S 3278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•1'INO LUMBING- HANK ELECTRICAL PE
CITY
3278
IBHI,DING DIVISION APPLICATION/PERMIT TING PRNc..MEGHANIc,51.
It1111.DING PROJECTIDENTIFICATION
SANI'1'ARV NU. APPLICATION SUIIMI'1'1'Ah UA'TE
BUILDINGADDRESS:
2 _
O I!H'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
NIC CON'I'ItULY
4
i,�RcnrTEc/ENGI Isr:R: .I�� utas: _ ❑
✓i•R2L Zc'�T _ �
CON'TAC'C PHONE BUILDING PERMIT INFO
y� ��o ❑ Consultant Pces Paid by Applicant(India) HLDG CI PLUMB MITCH
❑ UK— ❑ ❑
LICENSED CON'FRACI'OR:S DECLARATION QTY. ELECTRIC PERMIT PEE
I hereby of ino that[.at rcenad under provixionx of Chillier a(aarmmenaing JOB DESCRIPTION
MZZ whh Genion 2ag)mfnivixinn?nnhe nnxinera and rroteuiona�r ae,mdmy halr,cm RESIDENTIAL:
u100 �S� Z I'I:RMII'ISSUANCE
full torcc an a 17 ❑SFDWL C KITCHEN REMODEL
aUU Liecnye CWcv LiaN APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Doc Contractor
tnQy 0MULTbUNI'r ❑STRUCTURAL
A 111'IliCl"S DECLAHA'1'ION PANELS
Z O A Z I understand my pions se ux
hall bcd cs Public resat[% MODIFICATIONOZ=- UPTO 200AMPS El INTERIOR C Cl I NINEY REPAIR
1-�F'u1 Licemed Pnde,,innal 201-HKOAMIS IMPROVIi TENT E]SWIMMING POOIS
OWNER-BUILDER DECLARATION OVER I(NNI ANIPS ❑BATH REMOD�UREPAIR El DEMOLITION
E C C a 1 hereby u0inn that I am exempt from the Commeno'x Licen.m Law for the
3 W FU.. following rcn.Start 19031.5.Huvme_v and Ponfivssians Code:Any city n county SIGNS EI.FrI'RICAL ❑O'1'HIiR
y which requires a Perini[to consumer.alms improve,demolish,err repair any structure
r-�•Oa
Pon,toiB manes at,,requires meapphcam her,uch Permit to fima,igacdaBaerrent SPECIALCIRCUI'F
}'4 that he i rairu,W punuont to the of Di,inns mf thehe Business Liarf ssio is Cone) 9
ad�.00O (cnnnncncing wnh Section 9fNN11 of Divixion3nOM1u Business and Professions Cudal or ENEW
IrI'I!H 11 ,'r.
a 1.19 thin he ix exempt thnvfnrm and dm basis for the idle,ed csca.piton.Any viulmion of C NEW BLDG/ADDI9'I)N C DI!MOI,ITION
y Secular 7031.5 by any applicant fora Permit subjects theapplicaul In a civil Penalty of DEVICES `rl,r�{',NAN'I' ❑F(R)DsFRVICIi
dt more than Bvc hundred dollar(550X). XPROVE•MENT
fS0
L]1.a owner of the property.or my employees with wages as their side compensation. ING P( ' C
P. will do[tic work,and the suvemre is not intended or offered for sale(Sec.7094,Basinco ❑OTHER
C m and Prolcxsions Code: the Cnntrunor'x I,cenm Law dues nut igrply to an owner u( TS-SWI'IC iS-P 1 'S
5 property who build¢or Inrprnve,Wera.n,and wpm do,,mch work bin self nr naough
his own employees.Provided nal such impmvnne d.am nor maddest m nflcwd dirt i.SIDI!NFIAL ELECTS SQ FT.
sale.IL how'ea.the building or improvenent is sold within one year of compdaing[he O SQ.ITT FLOOR AREA VsQ.FT.
owner budder will have the burden of proving that he did not build or improve for our-
elorol'xale.). 'TOT t
❑ Las owner of the prmpcny,an exelmively contracting with Ilconsed cou n taus In
usmsc[ he Project(Sec-Il94.Ifuxiness and Prnfcs,innxCmle:)'the
Commnnr'sLi-
seLaw does nm apply toanowncrnf pmpeny who builds to impmvesthemon.and QTY. PLUMBING PERMIT FEE
whn cnmmeu former Projects with a counacrorls)licensed pursuant m the Contractor's
License Law. PERMIT ISSUANCE
an,caanpt mode'Sec ,H&it C foo this,'axon
ALTER-DRAIN&VENT-WATER IIIA) VALU61'ION
Owner Date
WORKER'S COMPENSATION DECLARA'1'IUN BACK FLOW PROffiCT.DEVICE
I hereby affirm under pnully of Perjury one at the of law ing declaration%:
I noraml 01 nminmin.CendicmcofComcdt m,clftinxnm fur Worker',Cnmpan- DRAINS-I1.00N,ROOF.ARBA,CONU. STORIES 'CYPI3 CONS'I'RIICI'ION
,mind,as Provided It,,by Section PILO of the Labor Code.fill the Pe famunce III he
work IT which this ist rmit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
PINI of the Labor Codc,tor he P,rhainanccofthe work for which this Knod I,issued. GAS-EA.SYS TEM-I INC.40OfLETS OCC.CROUP APN
My Coyq�oalln 1.sw'xn' I-end Policy numbcl'aI'c:
rr V} �k s�� r ai�l.,�
Cnnm �z_3 n •"�^^^^Iiry No.: GAS-EA.
