S2134 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER.PINO BIIII.DING-ELECI'RICI
R(1I''��1TN02134
BUILDING DIVISION APPLICATIONMERMIT PI,UAIBING-AI4:CIIANICAh
BIlILU1N0 PJRCT IUtN'I'If ICAI'I(1N
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'i NAN " PHONE: CO,V�CTOR'S NAME:
11//JJ�INIC Q�M1'IROLA/t
ARCHITECDIiNGINF.I:R LICNO� ADDRESS: S ❑ Q y
CONTACT:• PxoN//B,,: p BUILDING PERMIT INFO
z0O ❑ Consultant Fees Paid by Applieam(Initial) BLDG riFCr PLUMB MEcx
LICENSED CONTRACTORS DECLARATIONQ'1'y ELECTRIC PERMIT FEE
1 hereby affirm mu 1 em Tian.a mat'e,iosser;of Chepmm.e.v Icr ," JOB DESCRIPTION
D d'Z uiih Section]rlWlof Vivi:inn 7of the Rusiia¢aiinJ Profwiufn Crile.aN myliameia RESIDENTIAL:
w p O PERMIT ISSUANCE,
F12 in full fma vat effect. ❑SFDWL ❑KITCH6\RFNODEL
QUU Li.Clew Lk.Y APPLIANCES_RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
9zW Due Contractor
mQa ❑MULTI-UNIT ❑STRUCTURAL
ARCHIIIiCES DECLARATION
I„D oe PANELS MODIFICATION
zNZ lumkniaml my plwx:hall be used u.puhlic rtards
p,gNa STD 300 AMPS 0INTIiR10R 0CHIh1NEY REPAIR
F'!1t, Liccmed Nrnfesaiored 301-1000AMPS r IMPROVEMENT 0 SWIMMING POOLS
Y _ OWNER-BUILDIJi DECLARATION OVER 100AMPSle ❑PATH REMODEIIREPAIR El DEMOLITION
ZO I hcrcby atimi Ihet I am uixmq from the Cm-tush sr's License Law fur the R
a fnllmving rearm,l eetion 7131 5,Haines anal Profciew.,Cede'.Any cis,or muay SIGNS ELECTRICAL
3"� which y permat relareel,all, pro c J. Xi.h W ny wua woe
0W pnort its Ih"moome.,fieutf lb mrmOo file a ii,ravd,tatament SPECIAL CIRCUITIMISC.
Fy`y Ihul le I lied PurvaTn th p flhC t 't L I 'IC"m9
4041..0� (amimn�npwlhSccfm71MX11i1D vdionl irlhcllux ix.a.didlr fn:'unsCNc)or TEMP METER OR POLE INSI'. COMMERCIAL:
'L ea Thal he Is exempt lb rcLoto and the Nein For me ullcg vl eicmpton.Any v'nduion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W N Section 90313 by any upldlcam Iia n ry onit whie in the apPterat to a civil rIralty M POWER DEVICES ❑FOOD SERVICE.
F nal nave Ilam Eve hundred a,llnw(S50)l. IMPROVCMENJ
Sp ❑ I.ns11f be,ropcoy.or:nye:nployes wllh wages us their.olcennPcnmfim, SWIMMING POOL EI.I!CI'1tIC
t• will aitho wink.valtbu smrmm is lax inmm4M nruleaId! irxnlo(Soc.]UTIs Itusihe,u CQ'ITIIiR
wJPrt G,ci IbeC I t 'sl I' x a "rib, acro OUTLETS-SWITCHES 11X'I'UHILS
Pro e Y E Ih
n h h'I is tr :Ih lbh d 'M1 1 ch ea r erroe
hie,I awe cr se pt 0.11h c hill a n t' I k l I.nil t'he NEW NESIDENTIAI,fIbCl'R SQ PI'.
wIc.If.M1nwdcr.Ihc NulJmg or Pnmmvcmcnl is ndJ w'tM1 i me yaan Tm gde'1i,the SQ.PT.IrLfl)R AREA LSQ.FT
ren ilJcr will most IIIc hunks of pr,n'iny that le did aaa hold or io,rove finpar,
Opose,1,as owaeT of the Pmrcn y,am csel aslwly emma.ii ng weh li... ial entnmbcmn Io EAI.
mnatroct the projcu IS.+'.7044.Bunincv'mal Irol a.c ions Cact,)'Pe Contmetor'c U Q 2.00 s., I
,eme law does ma ari an owners ro,,coy who No ilds m improv,,Hereat.and QTY. PLUMBING PERMIT FEE , V
who cmlere s rot well Moesis with a connanngs)licensed Pursuant m to Contractors
Liccme law. PERMIT ISSUANCE V
0 1 em emmp.makr See. .It k 1'C for this rectum
ALTER-DRAIN k VEVI'-WATER(la) VALUATION
O m Delf
WORKERS C(lly of NSA770re DECLARATIONfmBACK Fl.(1W'PROTECT.DEVICE IOC MO
Inad, aR and.b.'a:^byne.ffjaryamenfthefol i.forrmg'4'ler',C : ( VlJ
❑Ilmvc vml will maiivaine Ccnilica¢ofCimsrnuoadGimwe fm Wnacr's Cumlrm INS-FL OOP.AR..CONI SfORIF_ TYPE CONSTRUCTION
swim,aspromaded for by Sactitm 3701 of me lecher Cele,for the lcrf«mare of IM 1I O
yit for which thisPreit is issued. ` RLS .RT
A I herr ud w'in nminmin Worker's Com em,uRm Imurerre,—N.-nal by Seek,
3700ofthe Latin,Cedar.for thepMlnnarre ofdr work for w1deb this'reat is kcsL4,SASF�'21''Nc 19 rOCC.GROUP APN
MyW Cu tion amu and l'Miry ny�.,..'
