99110116 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUTE RTINO BUILDING-ELECTRICAL PERM
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANTCAI.
BUILDING PROJECT UYENH LFICATION
BUILDING ADDRESS: !SANITARY No APPLICA'I' V. 'rrAI,DATE
OWNER" AMG PHONE: CO ACIY)R:S A E: LIC 60'.
NIC 'C N ROLN
( R IIITECI'/ENGINEII¢ LIC NO. ADDRESS: ❑
�' F `* y 51, CAgcy
CONTACT: p PITON]! BUILDING PERMIT INFO
YiJO 77� II7 O ❑ Consultant Fees Paid by Applicant(Initial) HO ELLS PLUMB MIECH
Albea
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 tehy affirm Thal I salt Iiemxd tndm pmvidm.s of Capes 9(commencing - JOB DESCRIPTION
re
DWZ In Seer on 91001 of Div Inion 3 at the Nuri tris erxl Pmfcssiem Ode,and my liansc lx
u]00 wI i'I?RMIT ISSUANCII RESIDENTIAL
FC in fulYfortc end cmc 7./j� �' WL ❑KRCIIEN RBYtODLL
<UU Ltcauc lacA Q7.7 APPLIANCES-RPSIDENTIAI. ❑ADDITION [I PLUMBING RE-PIPE
HZW Dca Catumnm
to VQ�a ARCHITECTS DECLARATION 1'ANFlS ❑MULTI-UNIT ❑STRUCTURAL
Z O tq ZJ
ttmkmtand.ry plNta sndl W twa a.orotic cauda MODIFICATION
OZ—n UI'TU 2f0 AMPS ]INTERIOR ❑CHIMNIiY REPAIR
F4Fa1 Reenact Profcviaal }BI-IOIOAMPS IMPROVEMENT []SWIMMING POOLS
�YE� OWNER-HUTLDERDECLARATION OVPRIOBOAMIS ❑BATHREMODELJREPAIR ❑DEMOLITION
x1'IY C 1 heeehy affirm that 1 em eacmPl from the Connector,License law Nthe e
W O y U folhrwing roma.(Semon 9031.5,Noritsess end Poxkc;ions Carle:Any city ,m county SIGNS ELECTRICAL OTHER
3 W which lectures a le..it to can..(.aIle[Imawe,pokn0lish,or a,eir'any sI.mm -
F'u•� prim to its isrance,also requires tae applicant fn such permit to lila a sigred nvement SPECIAL CIRCUITIMISC.
f y tMt W is IiamN pumreruto the provision a the CultavTc s License law(Ch.per 9 ,
�p(QO (emtneam8 with Scctim90r0)af Duviaian3o(tM Hvirex and Prnfe-siom Cahlu TEMP.MEEK OR POU INST.
a ea t re W is cxcmp Itemplem vel the NNs for the alleged a curoom.Any violation of B LDCJADDITON ❑DEMOLITION
NSatin.91315 by uny a,lamm fur a Ixmtit,phaco,the applicom toa dell leaky of POWER D17VICI-S _ ANT ❑FOODSERVICE
nut more tlw Five humleN dollars(SSD). PROVEMPNT
Z0 ❑Lv wrxr of tie ptopeny.ox my cmploym with wages es theirwk cmrpatsttioh SWIMMING POOL.ELECTRIC
ER
writ do the work,and tie rrtetltm is nstt iNcndanl oroRcrtd fm siloT(N4,fluaireess
W Heal Prommices Odc:The Cone.or's Liomse Law aces int apply to am o wmcr of SWITCHES-FlXTURPS
d 3^ pmryxny sono.,ats.or rviurd Va coachi end veno tkxv rton work mt]o rp through
ht,,-c empltym.InnviJ 1 Inv coach imrynvcments art ms intctxh I mr nlTcrtJ for NIiW RFSIDIN'I'IAL ELBCTR SV I'1'.
sek.If.Mavesc,the WiMineuimpnrvemeN is sod wiNinme Yaar ofcompinie,the SQ.ET.IT.IX)R AREA SISQ.FT.
