S 1141 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITV OF CUPER'fINO BUILIMNG-ELF.CFta
PERM(NO.
BUILDING DIVISION APPLICATIONWERMIT I'LUMBINC-MECImS 1141
BUILDING PROJECP HIPIN
BUILDINGnDDRIiSS,. SANITARY N(l. APPLICATION SUHMI'I'IAI.UA'IE
OW ER:S NAME: ON@ CO ACTON'S NAME I I _ • 1
L Ii01 741PPA
NI(: fDN't'HGI.N
AM
ARCHITGCI'/RIGINPER: IC NO: ADDRESS: ❑
CONTACT PHONE. Ii UILDING PERMIT INFO
❑ Consultant Fi d%Paid by Applicant(Initial) BLDG ELECT PLUMB MECCH
�
56j�_IZA213- Z,
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PIiRMIT FEEI bendy a1Bmr mel I am Eeea.wd under provision.a,fehapmr 9(a.nm,meine JOB DESCRIPTION
O�Zwise Sectim]gX)Itef Uiviswm3aYmc Btrvillcs and Pndcui«u Cak.erW myliceme is RFSIDENTIAL'
'05 with
aW. in full fame and `.t ❑SFDWL ❑KITCHEN REMODEL
ca.UU LscmcFhe,} ,� Lic.N APPLIANCES-RFSIUt1.'1lAL ❑ADDRION ❑PLUMBIFG BE PIPE
N ct I. -C ConI., ❑MULTI-UNIT ❑SfRUCfURAh
FOm AHCHr ECI'SDECIARAIION PANEfS
Z lundnwrd my Plena snail be ratty as public record, MODIFICATION
ZO.Z O UP 10 2(XIAMI'S ❑wmRIOR ❑CUMNEY REPAIR
I-I?Fu1 Iicensal Rofesxi«W 201-I(KKIAMPS IMPROVEMENT g'$N'IF1A11NG POLLS
OWNER-BUILDER DECLARATION
C W Q I hcrnb affirm tear I am temp food me Contractor's License Lew for the OVER(UMI AM15 ❑BATH RI;MODEIIREPAIR ❑DEMOLITION
O a U fullmxing remm.(Smitten 7031.5,Bud.us amt Prtefeoio o Cask:Any city ornnntYSIGNS Y,LIiCf1UCn1, ❑SER
41�+W h t wryich rryuirtv a pmnit'o mnvwC4 filer,impmrc,akmolih,ar repvr any sum'mre
I_1='Og pier to iia icwarc<.elw requirtsthc applicant(«sten permit to fkasigrcJsutcmrnl SPI:CIAI.CIRCUITIMISC.
Mmanhe is licensed pumuannn the prnvlsitws or Conptcmr'x License Ww(Cmpter9
Icommcnetng with Smtion]rop)MHivisiamJODhc Bu.incu tool Ftofcasw.rs Cadcl« TINE METER OR POLE IN.ST COMMERCIAL
a a eK (hut he is eaenttt therefrom and Ine Not,for Ou.licked exanption,Any vimiaiun of [:]NEW BLUGIAUDITION ❑DEM(11.1'I'[ON
XmN Semian703"by any ittPheam for.pool'objects me applicant tO a civil pewlty of POWER DEVICES ❑TE,\ANT ❑FOODSERVICE
.F+Z.p., rat exert Nan Eve hundred ddlan WOOLIMPROVEMENT'
E�� D I.wmsarcr of me propmy.«my employeea with wvgcs¢a their ole cumpcnswinn. SWIMMING POOL ELECTRIC
will do Inc w«k,and Inc slructurt is rot intmdai m oRcmJ for.sale(SCC.7(WL Bmdncsn ❑OTHER
tai] and 1'nrrn.sunv Cadc:The Commuter's Lircnw:Low dun nor apply to an owner of OU'LLEIS-SWIrCHI!S- LS
4' property w1n huiw[s or impuves danv.,and Islas awes,such work himself«through
hie own employs ,provider]mel each imprnvemants are sex inednd ar offered for NEW RESIDENTIAL ELE SQ FI'.
eek.If.however.the building or improvcarent is told wimin one Year OfcaarnPlmirre.0e SQ.F1'.FLOOR AREA 5/SG.1'f.
a-huller will Amo the burden of proving that he did not build«improve for par-
pene of oak).
