S 2465 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPER'FINO - - BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICALS
>' BUILDING PROJECT IIIFINTIFICATION "
- PERMIT. NO,
2465
HUILDINGADDR ISS: - �) /1 .� Olt
V
SANITARY IN
APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE
LIC
CON'IRACI'OR'SNAj.
NUC
CONTROL#
❑
VI ARCHITECT/ENOINEEIi: LIC N(l:
ADDRIISS: �:•�4-1 14s- 0X-jxvx&4/�
CONTACT: PHONE:
/ /� '
/J70
❑ Consultant Fees Paid by'Applicant (Initial)
't r "BUILDING PERMIT INFO `,1
HLDG ` ELECT PLUMB MECH
171,
LICENSED CONTRACTORS DECLARATION
nmrkny errs Ton am ucen.ed n,mer pros, ant er rbxpler9 (ea cin nos
QTY, (Bj,EC7 RIC'PERMIT FEE
_ .�,e rl
-
P ,JOB DESCRIPTION
- �f'r �
PLRMI'I'ISSUANCP..' r J
wigs i p0B0)ofDiemen 3 ftee fredne,sandP f e„ve d ryTernee',
e d Itecl
RESIDENTIAL(
❑SFUWL ❑KITCHEN RF:MODCI.
AIPIIANCES-RESIDP.NTIAL
--/p�n
Lic se, Cltq Lich 6•C
License
RC T'SI
Dvm IundcrdunJ my plans
IR Contractoras CILAIRAII N
1
QOM
❑ADDITION ❑PLUMBINGREPIPE
OMULII UNIT ❑STRLC9 URA[.
MOIIIPICATION
NTERIOR ❑CHIMNEY REPAIR
IMPROVEMHN'I❑SWIMMINGPOOLS
BATH RIiMODELIREPAIR ❑DEMDLITIQN
OTHER
PANELS
UPT0200AMPS d'
I,icervscl Pane"lonal
OWNER-BU?R)ECLARA'HON
1 hcmny affirm Ihnt I ,nth cxenhp Ikom the Comraemr's License Law Lor the
fallowing rent... (SacYmn 7031.5, Businc,s and 1'...r .. un, Codon. Any nil, of anal,
201-1000ANIPS -'
OVER IItW AMPS
SIGNS ELI?CfRICAI,
which rcyulr'cs a Fermi, m tvmlmtl, cl a,, Improve, dcmNish, or repair any sdri
SPECIALCIRCUI'I/MISC.
"
'
prior no els iasnan,cal,oreyair:a the applicant forsnen permit u, file aignul smmnmnt
,act hois Incensed Peroaanl to the poor ,ium,rt he Commanr_. License Law(Cham,. 9
@mnmencing with Section 7000)ofDivision 3oThe Business and Professions Code) or
TEMP ME I' UR OR POLE INS' I
COMMERCIAL:
that he is cxmnpt meri and the basis for The aloged exemption. Any vieLi ien of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 nyany epFllcanl for a permit sulljecls the applicant ou civil penally of
nor mom Iran five handrral dollars ($500).
E]Ens ownendlhe pn,pany, nr my onployce, aim wages ns their sole cnmpenso,ion,
,,It do the work, and the,Inmlare isnot intended orv0ercd Ionone (Sec. 7094, Ranine,,
❑TENANT . [-IFOODSERVICE
IMPROVEMENT,
❑ OTHER
SWIMMINGPOOLELI3CTRIC
and P ofan,inns Code: The Catco s Licen,e Law does sol apply le an owner of
OUTLETS -SWITCHES -FIXTURES
'
propedy who builds ar improves Ihcrmn, Imd who does such work himselfor through
his own employees, provided mal ,rich improvements re not intended of olrmed for
sale, If, hmwcvcr, he IS Ida,.,impmvemenl is sold within one year of reinfection, the
NEW RESIDENTIAL ELECTR SQ FL,
SQ. Fr. FLOOR AREA
S/SQ.FT
ar-
cr-bnllder will have the burden of proving that he did not build or improve for par-
ry
'
I tch ),
pu Itch),
❑ 1, an "I act If preen, an, -1heneely aominrnmg won licensed enowamrs to
,on,cr.elnt p,.ice, (See, 9044B .: ] Plote,lealC.' I I no C 1'1 I
,
d rPp1Y1-' fp n Iv n b"1d. I .t
who conflosdo,he -ehp J I,w"macoa at ... Go lecrivord'oeterainT lConcoetar,
QTY'- Ir, PE, UNUTTING tPERMFC. r 1 _IFF
PERMIT ISSUANCE
I.Iceire Law.
EJ I am exempt ander Sec B & P C ha do, mason
Owner Dam
AUIER- DRAIN & VENT -WATIiR(RAI
- VALUATION -
-
WORKER:SCOMPENSAI'[ON DECLARATION
BACK FLAW PRQI'ECT. DEVICE
1 hereby allirm ander penalty of perjury ane of the following declarations:
0 I have and will nmintein a Cerlifncale orGnsent m,ed-inewV for Worker',Compen-
,aline, a, peoidW far by Soalimn 3703 of the Lahor Crate, far me parla'n i nce of the
DRAINS- FLOOR, ROOF, AREA, COND.-
STORIES
TYPECONSTRUCH"N
work for which avis permit is i,acd. -
FIXTURES -11178 TRAP
❑ 1 baso and will maintain Worker, Corrryemsolmn Imsa.'.. ace, us teeth✓ l by Saabs
3700 oflhe Lab Cr I In IF perfnrnrancenrmc work for wM1ich avis permrl lei ed.
