00040054 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWFINO R1BLDING-ELE,CI'RIC'AL FERMI lNO,
BUILDING DIVISION APPLICAI'IONMERMIT PLUNHnrvG-MECHANICAL
Intaid IN(:I-ROJEdul IvErs I'IFICA'I'[ON
BUIITINGADDRESS: SANHARYNO. APPI.ICAr10N HIEdUT U,DAT'
OWNER NAME: 1'IIUNIc CON'IAACIORS NAMIi; I.IC NO'.
\ �f.' „ NIC COY]RAI,
• ARCHI'I CC'1'll? .NGINF : I.IC NO: ADDRESS.29 "
lA A V ❑
lC/
CONTACT: ( 1� PHONE. BU ILDING PERMIT INFO
`^ ❑ Consultant Fees Paid by Applicant(Initial) BLDG .1 C1 PLUMB Ml-Cll
LICENSED CONTRACTORIS DFCLARA'I'ION QTY 17LECTRIC PERMIT FEE
I hereby afiam drat I am mansm ander provisions of Chapml9 hm
omeacing JOB DESCRIPTION
QU �"t—^llic Ul?CLARA1906mxGdc3 my liacnw In El SED RESIDENTIAL
PAZ with Section 7000)ofD"
W O VERMII'ISSUANCE
h-W_ in full tomevnd effect. '�, p31 ❑SPOWI, ❑KI'TCHEN REMODEL
U Lmcnec Class LIc,x -- APPLIANCES-RESIDENTIAh ❑ADDITION ❑PLUMBING RE-1'll'E
FZW Ham— Como. f^
et. - N 1 PANI?LS ❑M11L1'1-UNIT ❑STRUCI'l1NAl.
N Z_ I understand my plane shall he used as u hhe remNs M(JDIIICA"TION
�D�C UPTO200AMPS ❑INTFIUOR ❑CHIMNEY REPAIR
F.h...F'.W 1ic,mwd 1'mI...fact 201-I001AMPS IMPROVI?MENT SWIMMING POOPS
OWNER-BUI1.DIik DECLARA'T'ION OVER IIX111AMP5 ❑RAI 11 REMOUIiLIR1iPA1N ❑UEMOLI'1'ION
W C Q E hereby affirm first 1 um e,eenpl from Ibe Cnm
mcoull license I.nw liar the
3 1 U following a res a.(Section 7031.5.Business and Ive.de inn,Code:Any city or nnnrY SIGNS ELECTRICAL, Q
W N wmm requires a perfrrit to construct.inner,improve.demolish,or repair any vwctnre
Cd ,If t '1: fl u,"Ah'tanf -such pc itl,,de a,b,r,dmmcmtl SPECIAL CIRCUO/MISC.
but he is licensed cousint Ihe PI Non,ofll Coat—tail's Jlcirl,,Law IChaptar9
W CO 1°nfnmencrngwth Section]IX%qof IYvii nn Sof the Bu:neer and Yrufe. CNe)01 II:MI'.MI-TCR OR POLE INS'T COMMERCIAL
a 6 e C film he is excnrpl meridiem and the mous for the alleged exemption.Any violation of ❑NF.W BLDG/ADDITION ❑DEMOh1 TION
XmW Sedi...170315 by wtYnPpli-al(nr u Pcrn......bica'na'lheapph, I to a civil punaltyof' POWER DEVICES iNANT ❑FOOD$13RVICIi
W y I o,than five hundred dollsre 1$51X8.
�=GLos owner offhe n'.ora Io sec wim wa ccfofheir role cam ftsmiun. SWIMMING POOL ELECTRIC B'li(lV1iM1?N'I'
ce C Q P^ape ) Yot iP 3 S Pc Ol'111:R
F• tdo.I work,end lire the Cleeisnmmmndcdorow(bibbered l norit"lysile In Wn.Business
awanderlyeshis is hilikut,I'hcContnaerev Lindnaa lduass notrk hii..intownerof (lUl'LLTS-SWITCfIES-PIX'I'11RE5
properly woo Huila.or ilrrprovaa merean,and who doe.eater wort nio..auo1 mroagn
His own employee,pmviJcJ that such impmvmrmna arc nm'mended ar it barred liar NIiW RF:SIOCN'TIAh lil.l!Cl'R SG I'I'.
sale.If,however,the building or impnn¢nmat is sold withinone yearofcomplctinn,the SQ IT.IBAOR AR5/SV.IrI'.
