29921 APP,LICANTTOFILL IN INFORMATION WITHIN RED LINES'-USE BALLPOINT PEN ONLY
CITY OF CUPERPINO BUILDING.ELECTRICAL PERMIT NO
t PLUMBING-MECHANICAL ?'9 9 2 i1
BUILDING DIVISION' APPi,ICATION/PERMIT' �/ V
'
BUILDING PROJECT IDENTIFICATION
BUT L)DINGADDRE//SS: // SANITARY NO. APPIACATIONSUBMITTAL DATE
/O,i IE,
L�r, �Il/ iI
OWNER'S NAMEall : 'PHONE CONTRACTOR'SNAME /„ ,•LIC NO. /011
.c IIS ITl'1—d�- IJ�SYD/ ` NIC CONTROLp
ARCHITECT/ENGINEER: LIC NO: -' - ADDRESS.- .. `_ •. ,.p .,
CONTACT: - PHONE: ^ BUILDING PERMIT INFO
I A ❑.Consultant Fees Paid Ry Applicant(Initial) BLDG 'ELECT PLUMB MECH
LICENSED CONTRACTOR S DECLARAUGN QTY ELECTRIC PERMIT' FEE
I hereby ffrn that I r aed'na r p ren pt 9( nciag •." .JOB DESCRIPTION
w '
'0Z wifh5 f ]000) fDi 't 3 (the cosines dProfess on Cale'und my license is
p0 _ PERMIT ISSUANCE ' • ' ^ RESIDENTIAL: .
F .ILII f rc and effect�V�ULmense Class J Lic.M g 'S rlo�l - - - ❑SPDWL- �KITCHEN REMODF.I:
HGy Dam 3 �7-x.11 Contractor ' APPLIANCES-RESIDENTIAL` ❑ADDITION El PLUMBING RE-PIPE
E ARCHITECT'S DECLARATION - PANELS [I MULTI-UNIT 'OSTRUCTURAL
Z pTab 1 areae smnd my plans shall ha mut :p 61 c records u� _ - MODIFICATION
CZ4 - ` UP-1'02MAMPS- -
C - - ❑INTERIOR ❑CHIMNEY REPAIR
fro Y1
LicensedP OWNER BUILDER DECLARATION Professional 201-100D AMPS.; •-I. IMPROVEMENT ,,,�,,//-
MOLITION
Z
9 � I
1 hereby offimt that I am exempt from the m
Coraao L Ratio r the OVERf1t10AMP5 ❑BATH REMODEUREPAIR � UE
iy(C d U Follow g re son.(Section 90i 15 Bua nese and Profocsmn,C cel A y 'ity or county SIGNS ELECTRICAL ❑OTHER R,�,r �,0 L G
,4131+,F whin q ' p tt i t It P d 1'h p y'I co
VIo priori t,i,x...ca,ii,.ma,um,the applicanti such pt[ fl gstatement
o
d t t e n t SPECIAL CIRCUIT/MISC
pr Char h 1' ad p t t th p o f th C t t L L (Cli pier 9
(commencing withSection 7") fD' " 3 of the Business dP f "Carillon TEMP.METER OR POI EINST COMMERCIAL: '
That h exempt dtemirem and the basis for the alleged axed pt Any I_i on of. ❑NEW BLDG/ADDITION 0 DEMOLITION
W.�.N
Section 71131 5 by anyapplicant f permit subjects the applicant to 1 Penalty of POWER DEV ICES ,
of more th f h drcddollars($500), OTENANT .O FOOD SERVICE
' Q Q 1 mer f[he pmpeny y pl yees with wages as irk I pe ..firm SWIMMING POOL ELECTRIC PROVEMENT
will do thek dth .t et hot it nded oroHeaed for ale(Sec 9(144 Business OTHER
and P fess.',Code The Continuum's License Law does not apply,to an owner of OUTLETS-SWITCHES-FIXTURES'
property who builds or improves thereon,and who does such work himself or through
his own employees;provided the such improvements are not imanded'or offered for NEW RESIDENTIAL ELECTR SQ PT
saga If.however,the building or improvememis sold within one yeaim, mpleiwh,the - - - - ,SQ.P.FLOOR AREA $/SQ.FE
. - owner-builder will have the burden of proving that he did oaf build or improve For Aur-
pose of sola.): " I . .• -
❑I,as owner of the portion,am exclusively mmmeting with 11ee.ed c'mm tem to TOTAL:
onstiat the project(Sec,9144,Business and Professions Code)The Contractor's Li-
cause Law do,,net apply t6 an owner of pros eny.whu builds or improves nmreon,and QTY PLUMBING PERMIT FEE
whr'eonaia9s forauch projects wifhacomrgat licensed puntsanrmthe Cmarmaor',
Liceme La "
w: u PER TISSUANCF.
