S1038 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PE�Mtff NO 1 O 3 8
BUII,DING DIR'LSION APPLICATION/PERMIT PLUMBING-MECHANICAL J �YJ[
BUILDING PROJECT H Yl IFICATION
SANITARY NO. APfgJCAT10N SUHMTTAI.UA
BUILDING ADDRESS:
o ZS i2� s -ez ��/rT Lit' Cb-1
O S AM17 PlIONE CON ACTORS NQ LIC NO:
1�f+ �� // NIC COYIROLM
ARCWA-
IHf 'CIENGINF,ER, LIC NO: ADURESS El 6rr
A,/442 oQ
CONTACT PHON Q I{(..'1 A'c-47vm- BUILDING PERMIT INFO
S I3 •} ❑ Cons oltenl Feet Paid by Applicant(InitW/) BLnc ELECT PLUMB MFCH
LICFNSEDCO CTOR'SDECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm met I am licensed under pre iumis of Charter 9(emmercing
,QZZ wilM1 Seetirm]IXMp of lTvivionioflhe Busire,a eM Pmfu'imnsCM.and'ny liecnw iv PERMIT IStiUANCG T
��F in full has,am eRcn. :7 .f 'OWL ❑KITCHEN REMODEL,
U IJcrne Clarets Licit APPLIANCES-RESIU6YIIAL ADDITION ❑PLUMBING REPIPE
Fax Dvte Cvnuanm N ❑MULTI-UNIT ❑STRUCTURAL
n�nn S ARCHITECTSDECLARATION PANELS MODIFICATION
QZF n Z 1 undnxwnd ley plens,hull lw m.d an puhlie mvrde 2tM)Ah11'F
-Q DI'TO ❑HNTF➢t10R ❑CHISINEYREPAIR
I„4tw Licensed professional 201.1000AMPS IMPROVEMENT ❑SWIh1h11NG POOLS
-� OWNER-BUILDER DECLARATIONE]BATH RFMODFIJREPAIR [I DEMOLITION
%= OVER 1000 AMPS
1 heathy affirm that I um exempt from the Conmacmr,Licenw Law for the ❑(TI'IIFR
Ow U fulknving mama(Stanton 7031.5,Bmarcra and Profc,dmes Cock:Any city or county SIGNS ELECIItICAL f1 p
3 LL which rtxpun,a permit to nmstmct alter,impmvc,denambsb,or.pair any strvcocrt P
F�'Og pnmtn it,is,uanc also reWitatlr applicant fon such Permitm file a timed datement SPECIAL CIRCUITIMLSC.
s } mu he no liamsed porandann to me povi.sitn,of the Comtmtor'x Lkrnse Law CCnal"'n9
,dO (nmm�roncing wish Sev...700(nofDivi,inn 3ofine 3uaiocc,ort Pndosion,Cm,)ur TEMP MM17R OR['OLE INST."
a OC that he is exempt beref.and Bae hams for tlw allotted escmpuon.Any violation of NNF ' D N MONITION
Senam70313 by.nyapphinvot fslapcmit subjcis he applicanttoacivil pcstaltyof MWER DEVICES ❑rr��rr++�ANT ❑FOOD SERVICE
nm tonne man rose namond"I .(ssaB). I6f`vW-TUYEIIIINU
f-ZQE] I,as miner rd the prnpeny.mmy cmplym wim wages es their ale cnmrys:ammo. SWIMMINGI'W .I XCTRIC
will a,me work,matt th<,trecwm Is int mmndcd moffere l fm ale[Seen.]B44,Bosincu OI'HIIR
3 amt Rofcetion Code:The Contractors License Law docs not apply to un mxmr of O ITCHES-FIXTURES
prolcry who bmilds or itryuovea thcresab mal wed darn coach wink himself on rhai NFWR LFI.I;CIk SQ FT.
his own empluym,provided that such imprvemenmrt anm intended or elfcmvl for SQ.FT.FLOOR AREA SISQ.FT.