G
cr-builder will have the burden al'proving mal he dad not hoild ar inrpruvc for pun
pane orsdcJ. T(Y1'AL'
C]1.ac owner of me prof am corlusively amtrnsting with IicenxJ nnnracmn nr
construct the project(Sec.VDW,Business and Profcsions Crdca The Contractors Lis
sense man not apply to anowner it property who builds or improesthemon,and QTY. PLUMBING PERMIT FEE
Whormet
raelet....I.pra)nn will,a cammnar(s)le-c'ed, aunt lac l he,Cantru...a,
Licca¢t.ax'. PERIOD ISSUANCE
❑I ante,reas under Sec. ,B&PCfar this mama
ANTER-UNAIN&VIiNT-WATER(GC) . 1 VALUAI'IUN
Owner U: K
WORKER S COMI'IiN5A'IIUN DECI-ARAfION IMCK 18AW Pk(YI'I?CT.ULVICIi
1
Ibavc and wsv vffimf under pcnvhy of perjury one or sdf the fnllm Tim lameans
� ill maintains CcnificatenfCon¢nt 4hWoinsnm for Workers Compen- DRAINS-hLOOR,R(H)P.AREA.CONU' STORIES T1 fit.!CIINSTRUCDUI
sanon,as provided for by SW wa 3700 of the I.abur Cnde,1111 the bedunaance of the
work for which this permit is issued. 19XTUIt I?S-1'ER'I'RAI'
XI haws uad will maintain Wader's Compensation lice m ace.as rcyuirW by Section
3700nflhe Labor Code.Ia the perfnmmnce.f the work tin whim llys alit isixsucJ. GAS-G.SYSTEM I1NC,i OUTLETS OCC GROUP APN
NJWorker Cnor :n In r 'land folic,nonrcF'0 �� O
Y In't ArStD GOO GAS-EA.SYSHCM OVHR407AI J ��S
Carrier ,ty�l.r 4 Y/kf�hlCw'olicY Na.:r_.._,_.o_,—
CERTIPICATEOFEXHIVIVIRON FROM WORKERS' a,Q GRGSEANDUSTRL WASTE IN'ITRCEP10N
COMPENSAHON INSURANCE BUILDING DIVISION ITES _
(Dissection and nun hecnnrpletal it the Permit is furore hundred dollars1$1108 CREASE IRAP
PLANCIII!CK Bili
cod
Iccnily that in the any
o aI work forwnicn mm thr iosiN. Coed,Phan SEWER-SANITARY-STORhf EA.200 F'1'. ENERGY
nrnemploy any person in vDa mvnnvr sgv5ly c�rmOcpuM1jeet to the Wurkaei Compete GRADIN FE
O EE
z Applicant
ant ad Chlifurnix.Dow�✓� 1 V WATER IIIiATER N'IVIiKf/F.1.[CI'R GRAVING FEF;
Z fA Applicant V
fA became subject
ubj ct 1.b ANE IL alter making tnpr sisLo s of of Exemption.alborad You should WATIiR SYSTEM/BI3Al'INO SOILS I'lili
hearmchuhjcay me Wnd.cra Coons or this ernvidons of the Laboresoked. mutt
W �...,
forthwith comply with.each provisions or this pcnnh shall he JccmcJ revoked WATER SERVICE
PAID
Q
C(INSTRUC, CY ION LENDING AGENNEW RESIUI?NI'I AI,I'IJ.1B. SUIT. Date RacciptN
UO l hereby allinl that mem is a construction lending agency for the performance of
IL P the work ll r which this permit is issued(See.1mA,Civ.C.) 'TOTAL:
O L)U Lead—Nnmc
Lenders AJdrms 'l l)'IAL:
} 1 BUILDING FIJI
1 ser ifY that I have acral this application and slam that the atswe inhnmation is
Fy ecL lepra brttnnplywithall cityand nmmyoNinanm>unJ stmc lawsrdmingm QTY. MECIIANICAL PERMIT PEE SEISMIC FEE
U 'Z haddingan.truenan,and hereby:'fit re"ac su.i i"e"u'lis city t umm"amanthc
alone-mentioned prnpeny far inspection purposes. PERMIT ISSUANCI? II.EC'I ItIC I'I-1
(We).,me it,save,indemnify and ker,n:mnlcss the City of Cupenino against
Iiabllitics,judgmenrscnifs andcapcuses which may in anywayaccme agairestwialCity ALTER OR ADD TO MECH. PLUMBING FEE
in nmFuencc of the pointing of Ill's permit.
AN LICANT UNDURS'I'ANUS AND WILT,COMPLY WITH ALI,NON-POINT AIR HANDLING UNI'I'(1010,000 CIsM) MECI IANICAL THE
SOURCE REGULATIONS.
^ ` _ ^ �—L)-- OC)
11O0 AIR HANDLING IJNITIOVER I(I,IpB CPhp CONSTRUCTION TAX
s K l k'��C7)P �-1
SigwuncofApplicanl/Comiscon Date 17XHAIJS'I'[]()Oil l WIIIUC'1) HOUSING MITIGATION FEE
I IALIRDOUS MATERIAIS DISCLOSURE
Will the applicant or future building occupant store or handle hmmdoas material HEATING UNIT(TO 100.800 N'IT)
as defined by me Cf,,m nn Munleipul Cod,Chapter 9.12,and the I lealth and Safety HEATING IJNIT(OVI!R 1011,1X0 BTU)
Gde,Sciaion 25532(a)?
❑Yes N° VENTII.A'I'ION FAN ISI NGLE RUSID) PAIII
Dine Racciplk
Will the applkmn or from building occupant use equipment or devices which BOILER 13111'OR I(XI,1XX)BTU)
mit hannlone air amaininunl.v ax defiled by the Buy Arca Air Quality Manngcnmm TOTAL:
D eviei! BOILER-COME(OVER 100.000 BTU)
O)'cs xNa —
I Loc read lire haeunlnu-nal,alma retaNar
er Ch,pin. 95 m'I he Cul,- AIR CON INI-IONHR t ISSUANCE DATH
m
Ixinen
buildigdoes&Safetyd,basecaitua.Ilea,25533 anyand25531 unJemm�d mal it NEW It1iSIUliN'I'IA1,MI?CII. SQ 17.
building Jas tart eufrenJy have x mount.Ilean is nrY responsibility w amity me swvvpam
uflnc mmntswhicnmuelMnr� prion' uantt of n Ceni ficam t0,ralency
s A �
Owner ram nn�sJ agent Ont 'IUI'N.: ISSUED I1 Y:
OFFICE