GAS - BA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP"
APN
' My Worker. •In q� IPnlicy narnbr, �e ,,//��
Carrier:ePolleyNn..
-
CAS-BA.SVSTF.Ms)VER4(EA)
CERT FICCO, OP COMPENSATION INS PROM WOItI�'BIllS'
COMPENSATION INSURANCE
CRBASPIINIlI15TRL WASTE INTERCEPTOR
BUILDINf3111VIS310N IZII?S
[fhin,a:rinn ncW nal hommplctcd ifinepamil ix fonnrehwNml dollars ($lap
or he")
- -
GREASF,'rRAP
- -
PLANCHECK PEES
-
Icerod,The,,.ler,r,fannaneeof the walk for' which lhispamil is i,seed, lsball
nal employ city person in any manner so es to becunne sahjecntire e Workers' Compen-
SEWP.R-SANITARY-STORM EA. 2fN1 PI'.
ENERGY PEE
WATER HEATER WNENT/ELECTR ,
,soon Law, of Calderon. Unto
Applicant )
GRADING FEE
NOT ICE TO APPLICANT. If. after making This Cemileb , of Ri amprioa, you should
bacon subject to the Worker's Corrycn,adon pervasion, at me Labor Code, you need
WATER SYS'1'I?M/rEEATING -
SOILS FEE
'
WATER SERVICE
fo0hwithconnPlyw10nsuchprovisionsorthisperneilshallbedecmadmmnk.d.
CONSTRUCTION LENDING AGENCY
- Ihercby uffinn that mere isuconsmmimn lending ngenry for the perfnnnanceol
,NEW RESIDENTIAL PLMB. - r SQ. FI'.
PAID
I Receipt IT
she —il, bar which this Fcrmil Ix i,sued (See 3097, Co. C.)
-
LendkrsNmnc
'TOTAL:
`
Lender's Addre,s
I certify That I have read Ties appeeml me and dam Thal the above of in. i,
TOTALI
BUILDING F ,
-
.QTY.,' MECHANICAL: PF.RMIT
- t R
rearlagmcm cvnplywiO,.B,.tyandeotnyon0nm�cesdslaiell�ringto
boils stn,to,edn, and hereby,ntlerxo repmsentarves,nn; city (Icmerapnn me
ebove-mentioned property for alorl"Fan pnrposc,.I'EIt
(Wo) agree to sive, indemnify and keep hennas, be Cn, of C.,amo agni of-
liabilhie,,judgments, cads and cxpknnen which may many waysecnmagaindsaid C,
ISMICF -
MI'f ISSUANCP.
ALTER ORADD10 MECH.j l: '
'>
PLUMPING FBI A
in nN,denceof The gdinfr,ol' avis pumit.
APPLICANT UNDERSTAD S AND WILL COMPLY \ I'rH ALL N N -POINT
SOURCE REGULATION( /f
^ I 1
AIR HANDLING UNIT(TO 10,000 CFM) r( �'
•
1 ANICALP .
AIR HANDI.INGUNI'1'(OVER I0000d,
CONS 2UCfIO d'AX
SignalureofApplicanVCobors, 'Dam
HAZARDOI] ATERIALS UISCLQSURP.
Will lheappbcom nr rumrc huilAing otenpnnl,lure ur hendla hazardens m:vcriW
FI HOOT)(W/DUCT) �)
.1IOUSINGMHI RIION FEE
-
-
_
11HATI_NOUNIT(TO100,O)OBTU) .r��'�
o, defined by the Cupenlno Municipal Code, Chapter 9.12, i I The Health and Softy
Code, Section 25532(x)? -
❑Yen rNo
Will The uppliaml ur fare Threat, mwopaal use cgnipirenl orde,or, which
inos as defined by the Bay Area Air Q adily Mari
emit hoeardoas sir mnnomm
DAbiclI Yes i]f N / n I
❑
HEATING UNIT (OVER 100,000 BTU)
PAID
-
VENTILATION AN (SINGER RGSIII)
Dam Receipt IT
BOILER - COMP (3HP OR IOO,aNI RTU)
TOTAL:
-
BOILER- COME (OVER 100,000 B U)
AIR CONDITIONER
I havcread The orowdooneapaluihd_,reym,unIII, under (Battler 6.95 of the Call-
ISSUANCE DATE
NEW RESIDEN'PIAL MSCIL SQ, EI'.
fornia Herith & Safety Cod Sections 25505 25534 and 15534. 1 andeeTa.d flan it the
hnk yd t Oyla' 11111' Y p "b10t itm m am
-
oflh 1" t 1' nu pr'r t ,n,lw nf'IC rIl I�f�nt
•.
J
ISS BY:
TOTAL:
Ownen,raulhor vent rgk
Dale
OFFICE