'rcnlvildcr will last Ile Without of I covin that he did met Niki or impost,for No
pose of TOTAL
1,as itwner of Ill M,emy,am exclusively coNmeting with licrnxd cantraetorn to
instruct Its,pro ect(See.9(44,Ifmiruu sod Pmdcsuao.Cale:)Us,Contract's l-
vs.Ww das nm applym anowneruf pmpemy veal haldsor impmvc thereto.sod QTY. PLUMBING PERMIT FEE
whocsnmera for such prejaa vena.cmaaaTptlt)rimed purse Ito tux Cmeasta a
license law. PERMIT ISSUANCE
I am cxcmp mdm See ,B&1'C for this rearm
ALTIiR-DRAIN&VENT WAI ER(EAI
VALUAI ION
Ox r Dux
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TIECI'.DEVICE
I tierebY.Ram under permlty of perjury use of the fallowing dalmuiuu:
❑ IhavcmtdwillmaintainaCWificaxuf Conaenllmxlf-Instnt,ftn W(Aces Compel- DRAINS-FLOUR,ROOF,AREA,COND. STORMS TYPE CUNSTRUCIION
satin,wv povidM for by Smlam 3910 nfthe TaMr Cele,for the pri fonnarce of the
work Tic w1h'teM1 this pemNl is iuued. FIXTURES-PEK TRAP
❑ 1 have and veil maintain Workers Canlematioo Imurvnce,as nitrated by SecTin
3900of the labm Ca9de�.falhc Pcfmm. safthe wvx for which this perpmr,instead. GAS-EA.SYSTEM-]INC.4 OUT.M- OCC.GROUP AYN
Coym Work e canner vtd,Nky/ �i✓ w I/ GAS-E\.SYSTEM-OVER 4(I:A) /^J
CIaLIFICATEOIt EXEMITION FROM WORKERS' T
COMPIIJSAUON INSURANCE GRED SEANDUSTRL WASTE INP.RCEI'IY)R HUILDTNG DIVISION FEE-S
(ntis section excel nal lecrn'ttad ifdte Permit in fame hu. ,ddL»(SIM) GREASETRAP
or Ina.) PLANCHECK FEL;
I cenify,el the peffurmmecnfre work foewhich PhiPermit is Peris issued.I bull SEWER-SANITARY-STORM PA.2(01T.
to,employ any I,,ma m uny mummer rt nr to Ise, see nub*,In enc Wo nce;Compcn. ENIiRCY FEE�Z sal laws ofCnifttmie.Her, WATER HEATER W/VENIELECIR GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:IL.Bef. making this Ccrtiante M Eacmpiom you should WATER SYSTCM/TREATING
a beculn,sunjat m the Warloers Compameirk n pmvikrmh
s of the Lar Coda,".mut SOILS FEE
fonhwith comply with ouch Down oar urthe a permit shall he tkenxd revokeel. WATIR SF.RVTCH
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,IT. PAID Dae Ravi N
I hereby alum hearIliac is•ccmtrtelimn keeling egcrcy fa ole pMoxmvec of p
�- tux wort fmwhahthis Permit is iswad(St,.3099,Ci,C.) TtTI)\L:
C) f<rdlc'n ABdms '10'fAL:
WBUILDING FEE
1 calmly thou I Mee x:d Los appli ation Ind vale the tux above iaftmmation is
Tai) conece legme to comply'irb.11 city and county trdinaeaa and sere lass relating to QTY. MECHANICAL-PERMIT FEE
EEP
U Z ca,,agalanmetim,amt hereby wlhoriee relre*ctx.tivcs ofthis city to enter upon the s Uflc
sMmcmemimse,J property for ill,ertim purposes. PERMIT ISSUANCE
(We)agra or wee,mentality owl kap humtkar cite City of Cupemino agaioa
Iiabililka,jWgmeNs,coati Nal<xpemes which ray in any w.yacme egsimt sed Cly ALTERORADDTOMECH.
io conxgacmc of the grmtting of thu perwt. LUFIBTNG FEIi��S I I I1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO In"CFM) HIM
FE' II '
SOURCE REGULATIONS.
AIR HANDL INC UNIT(OVER 10,000 COMJ 11,51 RUCOON A 9 I
SigeWum of AppliconUCmvaTm One EKHAUST HOOD(WIDUC) USING MITIGATION FEF
IIA]ARDOUS MATERIALS DISCLOSURE -
WIItheaMlicrtor(Mare building occupant slue or huWle ha>,Ntws material HEATING UNIT CTO 1010.00 BTU)
an dcfred by the Cu,xmim Mt lcipd Code.Chagcr 9.12,and tW Ilcalth amt Safety
Ctdc.Section 25532(0° IHAGNG UNI'F(OVER 110.1001 BTU)
EJ Yes E]No VENTILATION PAN(SINGLE RESID) PAID —
Uvc Racip g
Will the,yr,kcien,or forms Wilding aeupant use egra,una l or devices which
�
lTlil vOmtloto eir amtamianu v dclrxd by the Hay Area Ar Quality Maagcmant BOILER U)
R-COMP UBE OR 1(0.00 BT .-y
C
OiNr'x.Tl TOTAL❑Yea E]No BOILER-COMP(OVER Plogto PTU)
I have read as,hazvdas rwvidsATR CONDIIIONER
mytnrettxna uMa Chapter 695 ti the,Cdi- ISSUANCE DATE
foxn1.health Safety Cede,Sec' s 25 . 25531 W 25534.1 urdemtvd that if the N17W RESIDENTIAL MEED. SQ.IT � 9 � (:9,152�j
M1uildor m ylav me Int,thvltiamym Fly lW ir<upvn / /
close tel pn toiswam.ofac to of Occupaay.
dell
Own toedemcd Dae TOTAL ISSUED BY: T
OFFICE