S 3896 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3896
Y"1^ 4 BUILDING PROJECT IDENTIFICATION IiIIII HjOi/R
Bf1iLU1N'G ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
O lilt' RMI? P11DNE: �B IRA DR" q P LICNII:
e NK I NIC C(1NTROLtl
HI PG EJC NQ'. A 1:1Co ',NCT. PHONE?, ";G�tsll"I' `BUH:DING PERMIT INFeW,r";
GI �6s l�p���3_ �P66 ❑ ConsuBan[FreePaid byApplicant(Initial) BLDG CLECs' PLUMB MECH
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IICI NSI UI UNIRd under5DICI ARAIION QTytr1 ELECT RIC IERMIT1;i- 11lII If r)I I�
I herebyshum4041 that l licensed I p f,Ced )r mcng -_, ( - r I, L - a �:._ JOB DESCRIPTION
WOz wimsectlaml(xn)nrD -tmm3dmeea:n andRR..n,n Cede.and m.Ean.e>
WO, PF.Hh11T ISSUANCE ^� -joRESIDENTIAL:
m Lill Fla.and eff,",
aUV License Class Lic.p ❑SFDWI, ❑KITCHEN REMODEL
F+�Iv Dam Contmemr AVINUANCES-RESIDEN'I'I Al, ❑ADDITION DPLUMBING RE-PIPE,
In P'
F O to ARCIIITECPS DECLARATION PANELSPANELS ❑MULIF NIT ❑STRUCTURAL
Z p h Z i understand my plan..hall be uwd as pontic renmlr MODIFICATION
p240 01110210AM11 [:1 INTERIOR [_1 CHIMNEY REPAIR
I-i�l"'; LlccnneJ Profneiunul 201-IaIDAMRS IMPROVEMENT SWIMMING POOLS
Om I;m,es,rops f DEC,Coul ION
��Q I hereby affirm Ibm 1 um exempt from Inc Cananemrs License Lax far 1M1c OVER INVAMPS ❑BAl'H REM EIlN1iPA1R DEMOLITION
X p 6 V following reason.(Sector]0115.Business and Pmmesi ow Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
m 3 U.h which reYmres anon,to'en'tmct,a11er,impmee,den..id,or tepah any atmcmre p/
LLp
i8 f-
pry 1 aNo re"llim,d ppl ,lor suchp to rile a signed�Iaaemcnl SIT( AI—CIRCCI NIMISC.
p. Ibut hiew licensee,'.t com the p tells Ath Contraactor�License Low(Chapter Y
Bounnermun,with Section 700(8 fDvtome3"ftheRusn—and Oofie,lans CMUar TLMP METER OR PDI.I?INST. COMMERCIAL:
6 ax e C that he is exempt therefrom and the basic for the alleged exempliml Any Timeline of [I NEW BLDG/ADDITION [I DEMOLITION
Wim Senino N3 L3 by any applicuat fin,a Benmd,oli meapplom,to anvil penaltyotPOWER DEVICIiS ❑TENANT ❑FOOD SERVICE
re than fill hundmd dollum($300).
AZO n I,ac owner ollhc n IMPROVEMENT'
grope y,army employees x'ilh wagestca tlorneole compenoeam, SWIMMING I'UUI.HLP.C'I'ItIC
P.. will do the work,and the structure is not intended or offered for%ale(See 7(t.-, l^.� [-]OTHER
Wim and l f Cd 'Th Cold I L I' 1 t pplyt mn1 Uil.i.q'S-SWITCHES-FIXTURES d`V _ _
proTemy h h ld .p therein, h i d k h II througl f--
In-us enployew pr"..red the noch'np"smot,ou tt-mendul .-"pend to' NEW R FSIDFN'I'I ALFLECI'R YQ d'\�
sale 11 M1 ih M1 Id g p t IJ 't- y r Bel Ih SQ.FT.FL ORAR A_-'`i SQ
'mine,-befider,lil1 am bmd,n ofp ,11ka he d1 art1mild or-impnOo for p D
p ne I'do.), ^^ 11'1^
i e 1'h p pent 1 I) t 'ti6 ll t t n Ali '✓ JUN U 1999
ou,lutuo the P j l(See '/BJa B ' I I ( Ir,J He G tOl 1 r 1... ,.i
x l.vwdoeenmuppty I build,,,, p _ 1 QTY
IPI:UMBING PERMIT iI FEE, I��
Otte,
nmcontractss for such
j as with ucmnt umrms)licensed pursuant Ctommmon u
License Law. PERMIT ISSUANCE
tum oxcn.p H&PCfnrthis c-on
it
ALI'i!R-DRAIN A VENT-WATER(EA) VALUATION
Owto Date
\ (1RKERCMP7 J( 01 fpANUC 1YI
bB dp rJ ry
of the fultowingd f
F] I oo,c and ll i of W k l C .pet I)ItAINS Fl()ON ItOOF ARIA COND.
