S3124 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPP;RTINO RUII.DINf.-ELECTRICAL PE rTNO
BUILDING DIVISION APPLICATION/PERMIT rt.0 I G-n1F:CnAIHcu. J - 3124
BUILDING PROJECTIDRIOn FIL'ATION
BUILDING ADDRESS: �� SANI'TARV NO. A%'LICATIONSUNMITI'ALDAIL
0200 iv Pc�TRl1 f
OWNER'S NIV11'Ac ' IS3 CUIS'I'RA(l()R'S NAh :� LIC NO:
S J Ili NM /� COMROI,M
-� ARC CrDENGIry(jF.R', - 1 �rsjLIC NO: I ADDRESS: ❑ Q o 7 0
CONTACT: `//± PHONE BUILDINGPERMII'INFO
I U-2"Lb-770 ❑ Consultant Fees Paid by Applicant(InlliaI) BLDG Ei ECT/ 1'LUMH MECH
2 U ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FIiE
I lertnr amr,n Nal I an.Ikensod am><r Frovu'tonc or Clapter 9(euerartm tg JOB DESCRIPTION
OZO ithlSm�m )al'Bykim J of he-Buslnas and RefeWee,CcIk,wW my lieer-es PERMIT ISSUANCE �� RR SIDS
(..cF in CsmWL ❑KITCHEN REMODEL
Nb` Lac�Clnw Lic.Y APPLIANCIS-RISIDFMIAL ❑AUDI TION El PLUMBING REPIPE
NQW Date Cmtrxmr ❑MULTI-UNIT ❑STRUC'IURAI,
ARCHITECTS DECLARATION YANF,I ti MODIFICATION
ZOr�Z .I uoderrarad my plans fall he unt Is public teeonu
OZ-� 1111 -0 AMPS C3 INTERIOR El CHIMNEY REPAIR
F�I^'w IJcrn+ed Ro(esaorml fill-ItXp AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOIXIAMIS ❑BATA RF,MODEIJREPAIR ❑DEMOLITION
x C 6 I heathy elTmn that I am exempt from the Convacum's License Iaw for the
K O L U folloss ieg.,(.a Non 70315,Husitews and Hofinema Code:Any city m cumry SIGNS ELECTRICAL
❑OTHER
LL!3 LL� which ren ims a prmtit to mnatrvn.Wtcr,tmpruse.dearoh,h.or a lour any moetart
"4:0 prior to it,i..manac,al.wi.,lair,,the applicant forxuth Psamtino filtasigted ortemem SPECIAL CIRCUTI'MISC-
HVAyy� Ihet be is liccrual pmmarm m the Provisimts ofd^Conesetorn License Los(Clwpm9 COMMERCIAL
lcomrrcriciog with Scclion7tM)Ul of Division 3ofth Nusirtw ltd Prufesswm Code)on TIJNP METER OR IY)I.E INST.
L y o p{ that he Is exempt thetcfmni and tM basil Ge,1W Nlcscd a laafl Any-,loin of ',,N� h/:W HhDO/ADDITIO,�' ❑DIiMOLITION
o" amt Semon 70315 by tiny almheent fora permit whims the applimo to a civil 1-111M POWER DEVICES COy!&ANT ❑FOOD SERVICE
F.
tml mart then five btudred"lars(55W). IMPROVEMENT
O ❑ Lux owner ofthe prnpeny,or my employees wool wage,as their wile ConlPoumn. SWIMMING TOOL ELITURIC C]OTHER
L. wtlhbthe wrxk,eml de ANtlum is mtinlentkd art nRerd(azale(Sa.7DIJ,11esite-
,1-12
C' vat Pmfeo iau'Code:The Coturector.License Inw does uta NVIY to en ass'ner of OUTI.FI'S-SWITCHES-EIKI'URIS
5 Property who luildx or impmws thereon,anal who Mas cud wtxk himself or through
hi,oxm employees.Pro d�d the,web impmcementY ort na imerded or oRerml for NEW RISIDENDN.ELECUt SQ 19'.
sak.If.howcsrr.the building mlrryrro.crreN is surd wind.mac rear dcvmabrim,de SV FL FLOOR AREA LSU.FT.