sok.If,Mwever,the lmolding n,improvement is add wilhin nne year of urmpletlon,then
wrer-haild c will have de harden of proving tMs he did a,.,build ion motion a for per- *a
pox asok.} TOTAL .J�` 7
Fl I,u owxr of the property.am exclucivcly contracvnt wim Beamed enan,lnnx to
omsrmat the project(Sec.904.Hudeers and Itofesvi<ns Ede:)The Contractor's I,-
sc Lad,does rxx apply m an nwmr ofprgcry wed,mikkmimgro
tv.1'lacrcon,xnd QTV. PLUMBING PB FEE
wed contractsfur such projects wolf,a eantmctMs)IiansN Pa t to the Cndamemr's
License Low. PERMIT ISSUANCE
I am exempt umkr Sec. .B&P C fm mix reason
ANTI?R-IIRAIN&VIM-WATF,R(EA) VAI,UAI'ION
Ore., Dwc
•
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby alr uod,r penalty of perjury oce M the fdhnving dccluatvx: L
IMvc vW will rruimein aCmifinem of Conwnuo ulf-inane for Wmkda Cmnprn- BRAINS-IL(XOR.RWE,AREA.COND. STORIES TYPE ONSTRUCTIOb
s tire,ux ph h that
f by SsVliun 3?fq of Ile tabun Ci+k.Liv the ptxliemmwc of dm
kt wM1ich this pemmit is i..med. I�1.\'TURFS-PIiR TRA['
eM will meimaia Wukee,Compcmuion Insuwoce,u 11-final M Sec lural
3700 ofthe Labor Came,fe,the perfam a.fate work For which this lemur is iuucd. GAS-FA.SYSTEM-]INC.4 OITTLEIS OCC.CROUP APN
My WohcYy6xppgxra t yin dI Stand PoIxy number are: GAS-EA.SYS'I'1?M-OVIiN 4(EA)
C.'. S�N'�G L IK. Y7M' olwy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.'INDUST2L WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Mis,earvn rcd not he completed iftle permit is for one humbed"Ixe,05 100) GRIASETRAP
1'L,\NCLIF.CK Elili
on Icxs.l
Loy ounythulinted anyaremarceolo,tobeken,subht to perda,Wi,issuedlballper- SI'WER-SANITARY-STORM EA.200 FT. ENERGY FEE
rxn employ any pawn in any manner w n rex hecoorc aubjct to ole W«term Cumprn-
Z union Laws of California Dine WATER HEATER WNEN'I TL Eo D GRADING FEE
O Applicant I
/..- NOTICE TO APPLICANT:IL atter making mix Rnif,me of F cmpilnn,ye Jomld WAHiR SYS'I'IJMiTR W INE
[-' SOILS FEE
beemrc wbjecl ro the
Worker',ComW.navtion provision,of me Laa MCode.you muss
farl6wim cmoply with such ponvisiorno minis penned shell be deemed ar- WATER SIJIVICE
W �
a
CONSTRUCTION LANDING AGI INCY NEW RESIIIIlJTIALI'LM11. SQ.Ff. PAID
Z I hereby afflml that mem is a comolZion lerdtn fm the Ummnac of I>dm x
t eg1 y
U O de wml:fm whieh mil permit is iesacd(.Sec.309?,Civ.C.1 TOTAL
0 F' Lander',N.
L) Lemki's AJdmus TOTAL:
W 1 cenify'hr1 I have mad'his application nM said chat the oMwc information i, BUILDING R
4' F QTY MECHANICAL PERMIT FEF.
V] ctrtu4.l agacmrnmply wllh oll city vnd county mditarecs etd„win laws retain m SEISMIC FF F,
UZ wiwiag otownuiiun.aml hereby vuthmire refaeenlativa of mu ritymemterupon the
amn'e-meow,ed pmpcady fm inflation fcarai. PERMIT ISSUANCE ELECTRIC FEE
(Wed agree to were,indemnify art keep hemnlcss me City of Cooperman eFa ma r'
lioohilhin,ju glit ntccosua Ncxperosawhicbnwy lnmtywayaccmcagaiutszid City ALTER OR ADDTO MECH. PLUMBING EI t
in cm,qucrcc of me grentinF of mis permit.
APPLLCANT UNDERSTANDS AND W II,tL COMP Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFA) MECHANICAL I'. Z
SOURCE
.� AIR(HANDLING ON]](OVER UIJn)CIN) CONS'I'RUCfION TAA
Sitreturt of Appl' wareC4,r Ewe FKHAUST IHOOD(WNUCTI HOUSING MTTGATON P'E
AZARDOUS MATL LS DISCLOSURE
Will the.pplicam or future building occupant stare nr hamle busNoue amonal L IPATI NO UNIT(TO 100.000 BTU)
w defiMd by the C-feeare Municipal Cod'-Clapt¢9.12,and 1bc Ilcalth mld Safety IH EATING UNIT(OVER IUI.n))e'HJ)
Code.Swiun 3532(.)?
❑Yes El No VEmrIEKEON FAN(SINGLE RF_SID) PAIR Da1c Roonllof
Will the applicant sr f acre building rrcmpent um a9uipmcnl or de,iccv wh'0 11(11LER-COME OIIP(1R HI0,0 011'ILI
emit M1vvdnu air ummmirunts as riefircd by Be Bay Ara Air Qua1'ny Meragunent TOTAL:
Disfinef BOILER-COMIP(OVER 100,000 BTI _
Oyes ❑Nn
AIR CONI31'1'IONER �ifDAft'C�DATE
Ihavenml'he MvmJou,.nacnolx mgoimmcros amer Chaptm(,95 rat(the Cul i-
f.d.[Herold,&Safely Cod,.Seeman 255115.15533 and 25531.1 dokmm�d my if the NEW RESIDRNTIAL ME 11 SQ.IT.
haiktiat dna int nmcntly bare•tcrmm,thaw it is my naponsibitty w maify de oaupara
M the mvbrnems which mw tot met prior 1n ie�uvae mid Cerif enc M Occup.ncy.
Owner cr authernenl agent Dwc TUI'AI.: IS5Uf:13 BY:
OFFICE