S1779 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE,RTINO BUILDING-ELE.CTRICAi, PEISIT N°. 17 7 9
BUILDING DIVISION APPLICATION/PERMIT PLONHDNf.-MECHANIC L
BUILDING PRII.IEC'IIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA[T.
hH� o c� q�
�L.,Are+^�4#Kt 1'IIONE: C���O(L.\eihn1EIVr LIC NO: t
J rCies (a
NIC CONTROL# 1
CHITF, tNGIN[ 1.1
:30 171
ADDRESS: A14
IZO 54
IC.�O,fNTACT: PHONE: - IUjH,DING PERMIT'INFO !
I,I,I Ke-� t GS - .3 9-3o3 Consultant Fees Pail by Applicant(initial) RIS ELECT PLUMB hf11
LICENSED CONTRAC ORS DECLARATION QTY. ELECTRIC PERMIT FEE LJ
In by t1 that( ml' J d v " istt Chapcer9(ct)m..e 'ng _.. TOR DESCRIPTION
OIZZ wins f 9110(11 Di,Won3ofde Ba. rc dP f:xio e,Codcandnylc ,eiu '^ RESIDENTIAL:
w0 PERMIT'ISSUANCE S`s O
F.10 in full fort"told c1l", /00/ rap bl• ❑SFDWL I'fCIIEN REMODEL
U F License Class Lic N / J�N
6 U APPLIANCES-RF_SIDEN'1'IAI. ❑ADDITION ❑PLUMBING RE-PIPIT
F Z w Date Comercio,
wCa ,\RCHIT PS DECLARATION ❑MULTI-UNIT ❑S'rRUCIURAI,
F.p m PNET ti MODIFICATION
ZOyZ IanJ�.S��ny shall a us d recur/l $� UI'T021XIAM1I PS
Czot-� IA I.I ZJm d�W� El INTERIOR L1 CHIMNEY REPAIR
F Licensed Prnfusinnul 2111-IINXIAMYS LZ• IMP�(ll^IiM1iN'f SWIMMING P001.$
OWNER-BUILIJER DECLARATION ��
OVER I0Ia AMPS TH RI3MODI4/REPAIk DUI?MONITION'
GG 1 hereby n..that 1 am nt
emn,t from the Conarnr's License Law tin the
x 3 LL FU- lollowi..g reaum.:thi6ection]031 S,Business and Professions Citta Any city or county SIGNS ELECTRICAL El OTHER
IA which require.a permit to construct,aper,improve.demolish or repair any slmre
clu
f C j poor to itaissuance,also requires the ppli t for suchpermit tfile % m:cn•ment SPECIAL Cl RCUGUMISC.
�uP•„ math (pursuantt top o: fm Contractor's f La (Chapter9
C (commeneingwhr,Section 9001gofl)'vidon 3of the Business and Profen...Cale)or '1 EMIL M ETER OR POLE I NS I'. COMMERCIAL
Thal he is cmn ft there .nu and the hasis fur the ullcgul exemption.Any vinlatiun of
X El NEW BLDG/ADDITION C1 DEMOLITION
wpm Suction 90315 byany applivanl naa,nnit-subject..the applicumo,.civil pcnnhy of POWER DEVICES �'��. E]TENANT ❑FOOD SERVICE
_� net mere man live hundred dollar,($NX)). IMPROVEMENT
❑Las ewner of the properly,or my employees with wagesasthcirsule mmpnsation, SWIMMING POOL ELECTRIC ❑OTHER
F' will Bothe weark.mhl theswcome is nm intanderimlif cool farvlu(See 70x4 Ble,iness
i 3 m and Professions Carle:The Cied.he"License Law docs not apply to an(Mme,of OUTLETS-SWITCHES-I'1\TURES �r
property%ho builifs or imprIous themor.and who docs such work hiself or through
his own ciatil,ce,provided th t such limproverricars am not tt d J or normal for N17W RESIDENTIAL ELI,CCR SQ I-L
,ole.11,howeveg0m buldingor'ne,......cut scold w'Ihln u.ycdof completion,the SO P;1T0XyRAREA $/SQ.IT
er-bolder will Luse the folderol ing deal he did urn build-improve for pe-
,, f vl ) 'VITAL: V?
I ner of the property. exclusively contracting g with licensed st n :t I J•Z
constructtb project(S 9014 Business dP fes-ons CnA:)B ContractorsI'-
c Law does not pply to an owner ofp pray who hudits or improves thencon.and QTY, PLUMBING PERMIT FEE
who� t cts for such p ) uswlhtcont t (r)licensed . tlsmeCont tars !O
( Law PERMIT'ISSUANCE Ys-n
xet tinier See B,P<
.. . Pefot miN lean....
