S 1792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'rINO BEILDING-ELRC'I'RICA L PFtI P No. 1792 792
BUILDING DIVISION APPLICATIONWERMIT i'LUMBING-MECHANICAL
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BUILDING PRO.IEC`FIDI;MIIFICA'I'ION
RUILDINGADDRESS: SANITARY NO. APPLICATION SURMI'I IAL DATE
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OWNER'S NAME: PHONE: CONTRACTOR' NAhIE: LIC NO:
S ���-t �/ NIC CONTROL#
�I Ali HiCT/ENGINEER: LIC NO. A DRFS.'. j,GU ❑
e64ulici
CON'FACK -y PHONE: BUILDING PERNHT INFO
t II J v C( (,z CS2 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
C� 3 S6- (41LI q H e ❑ ❑ ❑
LICENSED CONI'RACIORS DECLARAI ION QIY ELECTRIC PERM I'I' FEE
Ihereu
hyamtitl T ,,dr l 1 sofllul )( 't, a 'g JOB DESCRIPTION
Dd'Z with Svnl 9lXlflltlD ' 1 l l Rt,i II f:' C 1 yl'acleis RESIDENTIAL'
WOO I'Iixh11T ISSUANCE
1-1- in lull lune and diel /^t IQ�63 Cl SPDWI, ❑KITCHIiN REMODEL
a%UU hiccnvc pins, —hicp 1 rl " APPLIANCES-RESIDEN'1'IAh ❑ADDITION ❑PI,UMRINGRE-PIPE
F Z W Done Commcon
mGa ❑MULTI-UNI'(' ❑STRUCTURAL
ARCIi1T1?CTS DECLARATION PANELS
F-v7iZ 1madc,aadm hll w Media PublicncorJ.s MODIFICATION
Oyu ypan"sa W AMPS
OZ-❑ UP 2Ll INTERIOR E]CHIMNEY REPAIR
(-t?�W Licensed Putfio soul 201-IM)AMPS IMPROVEMENT 0SWIMMING POOLS
x C C'� 1 bcrcM1X'illicit
OWNER-BUILDER am-Ie emDEfrom the Cuntmnur',License Law fin the OVER I"AMPS [_3 BATH RESI0DF:1/REI'Alk DF-_MOhll'ION
a r
X 3 i U following mason,ye cion 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
W a H which rcquima o permit m<omtrun,alo u improve demolish or repair any smaller, eb. 1 K
F-�-OQ prions its issuance,ahs mquhes the applicant fn,Mth permit I.File a,igncd,I.Mmcm SPECIAL CIRCUITIM ISC. -
f' y� that he is licenxJ pursuant to the pmvisions of the Contractor's license law(Chapter 4 COMMFR I
Weg (commencing with Scaion]IXXrynf Divi,ionlo(thc Rosiness and l'ndcsiona CtNd ar 5NEWIRESIDENIIALELEC
R POLE I NS I'.
a a C Ill.[he is exanpt therefrom and[he basis for the alleged exemption.Any vi.latio.of El NEW BLDGIADDITION ❑UEMOhRION
W o o Section]1131.5 h jects Ih<apPlinml m a civil
y any uppllcanl for.permit sub penultyof S ❑TENANT TODD SERVICE
m store than live hundred coitus(551X0. IMPROVEMENT
.F+yQ I,asowncnn'the n
C � prnpc Y.nnny employ",with wages its their sok eompcmatinn, OL I?CECT ❑OTHIiR
F wd ilio thework,: Ithcxuus,ruenn[immnded..rolored far sill(Sec.7044.Hai,uuc,s
E, m and Po ll"ions Cn Ic:'IIn,Cumrmtuh License Law J"s to Irply m:m owner tri 'I'CHEt PIX'fI1RES
pmin�n,wI...build or ou,nioc,Ihurcut,and who disc,ouch work hivmuit or through
his own umpliwces,Prnvlded ihul such intPmve:ncnis arc nor Fntunded or onered lot L ELEC'I'It SQ
mlc.Il:hnwcvur,the huilJingor lntpmvcnaru ieanld within nucY:'yr nl ann:Pldion,the SQ.FT.FLOOR AREA EISQ,IT
,,,.air toodder will hove the burden of proving that he dol not huild or innprove lit put-
Pascal
ur-
P rte alxme.). UVEAL:
p1.ax owner of the property.am exclusively contracting with renn,ed cornmi b.