C.r.ke' .1�14mra I— grey rvn.:S41,Q197--�� S-EA-S 1.0 R 1
lull
CEKr119CATE Or,E%EKIITIONIRO, WORKERS'
COMPENSATION INSURANCE; ,REASMNDUSTRL WASTE INTRC BUJLVVjG DIVISION FEES
(Thi,satined ran be rebe mmpNted if NC Pamir is forme hunhed dollen(SIM) y
or ksrl 'TSE TRAP INANCHIiCK tt
Icenifythuinlhermhvmmoeoftheworkftew1iichthiaP mitisi.aued.Mall SEWER-SANITARY-STORM EA.31314.
not employ any pervm in any mania+so m beeonewbjeclmthc Worker,'Cmmprn. ENER*�F
Z � r 20
OZ atknlawsof CeliEimia.ume WATER HEATER W'NLNHELF.CER GRADA,Iaem
ZNOTICE TO APPLICANT':If,after making this Cendleme of Exemlaim,you sh.IJ WATER SYS EAV REATING
last.aiahjatto lx Workers Cmipenmlam pnrvlsiom of the Tali Ctak.y m nxm SOIIS
[ak1 RNlwithromply with such promiumor this Eminit shall he deemed revoked. WATER SERVICE
� z CONSrRUCIONLENDINGAGENCY N17WRF_SIDENTAI.PIAUL SQ.PE AID
I hereby dLm that mem manamstNClian leNlnr,rina:y fonts reHiamencc on m RarigY
U O the swat for which this lennit is issued(Se:.30)7.civ.CI
Ladder's Nene OT ZQ
} Q 11 k AJd _ hs 'I IIA t
n fy'h I l h, th PPI at al wl tIw a lh f w ❑UII,DIN('I i
v y co t gt t 'Tilly ''Ih II hyo I ty rTu w it stat,1 d'f gt': QTY. MECHANICAL PERMIT 1 FEF, •-'f C9
U � hu ld6 ) clot. ndlwnhyuuthm utlrrtx nt law of th sclye i.muupam the SEISMIC 17 L
aMrvcneatioaaN Pnryxny far insPcea:'":In9a`saT' PERMI'I'ISSUANCE �{ d 0
(Wc)ngnc lu suva,Incknhnlfy and kaplmnnlaws lNo City of Cu Pcnlnn apninat / < HLfC' 19'.
Ilahilitaw.judFnxnts,arts and uxllcn.ms whichniay in uny way ucmeagninu.laid Cit ALTER OR ADD'10 SUCH, ZD P[.LMIIINC TH
mvpaxnre of the ermitin,of this pcook.
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH ALI,NON-POINT AIR HANDLING INTI TO IW IX)CI'MI
MIiC11A AIJ'EU
SOURCIi fUhATI(1NS.
nip []p AIR HANDLING UNIT(OVER 10.000CIN) CUNS'THU 'ION'rA%
SiAAgradarare( AMlicuiXonarc(I�iaJ,(A 7 ODate ErHAUSI'HOLD(WiDUCP) HOUSING MI GATION FEE
11"dRDOUS MA'TERIAL9 DISCLOSURE
Will the applicant orfulae huddling lcet,,nt ssorosv lundle ba»udnux aralend HEATING UNIT(TO 100,00 BTU)
as defined by the CiiPcnirai Municipi CNB CbaEcr 9.12.and the Ilea11h and Safay
Code., toe 255RIap HEATING UNIT(OVER 110.1101 BTU)
Yn
ON. VENTILATION FAN(SINGLE RISID) PAID Dae NarigY
40
Will the appliam iv furore building oaupanl are,i ipmrnl m devices which
emh bvar60s air cmtaminanre as defircd by Tae Bey Area Air Quality Alvugrnrnl BOILER-COMP CHPOR 110.0X1 BTU) r�
T AL V
Diann' BOILER-COMP IOV ER 100.1101 BTU)
m1Yes [-I No
I ha.,reed die hvmdnas materials ms miter Chapter 6.954 the Cali- AIR CONDITIONER ISSUANCE DATE
q 15533
fornix Ilcahh K Safay Code.Smhins3hani is my afd'JS3J.1 wda ufth is ifthe NEW RFSIDCNIIALAIF.CH. SQ,IT.
I:aildir,r'-- ms mufcanly havcarnant dial it respansiNlitY to iadfy lir«ripmt
mi bicb acute inch katoa Me CenifiV uf(kxu (((/
t JAY 4-�-4�
OwnerarautMinada�en (late TOT ISSUED BY:
OFFICE