99120077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY _
CITY OF CUPF:RTINO I � ll1111.DBINUC IL iD'IItNOGAF.-LT I:DNNTIFILL
PIiRMIT NO
APPLICATION/PERMIT PLUh11N1MECIIANICAI Lc//
41611.DINGDIVI57ON
HUILDINGAD RESS, SANITARY NO APPLICATIONSUBMI'TI'AL DATE
a—/ o A Pr-� ,Aa e. Ii�� �. � q-7&9i3 �2_/o e.P9
OW ER'S NAME HONit CONrRACfOR:S N�164 LIC NO
LitSit ��i Qlt. ]J NCT 1f r✓/ N/c CONTROL x
fiCFf L� /i/q7 LIC NO ADD R ytQ�QK� nA -. ^ 7. ❑ .
-CONN)T_AL^CI'. 1/V' PHONE N// C. "?4/12-10
'BUILDING PERb11T INFO
j Cnnsullani Fees Paid by Applicant Onifial) I BLDO ELIiCT PLUMB Mla.11
L// ❑ r� ❑ ❑
LICIiNSEU CONTRACTOR'S DIiCLARA'I ION (QTY �t. IiLECPRICPHEN1I- i .-:FEIi )�R DESCRIPTION
1 hereby affirm that I am licensed under parx for of Chapter 9(commencing
D wdh Saalon7WO)ofDd Noo3ofine BirSnnei,and Pmfa,sma,Code.andmyluren t RFSIDENTIAL
CZ) rn full lnrcc endeBcct //�� I'15RMIT ISSUANCE
aUF Lmenoe Cluo, "T Lic p ❑SFDWI. ❑KITCIIISN RF.NIOOIiL
Q U / APPLIANCUS-RESIDENTIAL. 1 ❑ADDff1ON ❑PLUMBING RE-PIPE
FZW Date tmemr
.n c. .- COn ❑h1UI.Tl-UNIT ❑STRIICIURAI,
N tw 5DECLARATION PANELS
F ZZ MODHICATION
ZOyq InndercGnd my plar,hall he useda,public records UP TD 211(1 ANIPS
CZ-0 ❑INTERIOR ❑CHININ17Y REPAIR
hq•�Fy.�j1 Licensed Pere.mnul 201-1(glf)AMPS IMPROVflOENT 0SWIMMING PULLS
�J a,C a OWNER-BUILDER DECLARATION OVER IINNI AMPS ❑RATB RIih10DELfREPAIR ❑OF OLITION
ayJy l herchy nuiml that l ant cxempl Irma me C rion"tols Llecnse Law fit m^ 1
Sd36F follswmgrcasan.ISecplm)11J15,Besides,end Pmicsaun.Code:Any airy to anunly SIGNS ELECTRICAL. ❑OTHER
LLF�ON
which
rior mrcuusssuace,also requires canes the applcum Rn dromfilh,air
rile a sired statement
yQ p d, pp pennn stn SPECIAL CIRCUIT/N11SC
;!l y'-1 Iltul he is licensed piln11,1n11i the priv...... ot the wIm, License l.uw lChaplfl4
Q. 2 thnrmaremgwdM1Seefromad the basisf?the dlliuunessanJon.AmmnsCodm oil TENIP MI51'IiROR IY)hEINS'I'. /Q� COMMERCIAL:
Q.6 e C Sec io o eat 5 b therefrom and the basis far me alleged exemption.Any v Penaon of _ ❑NEW BLDG/ADDITION ❑FOOD S RVI
Section more 0han by my apphcam9m apemen subjects the apphcam toacavrl penalty of POWER DEVICES ❑TENANT ❑FOOD$ERVICIi
�^Y ..I more then live hundred dnllan 1851X11
Q Lo the work, nit re n,nrm Ioeeo wahu'a esrriale sole nun hers SWIMMING 1'OOIJJJ3CI'RIC IMPROVEMENT��L OTHER
❑ P Per romp r g Inenxa - ---- Rr��/
�,^
will do she work,and She stmnurenom mmWedsmBcredfnrale(SecJI/W,Biter if ❑OTHEk
a 3$ and Prefeaaona Code:The Commerce,Loco Law does not apply m nn owner of OUTLETS-SWITCHES-Fl%TURFS
pmpeny who build+.....proves thereon,and xho doe, meh work hrmocll in rhnnrgM1
his own employee,Provided n that such nmpeoveacn are not intended or offered for NEW RESIDENTIAL.LLEC'l it SQ Ur
sale IL however.the building or rntpervemenm is wild wMm one year ofcomplehnn,the SQ IT FL(R)RAREA $/SQ Fr
o er-buldet wit I...c the burden of,rivm,met be Jul oat hold or tmpmoe for par- ,
m'eof sale,
❑1,as owner of the pm,eny,am eocds vely contours with Leered Ordametors to I OTAI.
construct the perfect(Sec.7044,Business and Pmfessmns CdcU The Conferees',Lt.