sur-builukr will have iW madco of moving That he did ml Wild or improve I'nr pm-
gwo(sak.). - T
I,as myon of the I,ma ,w e.aclusively conwefn,wuh licensed mnmvas N
nat
ruct the PI(see 7(w,B.,joe,vW I'mra cions CrvH)Bee Conlramurs Li-
a.Law due.nm nerenm.xrd MR(X)KARF�,
ING PERMIT- FEE
who convects for such proln"u with u cevrxrWs)fiansN puwvN w the Cornaenurs
Leense We,. C'
F1 IamexemPtmmhrSes. ,B$PCfor Oistcuwn
AIN& -WAILR(HA) VALUATION
0wrer IAtc ' ( O
WORKER'S COMPENSATION DECLARATION 'IVR. 'GCI'.DI?VICE �D
I hmeby elfimt earlier Penally 4 pe)uD one of rbc fNlowing deelvatiort
I hast,and willntvnuin a Certificate MConmm m s Ibinave for Worker's Compcn- OOR(R(R)KARFA,GOND. STORBSS TYPECONSTRUCION
-tion,a pmvid 1 far rm Seamen 39ro n[tFe Iahar Crvk,rat Ne perGmiwu'c of the
wrMc fm which chis permit is issudl. %HI T1tA1'0 1 Tuve aW will nuirmam workers Ctempemaniun 1nwrNee,as"ainal M1y Surtors3700.fthe laNaCdc.forllcperbaarmoflIWaoA forwhich this Fe to I.,i1aLYSTGM-I INC..0U1l.IRS (xC.GROUI' APN
Aly Worri CnmPcmaror basset wrier-ad Poliq mumbo x:
Cumcc I'olky No.: GAS-IA.SY51'EM-OVIiR 1 fEA7
CERTIFICATE OFExFMprION FROM WORKERS E�- SIUIND SIR ASjll�ERCEIITOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
['lltis vnunn need not be<wnpinNif the lxmrit isfororo hurdmltWHnfSIW) TRAor lae.l PIANCIIECK ILL?I certify thin in thexef..ofthcvrk(orhkh this lsrmit is issued.Ishan S 'I'IARY- A.21X1 FI'.rax employ wy Fcrsm in any munter.m us les he oaae wb)ecl to the Workers'Carol 11:IBIGY ItiG
Z setim 1,,-of Ctliferm a-Date EATER GRADING FEE
Applicern
N NUUCE TO APPLICANT':If,n11ec nuking tni,Cenitic t e M Exentpiorb yae should WATER SYN IHAVTR
a ; baone wool to the Wml.dti Catn f nuc IuMu Crile,you maw SOILS Fl?l1
pamoum,u Permit
h.1 o
{k7 fmhwilh mmTdy witM1 such Fmvnimsmthe,memoir shallhdeemed m'MM. WATER SERVICE
PAID
7zr CONSTRUCTION LENDING AGENCY NEW RISIDIWI'I Al.PLMB. .FI'. Dene Rescift
1 hereby eRrm That there is a eo-auetim Icohn6 agency for de pMrmmae<of
TUT. Q the wed,for which th'u pemut is ismed(See.NI97.Civ.CA
0 U Landers Nurse
TGTAI,:
Laden,Addaas
I ecnify that I have real Thu applicator moil ave th u rhe abuse inforamnion
meis BUI
Zi cr et.I.sats m emmly wool all city a,d cNmy mlinaeev and aam law.mwms h, QTY. MECHANICAL PERMIT PEE
U Z huilJing cmNrwclirm,ed heathy a-Fain rcTxesentntivcY of this city to rnvr uryvu the SF.1S IC F
.have-mentimrl pmpertr for inspection purposes. PERMIT ISSUANCE EI.I: CITE _
(We)ugrce to orae,iock rify ad or,humde,the City of CUPcnirtr rrlimst
IieMlitia,judgtnrnu,emu end expert-a which mmyin any way aeem,agvnxt slid City ALT ER OR ADD'TO MECII. PL f INC,FIE.
earwquerec a de"t rsg of obis peamot.
APPLICANT ONLY. D W .L COMPLY WITH AL1,NONI'OINT AIR HANDLING UNIT('TO IB.000CPM) ME NICAL.I9B!
SOURCE RLGULATIONS.
1 V AIR HANDLING UNIT(OVF.R IBM)CIM) CONST ICIIONTAX
tgrvtumnfA Dtc HXIIAUSTHO,DD(WfDUC1) HOUSING MITIGATION FEE
�He.g�.RHKS MATERIALS DISCLOSURE
Will WapFieam or futum Wild'm....aPam sterner hurdle hvadims material HEATING UNH(To I ic.o )B'IL)
n dcfired by the Cupenim Municipal Code,Cbeon r 9.12,and the Ilcalh aril Safety
Cuda.Swum 25532(.)° HEATING UNIT(OVER 100,001 BTU)
❑Yes F1 No VFJPDIATION IAN(SINGLE RFSID) PAID
Dale RttviPtN
Will the apafe.a intent huddirniec.Paer u¢eettife for dcaica which II0I1EH-0)MI.(31IP OR IW,IXX)it'I UI
emit homNws air contaminants ss defiled by the[lay Anre Air Qwlhy Maagcment TOTAI,I
Dismal! BOILER-C'IIMP(OVBR IW,000 BI U)
❑Ye. E]So
I hast,nail the ham I materiels rnptircnemtx under Chimer 6.95 of IM Cab AIR CONDITIONER ISSUANCE DATE
505..i5533 aN 2574 I uukuvl WJ the
NEW RESIDENTIAL ME 11. SR FT
uedSwkrrtndy huvcaFeasibility N beiry the mevp:mr
rNt renenM1icT
an sof,Cmificeutf kxm icy.
11 fiD
Owoer of vtWu - TOTAL ISSl1F.O BV'
OFFICE