S 2369 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT7N0` •^ - BUILDING-ELEC'I'RIC\L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MEC11ANICAI,
BUILDING PROJECT IDENI'IF'ICATION S 2.3.63. .-
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
Olkill'S NAME I • PHONE CONTRACTORS NAME: "" -- LIC NO'. -
r G U'l` �/ 7 NIC CONrROE#
TIet" :N(il Nl 11: �, Gl�/ / 1 CNO ADDRESS: _ _.-. .-.•. --. _ � ...f-..
S P
CONTACT: PHONE: ���_•-- «q.,......_..............�,,,,•,,,,, ,,, BUILDING PERMIT INFO-
r ♦_,J-GOII5111{0tlEpee,Pai8 A�Ap(IIiCdOI(Initial). InAN3. - F,LEC'f--'PBUMB' --ML'Ell
LICENSED NSI D C(NTRACRSp LCLANATIQuIT ( ' QTY ELECTRIC PERMIT - IRIPTIONu herebyH that[;a,,T' J J o : ICLRarJt rte g 0HFFSC -
'OaZ withS T 00X01 IDa Snn3nl the Hu. nA ltrfessmn G.lC and ryl ce -- - RESIDENTIAL:
1+100 FERMI I'ISSUANCE
F�.. in full frox.nd elle, �� ❑SFDNI, ❑K REMODEL
VF Liccno Class Lic,4
FZW 1 .,,•3_� ANPLIANCEti-kFSIDEN'TIAL 20 ❑ADDITIOu � �PLUMBING RIi-PIPE
w¢a Cnrnractnr
II'1'EC'1"S UECLARAI'ION; ,� ! ❑MULTI-UNIT - ❑STRUCFURAL
p.pN _ ' PANELS ., . . .
I ZONZ 1 dm p . .111 -u
amAv• �•+ .r _ _ ,� MODIFICATION
.
OZ G - UP_T0200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
Li n.. iplot ca.innu -•-201.100lAMPS LMPROVEM6YT' ., SWIMMING POOLS
IYYE� NER RUILDCR DI CI ARA410N_ OVER I00JAME4" - ❑BATH REMODF:IJRIiPA1R',E]DEMOLITION .
K a¢ I h by fl m t I opt I Ih C l .tL' I aw hand,
h
X3v'U --
billowing reason (Section 71111511 sec IP `,,00r,C I,Ay rity Ur'lately SIGNS ELECTRICAL ❑(YI'IIFR ' �
W=O vFi which y 'm.a(zn to I t t,shat, p c.demolish M y.tmcmre '-
I: N4 Pdormiln iesuunm,uln�«quim6 lire a,haunt Rmwch Pemtil In 11le a signed vtalumenl SPECIAL CIRCUITAIISC.
Eby that he is live...dPhrsuanturlr,rewnio v,,dne CvnlmnoR.Elvettml,. (Chvper9
D IY L,C (,,an eicingviall Section TXXhnl Divivinn3 nftneBminesv unJ PrYrfeoinm Gde7on TEMR MITER OR POLE INS"1'. COMMFRCIAI.
a Xa• that he is eV,.,a Ibcrefrnm and the hm:v for Jm'allugeJ ucn:Pliun.Anq vinlw:oo of NEW BLDG/ADDITION ❑DEMOLITION
e
4' Section 7031.5 by any applicant for a l'cmdt object%the lipinnm to a civil p;nAly pr POWER DEVICES
m-rte - ❑TEPROV - El FOOD SERVICE
sol nom as wIrannc live hundred dollars($Ship). __IMPROVEMENT
SSD ❑Lothe work.the prpary,rnryet nyt maindleN,wilhered fowages slnei r(Sec.
aml'B."lien. SWIMMING IK)OI,ELIiC'I'RIC ❑OTHER
W F-o will eIr ion,and, Ple,structureor&,h,LicHno,Le.dos not apply to all Bu.iness -
63m and Pmfcesiona Cwk'.'Ihc Corwem(i I,indn Lawd:tcvnnlapplytolf rwner of OU'11.ETS-SWI'TCHIS-FIXTURES o`O '
his o ny whooyces.or impedes t wells,and who docs such work ided o f uv through
his own entpinyces,pnrvyJeJ that Heir impmvemenna are oof'ihtendN or offered for NEW RESIDENTIAL E=R230 'SQ".
owner-salt, howevice ll h v ilthe burden
d lnpmvemm�t ithat h within orb build
or hapro le for the SQ.FT.FLOOR AREA SISQ,FT.
vol bailees will have the burden of proving IharM1c die not build or improve for par- .S
pc I. I ). 1 T
1 ec fIn p rcri 1 y t ry InT : l I''Inn lu _ .,' �•• •_ - :-
construct the tried(s 70,00 Business and Professions Carl The Connoor.s _.
I w Jt ev wl apply I : r t Tp pe IY who moilds - p sec Ihereor and QTY PLUMBING PERMIT FEE
who vnntraets freshen pn...is vvhh a umlrecum(4)livcasul Phohanl m the Chrurfor' PERMIT ISSUANCE ISSUANCE
❑Iamlhnder Sec. H h P C to ft'acanv
H
e - m19 c -
ALTER-ORAIN N VENT-WATER(EA) VALUATION
( m Ua
WORK.'S 'OMPENSAT[ON DECLARATION BACK FLOWPROTECT.DEVICE '2- -]//J .