cerise Law does nil apply to in not net of property who budd+onmpmve,thercon.md (QTY. �� o PLUMBING PERMIT ,1'FEE -
hoamnrecnforsuchpmpel+wrlh aeonlmmoev)hecrcdpannammlhe Cnntrannt, "' " ' •'
License Law PHRMIT ISSUANCE
0 I.am exempt under See ,li&P C fair lot rexin
Owner Dn'° ALTER- 'RAIN%V ENT-WATEk(EAI VALUA'UON
WORKER'S COMPENSATION DECI.ARA'fIGN BACK PLOW PROTECT DEVICE J
1 herby.alBrm tinder penahy of perfury,one of the following declarations
I havumd will nmunarna Cenrficutc of Consent to+elf-ensure for Workers Compton I DRAINS-FLOOR ROOF,All EA,CONE) SIORIES TYPE CONSTR UCTION
mom to provided for by Section 3700 of the Who'Code*for the frefadnunce o1 it
work for which run perm is nsaed FIXTURES-PER'1'RAP
FI 1 heve end will mamtam Worker',Cumpcnatun n Insurance.d,required by Section _
37(1 my Labor Code,tot flo,rfodtooe.dme work fm,h Ohmd, dsnsuarl GAS-EA SYSTEM- INC 4OUTLETS
i Penn' OCC GROUP �/ APyr
C' Worker's Compensation Insurance carrier and Policy number are GAS-EA.SYSTEM OVER 4(EAI
Camcc Policy No .n
CRk'fIFlCATIi OF EXEM
SAIIONINSURONIWORKERS' GREASE/INDUS I RI.WASI'It I N'1'ERCIiM OR I O ES -
CON,PENSAI ION INSORANCE BUILDING DIVISION FEES
This section need one he completed if the Pamir S for one hundred dollars(A(Np I GREASE"TRAP
or le,.1 I'LANCHIiCK FEE
I unify lh.n in the whop manceifine work for which this lx man isnsacd.(Shall I
,'at ennd person to any nanncr,o a,in hecmne,ub)ect.......Workcrm SEWER-SANITARY-STORM EA.20017
ENERGY THE
OZ moon Loss of CaLhnmm De¢ WATER BEATER M'/VENT/Ii1.ECTR
0 Applicant ) GRADING PT:F:
to NOTICE'TO APPLICANT If,after make dg this Certificate of[Exemption,you should WATER SYS'I'EMnRFATING
a ; become Object In the Worker's Cam uod f the Whirr Code,psi door SOLI S PCIi _
J pcnsa Pmvnumss
bnhwnM1 comply wdh such pmammon,rho pemin hall be deemed rvaiked WATER SERVICE
Q
� Z CDNS'IRUO,otolo lending AGENCY NEW RIiSiDGMfIAI.PLh10. SQ F1' PAID
UO Iherehy allirm mm mere rsawnNrvcaon lending agency lore the perlormancenl Dar Nttvnplx -
u' — k lot which this Whom,r,issued ISec 3097,Gv C) TOTAL:
Q bender',Addre••
1 OTA h: _
1 I ccm(y that 1 have read this d"dicmion and sole met the abine m oonalmn i, BUILDING I Eli
.H.o to comeu I agree to comply with.11 city end muntynNmance,and some laws reloads to (QTY. NIECIIANICALPERMIT' Flili
U 7� budding constriction,and hereby authonm re,remtnaaves r.frhio city to enter upon the t 513ISMIC FEE
uhnvcnsmtuned Pmpeny fur m,pen.on purpose, PERMIT ISSUANCEi
(We)agree nave,mdmnmfy and keep hamticsa me City of Col<nmo against IJ,LC'i'kiC FEE
habthoe,,Judgmers,own and expenses which may in any way factor against said City I ALTER OR ADD'I O MECN
,it at n,dcr a of the grunting of if,,,pcnn n PLUMBING PF.E
APPLICA NT ONDF.RS'TANIJS AN D W ILL COM PLY W I'I'H ALI.NON-POI N Al It fIANDLING UNI'I'(TO III,IXII)CI'NU
SOURCE REGULATIONS h11 NSTRICAL1 T
AIR HANDLING UNI'p(OVIiR IO.UO(1 CIM) �CGNSTROCI'IQN TAX
Srgname,idApphcanl/Cnmrecmr Dam HXHAUS'1'110OD IW/DUCI'I HOUSING MITIGAI ION FEU
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazmlnus materiel HEATING UNIT('10100.000 B Ui
a,Jclumd by the Cupertino hhmrupal Cade.Chaprr 9 12,i I the Hcallh and Sldely _
Cud,Section 25532(W HEATING UNIT(OVER I(N),()(Xt BTU)
0YS No VENTILATION FAN(SINGLE RESIDE ('AID
Uate Rccvrpe a
Will the aPplicam or hour,building ocetipant use x,mi mmol or devres ahich
n humidor,air contaminants ax defined by the Bay Area Air Quality Management BOILER-CONIP(311P Oil 1(0,(00 H'I'U) iOIAI.
neria9 ,o
NYC, ON. HOILF.R-COMP(OVER 100.00(f)BTU)
AIR CON DI'1'IONER
Iha.e real the M1aziNUU,nmmnep rqurrensms under Chapemb95 of the Cuh- I ISSUANCE DATIi
Como Health.@ Safety Code,Seen...25505,25533 and 25511.1 undeneand amid he NEW RESIDENTIAL MECN. SO Fit ///III
building does not currently have luenam.that n n myrce,ponslhriny to nerdy lheoncupam / /
uflhcreymrernard"l"Itto.+t lxmet nom to nwance ufo Cenificam of Centeno y. (/ Jli p
Owner or autlioneed agent Data TOTAL: ISSDHD 01' T°� _
OFFICE