dacs such work himself nr
his own employees,provided that such improvements arc not intended or off J Iia W RE I FT
Sale.lr.hnwevcr.lhe building or itnpmvcnmm is sold whhinoneycarnf complc' o,the. SV.(I'IbPI:U(Tt'AR rl SISV. 41',
rhold,f will have the burden of proving that he did not build nr initial,
nowf: )
Ej1 A
. ❑ I, f th pr pent' lycontracting Ililicensed I n
..........ath P j l(Sc 71Wq B ' I I 1 v Code)7h C t l :l IV`I MY U 7 1999
� nseL I rtpplyl Ip p.ny I b 'IJ. p stn d QTY. PLUMBING PERMIT .. j r
who a t:l Suchprojects wtha Our rlJlwmsul p+ . nuoaheCmo nrx ^ II
License Law. 1'IiRMI i'ISSUANCE .J J
1 an exempt under Sec. .11 R 1'C lar This mason
AI:I'i?R-DRAIN k NEM'-WATf3R(EA) ])) VN.IIA'IltlN
net -U:)re
WO ar,, Co,,ill Spa,IN DIiCI.ARAIION BACK PLOW 1'ROT[C'I'.DIiYIGB
I haad,Alnuuunder penally al'perjuryare ofellfollow ing derkar's of
IL���unJ will nmimvin aCen'tlicaac nfCnnsem msallinxuru or Worker's Cwnlnna- GRAINS-Igl)DR,ROOP,AREA,COND. S'IT)I<U} 'I'Y19?CONSI'kVCI'l11
smum,as provided fir by S,clinn 7900 of the litho+,Cda,for the Iarlitm;nme nl ma _� 0
work for which ahlx permit is issued. TIXTURES-PER'rRAP
1 Lava and will amimma Work e,Cromailledion Inavmma,us required by Section
3700ofmc[,hnrCode.lin the ptthmralarof the work for which this peoun,is issued. GAS-EA.SYSTEM-1 INC.q OUTLUCC.GROUP N'N
My Wor ek Cwupep lit InxuruncJr mlermd Policy,ntup 0 Z, Z GAS-IIA.SYSTEM-OVER Y(EA)
Currier 1 Itv 1`ie `y H"a 1'olicY Nu.: II [0 -/
CERI"]FICATE OF EXEMITION FROM WORKERS' GRP.ASILINDUSTRLWAST1i1NTERCEY R
COMPENSATION INSURANCE BUILDING DIVISION FRES
(ThlssecGon nudnol heentnpleed it lhepcmtit kfornnchundmJdollims CH 0) GREASETRAY
I'LANCHIiCK 19iG
or le,)
Toy any matinthe any incnanceolmeltecomr w'hichthis pec W..is roiC.Ishd1 SEWER-SANITARI'-STORM FA.200 FT
not employ any person in any tnanner So as m become aubjttt.+the Workers'Coanpery ENERGY hili
O Z satin.Laws of Cali onia.Dom WATER HEATER W/VENT/CLEC R VO GRADING FEE
Z 0 Applicant P .
NOTICE TO APPLICANT:If,after making mit Ccnifica a of Exentpbun,you should WATER SYSTEM?REATING 50145 PL•li
" haeme subject ill Workers Compensation pmvixions of the Labor Code,you moa
LK forthwith comply with such provisions or this Permit shall be dccncd narked. WATER SERVICE
aft
7 Z CONSTRUCTION LENDING AGFI•ICY NEW RESIDENTIAL PLMB. SQ.PT. PAID
I hereby afirmthmthere,iso contraction leading agency for the performance of Ila¢ RweiplX
{UI. 0 Ne work for which This Permit is issued(Svc.3097.Civ.CJ 'TOTAL:
O Iende/a Name T AL:
T knit(,Address BUILDING FEE
6. I crnify that 1 have mad this application and nate that the above infnrmmium is
FIA coni Iagree,,+comply with all city and county nat...cet and stem law,relating to QTY MECHANICAL PERMIT FEE SEISMIC FBI:
U Z building construction.and hereby authorize repreunmtivesaf this city to anter upon the
.trove-mantioned pmpeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(Wel agree m save,indemnify and keep harmless the City of Cupnino against
Iiabildies,judgment,costs and expenses which may in any way accme against said City ALTERORADDTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
AI'I LCANTUNDIiRSTANDS ANI)WILL COMPLY WI'I'11 AI.1,NON-POINT A IR HANDLING UNIT(TO 10.010 CFA) MECHANICAL FEB
SOL CE REGULATIONC
( \ 5- - AIR HANDLING UNIT(OVER IBBBUCFM) CONSTRUCLONIAX
to,
gnawrc of ApplicanUCnntrector
.5-1- 29
Dmc EXHAUST HOOD(W/DUCT) HOUSING MI'I'IGATION THE
IIAZARU H S MAI ERIALS DISCLOSURE
Will thevppliant or fair,,buildingoccupantmore or handle hwunlova material (TEAT INC UNIT(VO 100.000 BTU)
defined by the CnpcNno snowipl Cde, pier 9.12,and the Health and Safety FI EATING UNI"I(OVER IW.(X0 BTU)
ode.Satin.25532(a)7
❑Yes I u (/y[ � ��` VENTRATION PAN(SINGLE REMIn SAID
Dam Receipt p ait Pali
Will the applicum or future building occupant use equipment or devices which NOILI?R-COMP(JHP OR 11X1,00(1 BTU)
ail hnmrJua,air contutninunw nv dcl7ncJ h alio Buy Arca Arty Munugctncnt Yf
)iarlet P BOILER-COM)'IOVIiR 100.000 BTU)
C3 Yes + L
AIR CONDI nolblift ISSUANCE DA'I'li
I Iowa S,L Code. us tnumriuB raryimnrenm u2553 1 too ,buld'l t it th
❑vain ilathh k Sufuy C+.Iq Sections 255115,2$571 nnA 25514.I nndcoumA IhW ifm, ry(;W all MENTIAL MECH. SQ
bniIll, i nolcnmmllhoe;uewm.Ibwitismymgamdhility u+nollly 11hel"vpam
m'Iba res ,trmmx wbnb�tn m•I pdmrtm'txs+ail„ant renifiamn m'oceatntmey. T
Ow vmhsn't.'ug"n Una° TOTA4. ISSUES)By:
OFFICE
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