❑I,111 nester of me mOlKr,,N eselutively Contranial with licensed I m.a-to TDT, _ P A 1 D
Onnor,Pm In,}+t(Sea.7(94.Bu.me.5,and Dotevitmx Code:)lire Connector's Li-
mixiUse dost nmapplytoanowerMprogenywMbuilds«imfaovn Heron.and QTY. PLUMBING PERM
who eontmctefor inch projects with a cnnwnnge) irea d pumnam m tw c«nrumr'x 1/� A�Ba e1�
Limmc Lew. PERMIT ISSUANCE JAN 12 A=
I em exempt order Sm. ,B&1'C❑othiarumun
ALTER-DRAIN&VENT-WATER(EA) CID VALUATION
(loner Date y�l l Ur 1/Vi LI'1111'll/
WORKERS COMPENSATION DE CI,rollow ON BACK FI.ON'PROTECI'.DEVICE
1 hadry aRmm tmdcr Ce+uhY of perjury acne of Ile im meL-Wo lien,C s:
anew ard ill paxiJedforbmaintain ml 377 of CeLator Cde.forIG, Worker's Comfcm DRAINS-IT.(R)R.RIXIP.AREA,COND. 5g0µ1(5 TYPE CONSTRUCTION
utwm u ptich On Rx mi Santee 3]W of Jn IW bolo Code.f«tit pufaxmanm of me,
work(«which mitpmardam iesuW. t FI%'NRES-PER TRA('
I love and will Coos,
far W«keh nampemwion Irumer whi as reyuval by Sextan
3'I(M ofthe Lvdx Cadc,[m Je pm«mamx Mine waukf«whicM1 this pertni'in imucd. GAS-EA.SYSfFJA-I INCA OUTLETS OC ROU APN
CWor�L[�' VII] and Po"F! rstag
CerricPdiry FROM
r �/� GAS-G.SYSTFAI O\'ERJ(EA)
CEKI IFICATEOEEKITIONINSUR N WORKIiRS' GREASPJINDU.STRL WASTE INTERCEPTOR CO}1PFASATON INSURANCE UILDING DIVISION FEES
(Ibis section m.'M not be completed ifmC pewit lsf«tmc huminil dallsre(S 100) GREASETRAP
or least1'L\, H .E
Icenifymat Ode perfasomrme.fLe wait for whkhthic pewits iwsued.I shall SpWER-SANITARY-STORM PA.200 FI.
on employ any goatee in tiny mentor o mm KucAo,summit to the Waroard Camper- ENHRG
Z satire Le.s of Celif«nia Dote WATER HIi,\IER WNENT/ELECTR
z O Afflict.' GRIMM:
NOTICE TO APMACANI:If,after massing Ok Cmiftcete of tim
epdm,you should WAMR SYS EM"EATING
F "N" beme
cosubject m the er
Work 's Comnon
pc .,,or Troon, a,of tloN
m Ld Gds,you mux SOUS G
fmthwib mmply with Inch provisiadts or'hN pewit stall bcn
e deeJ rt',dem, WATER SERVICE
� z COor
LENDING AGENCY NEW RF_SIDEYIIAL YLMB. SQ.PI'. PAID Dete Recd X
L 0
1 lercby aRm Jut Jere iso ci mite lending egcrry for'he perfectperfectPof
tt
Ithe work fur which thin pcnnn yUscc.3097.Ci¢OI 'fOTAI:
Lender'.St. : nn
IU 1<ndcfn AdAns TOTAL:
DING FF.Ii
BUI
y 1 comfy that 1 hove read this apPlication and state Jut mabove inftnmtion is
tq nnm'.l agree mcomply w'i'n all city and Conry enlinanee.wa x'me lawx«(ming tC QTY. MECHANICAL PERMIT REE
U Z building construction,cod hereby audnriie mprcGnutives of mu city m enter ups the SEI. IC FEE
above-romioncd prtrlmy for inspmtima PorP^ea• PERMIT ISSUANCE,
(We)agrce'it eve.i«kmmfy anm
d keep hedcv the City of a Cuamdou agwnELE HIC Ill?
Ealdlit¢s,jusch, LL cern vol cfacrom which may in any way xCm .i.said Cityxx
ALTER OR ADD TO METH.
in nstxlucc of grand ng of is pcmtit. PLUMBIN ?I?
mrn
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IR(COCFM) MECHANICALI
SOURCE REGULATIONS.
AIR HANDLING UNH'(OVER Ip.11flp CPM) CONSTRUCTION TAS
Silnmure of AUdoo d'Coutumor Dero E)(HAUSlHOUD(W)DUCT) HOUSING MITIGATION
HI RDOUS MATERIALS DISCLOSURE
'Wil'M1e of Clieant or future Funding ucuryun mum or handle hvmdue nwmrial HFA'IlNO UNIT I'rO IIXI,dIXI BTU(
u
de by me Cuperaida Municipal Code.Chatter V.1?,and the Hculm rand!Safety
Cade.Sermon 25592(.)! HEATING UNIT(OVER 100.010 B'N)
CYev 1;�/ PAID
VENI'ILAT10NFAN(SINGLERESID) Date Reccip#
Will me aWlicam or future building«cupent use Cyulrynent or des las which
by
exam eta ammandnvus u dafiai l the Bay Arm Air Quality Me^ngcmrnt BOILER-COF1P(]HP OR IOf1.pIIfI BTU) T
'Distrklt / BUILER-COME(OV ER MiBI'Iq
❑Yo �ly
I have real me hoaunom,maderialx raruiremew other Chapter 6.Y54 the Cali- AIR CONDITIONER ISSUANCE DATE:
forms 1E,Ob&Sa my Code.Scions 25585.25533 end 25534.1 urdcmtad that if Or, NEW RESIDENTIAL Mli C11. SQ.F1'.
buildingawn mat nvrmmly huvca tewn'.mm it isatY rcnfa esOnaty,,rvxifydne om'u1mM
rl1alut/C/-/Zof
-yyvmny.y(m or e6Tn uav� Nolrnt IY l`— L
D. TO AI.: ISSUED BY:
OFFICE