I am as
exempt under Sec. ;'B&P C for this reon
Own D m At - AIN&VENT cWATER(EA) ' _ VALUATION _
WORKER S COMPENSATION DECLARATION ' BA KF PR BUT DEVICE p
DO
II by firm under penalty ofpep ry n of the following declarations.
•❑Ihave d ill maintain aCenfcaa ofConsent m self-insure fir-Worker.Compact- DRAIN -FL i 'AREA'COND.., '
'r"STORIES• TYPECONSTRUCTION
cation,as provided for by 9eCt on 394of the Labor Code,for the performance of the
-
workforwhich this permit is lsucaL,v- FNTUREL- RT - ^j �SOG
f ' 4
0 Them and will maintain Worker's Compeoeation Insurance,us rcqulred by Settinn '
3700 of the Labor Code,for the performance of the work for which dtrs Permi t is issued. GAS-EA.SYSTN IIN OUTLETS ,OCC GROUP APN,
' My Workers Compensation Insurance cam and Policy number are:; GAS-EA.SYSTEM-I . PA
(`artier 'P ha No.: - UH )
CERTIFICATE OF EXEMPTION FROM WORKERS'
` _COMPENSATION INSURANCE GREASFAINDUSTRL WASTE'INTERCEPTER
'
(Ths section need t be completed ifflue Aaron is fumme hundred dollars IN p tOTUILDING DIVISION PEES ^
or lents.) GREASE TRAP- - '' - PLANCHECK FEE
1 cartify that an the performance rfmc work for which this permit is issued,I shall SEWER-SANITARY-ST(IRM EA.2110 FT. '
oaf employ y person' any manner o us to beco na subject t U Weaken,Compen- .ENERGY FEE"
,alio La sofCafmora .Dm -
'zR Applcant - WATER HEATER WNE /ELECTR GRADING FEE
y NOTICE TO APPLICANT If, ft ok ng this Ce JT'ute of Exemption you should WATER 9YSTEM/TRRATING
af;^ become subject to the Worker.Compensation provisions of the Labor Code,you most SOILS FEE r
W Iny forthwith comply with such p_visions or th s pea.shall he de d revoked. WATER SERVICE
Q
1UO CONSTRUCTION LENDING AGENCY a NEWRESIDENTIAL PCI MIL SQ.ET. - PAID F -
Iherebyaffirmthat thconstruction lending agency for the performance of - Dote Receipt If
C) IM1e work far whmh this perm i s sued(Sec J09] Ctv.CJ �JJ),Le -
U nders Name TOTAL:
'
W Lend sAddrcss - -
..TOTAL: ..
0. I n fy that I have read this application d state That the base ind tion is, � BUILDING PEE
Vn) -cort Ingen to comply with all city and c ty d d r t I 1 ting m QTY. MECHANICAL PERMIT AEE
'U Z building construction,andberebynuthonze pmsenm0ves ofthistay to enerupon the ANTS
above-me'tioned property for inspection purposes. PERMIT ISSUANCE
, (Wa)arce to save:indemnify and keep harness the CityofCupe niongaina
FCIRICPEEJ ,
Iiabilitime,jul,inces,costs and expenses which may in anyway accrue against said City ALTER OR ADD 9'D MECH.
in consequence of the grunting of this permit I I ' - PL UNBEND FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN (TO 10,000 CFM) ] �s MECH
SOURCE REGULATIONS. IT ti ANiCAC FEE '•
- ,� 1 AIR HANDLING UNIT(OVER I0,IX10 CFM) �V CONSTRUCTION TAX ' t
Signamrcof ApplicanUContiact., - J' 'Date EXHAUST'HOOD(W/DUCT)^" HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Oe ap,Iiaaat.rfumte building occuped scommiandle hazardous material HEATING UNIT('I'0100,000 BTU) ,s ,
as defined by the Cuporl Municipal Cade,Chapter 912,and the Health and Safety -
,Coda,Section 25532my'' HEATING UNIT(OVER 100,000 BTU) 4 ,
E]Ya., ON • - T VENTILATION FAN(SINGI.I..RESID)'' PAID ,.--
Data Rueip[k
Will thepdh ado r future building c p t use equipment or novices which hazeNo
eBOILER-COMP(3HP OR 100,000 BTUharmonicscorm tis as deMetl by the Bay Area Air Quality Mamtgemrnf TOTAL:
Di
sarm?
a" C1Nt;, BOILER-COME(OVER 100,000TEM)
e reed Ne hazunlcus mmuials AIR CONDITIONERrequirements under Chapter 6.95 of the Cid- ISSUANCE DATE
&Safety Code,Sections 25505,25533 and 25534.1 understand that if theNEW RESIDENTIAL MECH, SQ.PT.'otcar mtly hate a torem,tbe,it is my taspomsibilirym many the occupant 'ments which mull benim prior['iasunnceofa Cenificam nfOceopancyhorized agent Data I 'TOTAL: ISSUED BY.
OFFICE