co uuct the project(Sec.](R•t.Bonin,and Professions Cale:l"Rte Contract's.Li a
a,e 1.own«s ran trrlyman owner of rropenY who huims or onpn,ve.moreon.and QTY. PLUMBINGPERMIT FEE
wMamtma,fnr such projects with a..... qs)heenred punaanIt,the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. .H&1'C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
W'ORKER'S COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE , O &10 fD
I hereby allium under Penalty of perjury one of the follow ing declarations:
I have and will maintain a Certilicamnf Consent Ill...Mf Worker's Compem DRAINS-FLOOR.RGOr..ARCA,CON[). S"r ORIS 'TYPE CONST RUCr1ON
saint,as provided lir by Section 3700 of the Labor Ceda for the performance of the
work for which this permit is issued. FIXTURES-PER IRAI'
I have and will maintain Worker's Compensation Insurance,as required by Section
3]1X(nftlm Lubar Cute.lits the perfurmurce d the work for which this penitis ismnl. GAS-EA.SYSTEM-I I NC.4 OUTI,E'I S OCC.CRItUp APN
My Worker's Coulp asaion Insurnace carrier and Policy orate r um:
Catrior: Pulley No GAS-EA.SVS1'I?M-OVIikJ(IiA)
CIiRUICNIE OFEXCMPTION FROM WORKERS' GRIiASF/INDDSTRI.\VAS'fC IN'HERCE111OR
coMvl:NSAHON INSURANCE BUILDING DIVISION F ITIS
fl'hi„euti,n recdthe cnn:pleedodeprr:nil is lour one hundred dallum(S Its)) GRFASETRAP
PLANCHECK FITE
or less)
[ready lh.t junrepar,f annecofthe work for which this Pundit satiated,I hall SEWIiR-SAN I'PARY-STORM HA.21X1 PT.
not employ anY pe-in in Y as 1. .,q a ,yr the Wnrkeri C....,a- ENERGY IlPli
O'z ::vitt lrwx of C:IBGmri Dn,on: � 'I.I �R1jf�__ WATER HEATER K'/VIiNT/IiLCCTk G11�1�1C-it
.z O Aprhann ,,// f--
N.
NONCE 10 APPLICANT:If,after mekmg this Cemficae of Exemption.You should WATER Sl'STEM1VIRPATING SUIT$Pf: L I
E•-' two ac subjecu'Ihe Worker's Compensation provisions of the Latin Cala min
you t C
forthwith comply with such provisions.,this pnmitshall be deemed,c,oked. WATER S!�- 1
X11 •ty ,) )'
G C
0. CONSTRUCTION LENDING AGENCY NEW RESI'LMIi. SQ.Ff. PAID(/{{h{�,.}.X----
DZ I hereby affirm that is a construction lending agency for Perhationce or VVIMtl 1la�+
� - the work loot which this permit is issued(Sec.30)7,Civ.CJ
OLender's Name _ TO IAL
V lenders,Attracts TOTAL:
W I cortily that 1 have mad this application and true IME the ub.v.infnnnmior is U1 ' D�rA r
bycorrect.l goo, with all chy and county oNinames anA sum lows relmbtgto QTY. ANICALPERMI'F FEE SEISM( PPI: RT�NO
U hadling, suuccan,and hereby a0
aori—enc,mmiutm
vo, if city ru eerr:p'n E
nhnvwn¢minned property far in,Pectiun PUHxnun. PIdk MIT ISSUANCE pI1CI RIC ITL'I!
(Wm agree[n stye,irdearady amt keep I...r::aen,me city"I Capermm ngaht,l
Ilnhilir,,iudgidem..co.1,aadexpnmelviid alara:[toy wry ueeomagain,t 1:1111 City AEFER ORADD TO MFCH, PLUMBING II?li
in cmucquvmc 0 the Siouan,"I this permit.
APPLICANT CNDERS'If
'ANDS AND WILL COMPLY WI' ll ALL,NON-POINT' AIR HANDLING UNIT('10111,(X10 CPM) MECHANICAL 1:1717SOURCE Rl GUI.A'HONS.
AIR HANDLING IINI'f(QVIiR 111.1#X1 CFM( CONSTRUCTION TAX
Signature of ApplicaryC'ntmctor Date EXHAUST HOLD(WIDUCD HOUSINGMITIGA'I[ON PEI!
HAZ RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haraNnt,maleda] HEATINC UNI 1'('1'0((Sidi BTU)
o,defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100.00011I U)
Cottle,Section 355320)?
❑Yes F-1 No vENT1LATION FAN(SINGLE R131O) PAID
Dam Receipt#
p. Will[M upPlicam nr Imurc building ttvcup.m me equipment nr Jcviccs which BOILER-COMP EEHP OR I00dIXXI BTU)
call[buaanlnw air centi m num,a,JeEncd by[ho Bay Area Air Quality Management TOI'A1 O�
Dun:cri BOILER-COMP(OVER IIXI,IXXI[I I'U)
E]Yet F7 No
I AIR CONDITIONER ISSUANCE DATE
hove remit the hamte
nluus nwri;Js rcyuircmcm,under Ch:Nmr no$tri the Cnli-
@tmiu II,u11h&Safely Code.Seasons 25505.25513 mW 25534.1 1 ,1 1 that if(be NEW RESIDENTIAL MECH. SQ,FI'.
hnilAing Jas urn currently lurvcumnan,that tis lay n.pun,ihillly lu....lily it,"reliant �� �- O
nl the myuircmenp which moat hc:nc[prior lse i.vamnre ufn Ccnitieam of(keuPunry. �//'/�)�) //�� p//�
Owner nr uwhurireJ agent Did. DUAL ISSUED BY'.
OFFICE