ALTER VENT-WATER(EA) t -# 6
Owner 3 • VALUAT1q
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby ufhnn under pnultyof perimyone of the following declarations: / •J V
❑IhaveanJwiBm..ntain aCenilicam,d Comennnself-n,me lirt Workers Compn- DRAINS-FLOOR.ROOF.AREA.COND. 4 STORIES I YVE CONSTRUCT ION
Inion,as provided lar by Section 3100 of the Lager Code,for the perfonof the
work for which lho
l....tlls ie,led, FIX'I'LARFS-P17R'I'RAI' �3.3-2-
❑ ha—and haand will maintain W..k.r'n Cntnom,alie.Inammue,ns required M1y Scetion k�
3](Xlofthe LvMn Cixle,feractiefonumle..fine work for which this permit is issued. GAS-EA.SYSTEM-1 INC.JOl1TLEf5 Irk/{.I OCC CROUP APN
My Worker's Cnmpesatfon Insurance caner and Policy member um:
Cartier: Police No.: GAS-EA.SYSTEMOVER4INA)
CERTIFICATE 01;EXEMPTION FROM WORKERS' GRI!ASI/INDUSTRL WAS'i'li INTERCEPTOR
COMPENSATION INSURANCE ItU1LDING DIVISION fl!p5_
(T hiswvnlon.."Gloom be.....tplcledl dee permit is Etrone hundred doll-($1sh GREASI!'I'RAP -- _- - -- n
rat less.( I'hANCHECK PEE
I Crile,thin int he perfllialle,el'ihewmk for whim this permit I....led.Isbdl SI!WGH-SANITARY-S'IORM EA.2W FT.
not employ any person in any manner so az m become subject m the Workers Conten- 13Nf:RGY FEE
ZZ snirnlawsof California Dam WATER HEATER W/VIiNT/ELECTR GRADING RE
o Applicant
cel NOTICE TO APPLICANT:IL atter making this Cenificnm nl Enempuon,you should WATER SVSTEMaRCATI NO SOLLS FEE
become c.hje"n us the Worker's Cotn.le-aeon pro Irons of(M1e LaborOak,you mux(
forthwith amply w'ah such pmvlxionx nr It.,permit InIll a teemed lemtked. WA'I ER SERVICE.
6. CONSTRUCIAON LENDING AGENCY NEW RESIDENTIAL 'LMiiSQ. 'I' PAID
UQIhereby moral that
hen I,auon%trudiun lending agency for the ernmnce of Dam Receipt#
'j- me evrk for which this permit is issued(Sec.3097.Co.C.) L�
ofu Lender's Name TOTALLc d AddressTOTAL: I
n'IYIh' Ih 'J h': IPI i Ln' ih nM1 b f f n s oBUILDING TIE
.'�.tpl I l.ga lo 111111111 all all city ailtvnnl'uu"s.tdstatclt . rvFlgm Q'Y. MECHANICAL PERMIT FEE
U building eotructme,anauthorizew
hy authorize iepremaivcvofmisedylecone.upnnlhe �+ SEISMIC FEFmra�V
mouse mentioned profeny for inspection purposes. PERMIT'ISSUANCE '.S_l7 ELECTRIC FEE
re
(We)age 1.save,indemnify and krep harmless the City of Cope tion against / •Z I
linhaddies.judgtnents.costs and expenses which may in any way accrue against aid City ALTER OR ADD TO MECH. PLUMBING FEE �� t 5
in consequence of the sed dml of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'iTl ALL NON-POINT AIR IIANDLINO UNI'i'(TO IQ(Xro CPM) MECIIANIGV,1 T 72
SOURCE RIiG111.A1iON5. y r
`" •' a�^ / �� Q(/4 ^' AlltiIANIILING UNI'PIOVI!R IgIN111 C1*M) CONSTRUC'IlON'IAX
Signal nrc of Applicat Cunuacuo •`��/ —DAC— EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA'/.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle felicitous material HISATI'G UNIT(TO 100.000 BTU)
as Jetmed by the CppNno Municipal Colic.Chapter 9.12,and the Health and Safety _
Code.Section 25532(x)? HEATING UNIT(OVER I(XI(X)0 BTU) ) *,,#.�.,,"� (/
❑Yue ❑No UVEN11LATIONAN(SINGI"ERESID) 19.n ZZ I'AIU e ke�l# 2Will the applicant orfuture buildinglecupant use equipment ordevices whichP[JII"(ill I(X)(NM)BTU)mit ha¢allous air contaminants an defined by me Bay Arca Air Quality Management Diilriell P(OVER 100,001 BTU)Yes ❑No
11' 'J IM1 h d : 'I r,l y I' A CI'pt b.95ot the CalNER ISSUANCE DANE i 11 alh N S I,C I l :255115 25533 1 5534 1 I f u1 thou T Ih" 1AI.MECH. 50.1"1'.bold gdx.stol ❑y have.lenm6 maul crny tespnblly t oonly the ixcupanfhercgni hie a eccenl'o((j�ra/tglc/y[O(c�cJu�p�U y.Own ora. Seth tt,' (-+C-�DaITOTAL.:�"i 7. �� ISSUED BY:�J�e- QM UL.C�.C,s
OFFICE