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00080179 CITY OF CUPF.RTINO
ouu.ninc urv�siorv : pERMIT CONTRACTOR INFORMATION:
IlUII.DING AUUHI?SS: ' i'LRMIT NO.
OWNIiI<'tiNA�� . • � • — -• ' APPI.ICATIUN. . '
PIIONI: . � SANI9AHY NO. G (�1 -. i.
O�Z ANCIIITIiCl/IiNGW[IiN: ,� .i:J J - ItU11.UINf PLMMIT INPO
�O O❑ , I;LIIG LL[LT 1'LUNI3 MF:CH
aLy I_I I-1 I_J LI
N?N
i.icia;�senco:vrencrok�suec�.nawnoN Job Description
o S�'^o i nc�.�i,y oir.�,m��i����r��2.m��e.�,r,����.������romp��,�rc���„m.•��i�y
�„m F-iy wilhSccbon]IXNI)of Ulvi�inn 9 nl ihe 11uv'inur nnJ Prufcxelona C�Wc:n�A inY Ilcnuc
=Y�J It111�Y���OKCll1111t�1�`CI.
z w a Limnse Clnns I.ic.M
xodu ,,;,,, c���i��.��i,�. S01_AR ELECTRIC WFITER HERTER
y�i v�i ANCHITECI"ti DIiCLAHAfION
_°'�g I undan�wa my plan>zhall M mcd a�pnblic rccnrJ.
w y p�O Lii�cmcJl'rnlc...innul �
� OP'Nf:N-R011_DEN Uf:CLARATION
6 LL=u 1 herc�y atlirm�hat I am exenip�Goni�he Camnemr'x Liceme I.aw krt iM1e
C�;� lulluwin8 rcin��n.(See�iun'lllil5.RuninuFc und Pmfo�inm 6xla:AnY ciiY��reuniny
x�� which rcq ry. nii� �� ci Imc p ' J lict nM v�wuurc ?
prni 1 . . .I.0 4 .M ��u.� �r � n����� fl .6���a¢mcnt
da— n���i i :e� ,�� �� �i � � �� im � �- �„ryi� . � �cn����9 Sq. FL FloorArea Valuation
knm�ncnany wnM1 Scamn 91XNq nf Dlmion J ol'Ihc dunincnw nnJ Protcpvinne CoAel . . .
or iha�hc ia eacmp�ihcrtfmm unJ iM1e h sis for�hc a0c6N excmpiion.An>'riolaiiun
nl tie<linn 901L5 hY:ury aPPlic:mt fnr n Ixrmi�nunjccn iM1c upplirnm m a<ivil penuhy .
��r„„���„����a����r�,�.n��a�.•n m�n��.�ss�xn. A PN Numbcr Occupancy T�b
❑�.ns nx nor,d me nn�rcnr.�rt my cmr�osa.wnn wuge.�u.v md,.dc con��cnallon. . .
w�u a,��n�w�„e.����a�i,�.��,.�,�«�,��������.��aw�„„n���a a,�,.�m�SM nwa. 3y.21,30^c.R�t�ired Inspcctions
Omincn�and Prvfc.uiann C�vlc:TLe Comracmr'a I,icvnu I�x�Jcen nut npply m an
or� r of prapeny Who huiW�ar imprnves�herton,unJ x�M10 Jics wch warA hinixlf
Jnn��gM1 hln nwn rniplayw..pmviAcd�hm siiM1 inipnrvmnenrv urc nni imm�UCJ ur ..
oa�,�ai���,m�.u:�„�w����,mon�na���a�n���nrv�a��,����F.w�inwah�����„�r��,��,r 50� — FIN(aL PLUMElING ENERGY
compktinn,iM1c mrncr-builJcr will M1nvc ihc huNcn nf provins ihm hc JiJ noi FuiIG nr
m,o���.�r��„���F���r.,i�,�, S0E — rfaS TEST
❑i.�.��w�«„rm��.,,an,-..m�.�wa.�ir�,���.�����A,.��nr.<��a<„����������� 507 — FZNRL PLUMPING
msimci�hu pru]m�ISn'.'lIHJ,Pu�inecr anJ Vm(us.rons Cnlc:)'ITe Commcior'F -
i�������.��.�w d,�����������iy i��:��,��,.����,a��„i,�nr wi���nuum�.�m�.��.��F m��.�„�.
nnJ whn onweix fnr wcli pmjec�n wiih u comraeior(.)Ilconmd punmmi m ihc
Comracmis Liccnx Lux�.
o����,�.��„�,����..�,�� �,�P��,.,,�,��,..,., 9
�.��. � �a,�
WOHKF.R'l COM1IYIiNSATION DIiC1.AHATION � / �
1 M1enby affnn unJcr�nalry ol perjury onc of ihe fallowinp Jecl:w�inn.: � .
7 i n:���o��n Nm �„����:�m� c�,��r��ne��r c„��a.�� �� .�u„�.�,� i�„w�„��,. . 0^ .