CERTIFICATE OV EX13MPTION FROM WORKERS' GRIiASFJINUUSTHL WASTE IM ERCEITOR
COMPENSATION INSURANCE BUILDING DIVISION FLITS
(Thissection need not to coulllecd if the permit is formal,hundred dollars(SIIN) URIiASE1'RAI'
I'LANCIII!CK THE
lay any lhnlidr in any inaunrso as tohe bee for which this the 114 is Wokers'Cormsed SEWER-SANITARY-S'P(IHM LA.21X11°I'.
nor employ any penin in any noanner so a,nr M1ecome subjttr m the Workers'Cnmpem IiNERGY I�lili
Z mind laws of Culifomia.Dam WATER IIEA'I'ER WrIVENt'/IiLEcrR
zApplicant GRADING IliE
y NOI ICE TO N'I'IACAN'1':If,atlermaking[his Cendicamof l',icnop[Ion,You should WATER SYS'I E NUTRTM IN6 ' r" .lili
hcmmc stbjed In Inc Warkcrs Cuw.aeumbon Pmvi%inns of the labor Code,you mow[
D7 forthwith comply with such Provisions or this pendit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI,MB. SQ,ET. PAID
U 0 I hereby alfina that them l'u construction lending agency lnnhe Per......... n[ U1011
{U4.O the work for wlibld,Pcrnil is vo.rd(Sec.MMA.Civ.CJ :
O U Lenders Name
Isndcrs ABdmxs 'TOTAL:
(:;_ a 1 certify that 1 have read this application and%tutu that,the aMrve informdion is BUILDING FEE
RY
CIZ) correct.l agree m COTody with all city and county ordinances lint]mate lows mating m QTY. MECHANICAL PERMIT
U Z fuiidjug cousrmcBun,and hemhy anM1ndm"u"woun-, it lu".1,m enc.upon the
alnwomvdaoned properly Ior inupceriod purlmms. PERMIT ISSUANCE. FIAT FRICIT '
(We.)agree to,ave,indemnify and keep hnmdcss[he.Cdy of C.gvdino against
Iiahilitics.judgmems,costs and capets which may in anyway accrue against mid Cir, ALTER OR AILD TO MECI{, I'll,Nil <
in conotalticanc of the granting of this pcmoit
'PLICAN'I'UNUItHS'I'ANIIS 4 G()MPLY WI'I'll ALL NON 1-01 N'I' NR HANDLING UNIT('I0 10.000 CFM) MI!CIIAN ' ILI3
AIR HANDLING UNIT(OVER It1,gXICI'M) CONSTRL' (INTAX
Signature of ApplicuntlCnmmnor Dam EX HAUNT II[x)D(WNUCO HOUSING I'I'IGATIUN 11:1:
I IA/.A R DOUS MA I'F.RIA LS DISCLOSURE
Will the applicant or future building necupnnt amore or handle hamNoun,frill 1117ATI NO ON I'I'('TO Ibdj NXI 13'1'U)
as defined by the Cuss nino Municipal Coda Chapter 9.12,and the Ilwlth and Safety IIFATING UNIT(OVER 100.000 H1'D)
Coal,Section 25532(a)'!
0 Yc,a r VENTILATION PAN(SINGLE RES]D) PAID
Ua HareiptN
WII the uPPllcum or fumro building mcupinn use eyuipmcnl odevices which UOIhER-C(IMI'[?111' (XI
OR I ,(XXI B'I'll)
mil hamrdnus air ammminums as dchnnf by the Bay Arca Air Quality Mtes em
District' 1{OILER-COMP(OVER 10(f Xp ETD)
❑ a/Yes 1/
I have read Ila,bueardouslnmcriul%Ie. [s under Chasms R,95nl lbc Call- AIR CONIII'I'IUNCR ISSl1ANCl?DA'L'E
. i.133
folia banith,dor,&Safety Code,Sections 25505.25533 n p 25534.I underityl ohm if the Nfiw RILSIUIiN'I'IA1.MT;C11. SQ.1-7.
ofnengdaesmm,whicyhevebmatpool ofsnay mspumihilitymnotifythcrccupam L /
of rhe rcyuiremcmx which must R mat Priono is5uanee ofa Ccnilir m of IXcuNncy.
Owner or lm@oriecd agent Dam TOTAL: ISSUED BY:
OFFICE -