- 1 rtby u0irm under penally Mperlury one nl the following declarations .O O \
1 and will mainlain a Ccnilicalu of Consent osch-insure Sa Worker's Cumpcn- IIRAINS-FL(JOH.R(R)F,AREA.COND.
�b� inion,m ptovidcd Ibr by Scclion 3]1X1 of IM1c Chiron Calc,for IM1c perfnmmncc of the _
siblims - TYPE CON.(RUC'UON
work for whichthi.. ti.Imued. - -�- FIXTUREC-PER TRAP O
Itermi ....
0 1 hove tmd will nm—lain Walker.Cnmpematino Insurance:ux rerjrired.1,— l'.
3100oflbe laMnGala for the performance oflhe work for which this permit isi.ssued, GAS-EA.SYSTEM-I INC.a OMIJ-TS (ICC.GROUP APN
M W..ke'.,C �+J'Hance camas and Policy pYN
Credit, �/�% Policybh,v r 0-2•? sq' GAS-F;A.SYSTEM{)VER 4(HA)
CERTIFICATE Op EXEMPTION FROM WORKERS' GItF,ASFJINDUS"1'RL WAS 117 IN'1'F;RCIiI'TOk
. COMPENSATION INSURANCEFELS• _
(Thmetlinnneed net becnmpined ifthe peHall is fimhnehund )NC UIVISI(vhN
rcddolhos($lnlp CREASE'[RAP
or Ica..l I'L(s�NC11ECKE
Ie,anythat int he vilany manneenrlse Feconi subjetto the ovissn Coarsen- SEWER-SANITARY-STORM EA.2M FIF X
not 16'a I'oy any pmm in any mannerso)as to become subject the Workers Coarsen- t
-C1 0 ,
,� vainn lawx of CJifinnia.Uv¢ d
'Z O Applicant N'ATIiR HEATER K'/VENT/ELECfR
y NOTICE TO APPLICANT:If,after sinking fla.Certificate of Exemption,you.herd WAI'[R SYSTIiM/I BEATING
abcanne subject Ih de Wn:kara Cn:npa,aflota pmv sine,of the Labor Calc.you ma,l
forthwith comply with such provision,(it permit shall be deemed rcvhkal. WATER SERVICE
a �
5z CONSTRUCTIONLENIIINGAGENCY NHWRESIDENTIALPLMH. SQ.FT.
UO l hereby affirm that there is a construction lending agency for the feHorrearce of tn
Fthe work bar which Ibis perch k issued(See.3097,civ.C)
C) U Landers Nacre TAI:LendersAlden. A infirtmmmoa _QTY. - MECHANICAL PERM[r FEF ,U 2build 6 I 'fon.end hereby authorze p moves of lti:oily lo'crucrupn the - - I O
all Hemeried property for'napcelio n....... -'- - — _
Wc)a tosavc,inMmnif PERMITISSUANCIi
1 gm ro,s hepnannlead,set ilY.nfCupcninoagaina . lil.li 'P.li t 70
Iinhllilics,judgmm�N.co.a.unJ expenaev wliieh may in any dory accrue apainst.wiJ Goy ALTER OR ADDTO MECH. Z_0
n ANI U DE gmming of Nis pnniL- '• tCOI
PEE
t PI'L1 'AN'1'UNDERS ' NIl AND WB:LCUMPLYWITB.ALLNON-POINT gIRHANDLING UNI'T('To xhgXI CFM)
OURC 1 GUI.ATIO is _ - ALFEI:
... .......-vs-.,._,.�'• AIR HANDLING UNIT(OVER 10,P)PICFM) 'ION TAX5 net rvofApplicenUGmlm o "" '^"' EXHAUSIJpOOD(W/DUCEI'1lCA'1'ION FfiE) yt
IIA I (IDS MATERIALS DISCLOSURE
Will lfier,livenlorfnure huilJing tecupunt.vltiie of h"d Ulchdzurdoun mvrarivl - HEATINGUpIll(TO I00,000 BTU) - -- -�•-•..
cfned by the CuPenino Municipal CoWc.Chapter H.12,unA Ihu Ilenbh and S:Jety
ac.lc,Section 25}326v0l HEATING UNIT(OVER 100,1100 RTU)
•- '� - VENTII.Ar1ONI-'AN($INC11 RESID) i PAID { __ F
Will the applicant or future building occupant use equipment th,J - .which
pyit h' f m I. toed by Ibe Ii,y Amt A''Q Ily M age hent ISOII,ER COMI-(3111 OR I(X),NX)H'TU) -
'Oialricl! ' ' 'I-CIAL.
El Ycv 0 N HOLLER-COMP(OVER 100.000 BTIJ)
AIR CONDI❑DNER
I base and!drcI t:under Chapter 995 1 Call- ISSUANCE DATE F
Inni H ❑b tu Safety IY C d ae S ( 25 25 50155,25513 J 25935.1 'I J d Ih a,t it NEW RESIDENTIAL MECH. fiQ.FT.
build' gd rl til I IIhI y p -tiTlyl ratify ctpmt
nl Nc reyu're terns whish muSl b,nn prior m asunnec oI a Cvrfheac of U'cupmry,
..rnrn L
- (lwgJa m path 'll AL: ISSUEDBY:w
OFFICE