,������,.:�a���,. o. �„��.�d�� r�,, i,y s������, ?��w �n �n� �.on�,, nW�. i��� �i,� v
�e�����������rm�w�,�ro,,,�mm�n��.a�����.�..���e.
❑1 hnvc unJ will inuinwin WorAcr'x Compcn.wlun In.uranm,ue rcquired hy Scciian � ' .
•3]IXI nf Ihe IaMr C�Wc.Inr�hc Mrfnem+mm�l�hc work Inr uM1ich Ihic�nm�ii is
.cnucA,bly N'nrAcr'.Companaaion Invunnm cumicr mA Volicy mm�Mr um:
Cnrricc Pnlicy N�.: ' .
CEHIIFlCATIUN UF Pr[MPI'ION FNO)1 wORKERS' • '
CUMPENti61'ION INSUItANCF '
�ILissccUan ncM nn�Mcn�npined il�hc pemJi ix lor one hun�rcJ dollars . ' `
.. fEl(qlarlur.d '
1 eenif)'Ihui in iM1e peRaemunro of ihe xvrk lirt xhieh iLis permit is in>uvd.i . ' .
.n:ai�oi����Noy��y p.Ro������r nunncj� 1��o i blea m�M1e Wuders •
Cmnprnvnlion L�v:y aj�y��li��a l�u�Il�¢�,.�j�y �
Applicnm_/j�PW'C=tlWI�@_co�
KUTICE'f0 AYPI.ICANT.If,aft<r muAing�hi�Cenifcam o!G¢nip�inn,you•hould
hcenmc miM1,i�'c�m ihc Wnrkclv Cnmprn.a�inn provisinns of�M1c I.nMr C��Je,Yan mus
O 0 n,�a�»;m������viyw�n�.�d�n������.�����w�,e��.im�„���.i��un,�.n����.�nn��k�a.
Fy CON5fROCIION LCNDIHG AGF,NCY _ '
� ,� I hurchy nlfnn ihm ihcm i.c u cunn�nrtiion Icnding ngcncy fnr�hc pedonuuncc _
� of�hc x�orA lin which IM1i.perniii i.i..wal lticc}ryi].Civ.C.) .
a Q LvnJer'a Namc
� 7 LcnJcr'e'AJArec. , , . •
V � I mnify ihui I lim�c mml�hi�applicainn anJ awm�ha ihc aMvc infortnaiion i. •
' G+ F. cnrtccl.1 xbrn m<ninply wi1M1 ali<iiY nnJ o�umy nrAlnnncn:md.wie Ivxx rtlaing
0 U Iohuildlnsn�n,qrvciiun.mWliereFyuwLorimreprcmniwlven��flhi�miymen¢rupon ,
ry�, ihc ntrovc.mcminncJ prupcnY fnr im�nion puTu.�c..
E.�„� p, IN'e1+6ra�nsavc.inJcmniy�ndkecphannlc.�e�heCip'ofCupcninna8uin.� �
V] @ihilllia.lndenrenu.��ueu und ca�wn.�whieh muy lu vry way mm�s uPnin.t.aiJ
[:� � CiIY in conrv9uwm al�M1c yr.mtinb��I thin'pennh. '
� APPLICANTUNDERlTANDSANDWILLCOMYLY�'/ITHALLNON-WINT �t1ued by: ��_ ��11C �U U
tiOURCB HLGIII.KI'IONS. �
tii6�awreofA�li<unVCnmmnor Dam Re-('00�$
IIaZ.ARU0U5 NATEkIALS IlISCLOSUHE -
w�nro��„�,u.n�,�„�n�w2m�nau,a�k��w�,�,��„�o,i�����,u�n�.���a,���.�„�,�����i TypeofRoaf „
�.nm��a ny m�c��.n�����nw�����,i c�w�,cn���.�9.iz..�a m�x.:�i�n��a s�r��.�
c«i�.ov�.zss�zi�n ��
All roofs shall be inspocted prior to any rooting matcrial being installed.
�vum��rN��+�����r�wawadms�ar=��ux•�q��p�n�m�,.d�.���«..�n��n If a roof is installed wiihout tirsi obtaining an inspection, I agrce to removc
' emi�hanrAnuvnircontaininun�nunAcfnedhyiheHnyArcaAir(�uaiiryMawgcmem
ri,�,��,ov p� all new malerials for inspection. Applican� understands and will comply with
all non-point source regulations.
� I liaw nuJ ihu M1uauAnue inumriele mquismonis unAcr Ch;�picr 6d5 nl�hc
Culifomiu I Icallh�tialcry Calc.Scciionv:}505,2551?and 255J4.I unAcc.wnJ iM1m
il�hc M1uilJing A�wr nni cum.n�ly havc a�enam;ihaYn i.iny mepun.iAiliiy�o nmi(y�M1e
o.cu�r.vl�^mn�ni.wM1ich muri Me inm prinr w Ismance ot u Ccnifemc nf
�=�v����r. p. �� Signaturc of Applicant Date
0 �
µ ,: n—, s i���� All roof coverings to be Class`B"or better