,mil p,.,idr,i on,by Seen 3700 offlue[-all Code Nob,Beflionnance offfic STORIES 'TYPE ( UCTION
xnA1 M1 M111Be '. J.
FIN ORES PER CRAP
❑ IM1 and will ''m Worker Connor. I -1 c d IbySection
TI(Nl lme Labor Core,to,111,IBertommumi,ol,he workOn,x'hitch III. ..... s-sm.A, GAS FASYS I'IIM-1 INC.J OUTLETS OCC GROUP AI'N
M1ryW k L 1 f In,ol 11 l y m ^ �
Culr Policy NGAS FA SYSI'IiM-OVF.R4(EA) K
CI RTII ICA'l F OF i XEMI CIO\FROM WORKERS'
CONI i NSAI ION INSURANCE GRI \SF/DeDUS IRL WASTE INTERCEVTOR
(Uhr,—loar ruced not be C,tplcletll the permit'%for cite hundred lllars($do 'x r BUILDING DIVISION.PEI!5'
a,le".) GREASE TRAP PLANCHHCK FRE
I versify than in Inc pedonnunee o(the xnrk for xhich Ibis Bemtil is irouctl.
],hot]
not cnploy any Belson in unyn.uacra,as to became sahill ro the Wwkari Con" SLW'I!R-SANI'T'ARY-STOR>f EA-2IXIFL
xi tattoo Laws ot`Cubb,mU DateBen ENERGY EEE
W'AIIER HF.ATISN W'/VENIII!LI?CTR
7O C) APPllcmt GRADING FEE
F7 y NOT ICE TO APPLICANT:IL finer making C hit Cenifcatc of Exemption,you should WATER SYSTENVI RFAl'INC,
� — beton.,%object m the Worker's Cmnpenmaon pmvl.mo,of the labor Code,van must SOILS FLT:
W fanhwith comply with eueh mei..ans or flu,Beans,shall be deeoned re.okod. WATER SERVICE!
Q
� z CONS'I'RIJC'IION hI!NDINGAGI?NCV NEW RHSIUIIN'I'I Al,PLMB. SQ.FT. PAID
V O Ihorehy nllirm lhm lburc is�Cmstrvcdnn lending agency fonha performance nr Date RmenptR
1" the wank for,'Lich tins .all is i%wed(See.Mail,Clv.C.)
0 U Lenders Name TUTAI:
Lemlds Address TOTAL:
W I rtIy0had II 11suPPlica d.t mthed t funnar.'a I, r t I BIJUDINGFEE
CL.
Z conch g I Comply r II d, adtY mne—It a i11 .-rdatingm QTY ;MECHANICAL PERMIT Iv 'Iji-FE8•i'it
.
V z bullmngcnneredpun,cod for
:mthorimrpa,¢, n.'ev ill this car men¢r neon the 'l'1 d' -1 SEISMIC FEAT
annvr-(We) ted pun,co, kee,u- PERMIT ISSUANCE
(We)ugrec m suve,inJCnnify ted AecP harmlexs the Gly of Culwninn agoinst ELECTRIC FRP.
liuhiliticajudgmcnts.rusts nnA cxpcnms which nmya any way mcm,npuinst said City pla'I?R OR ADD 10 SUCH. PLUMBING FEE
I. n,,ti,c,of he grating of this Betmit.
APPLICANT 'NDERSTA 'DS AND WILT.LIMPLY WITH ALL NONTOINI' AIR HANDLING UNIT(TO 10,"CFM) MECHANICAL FEE
SO F;RF JI.A'I'ION
AIIt HANDLING UNIT(OVI?R IQ(NO CI+M) CONSTRUC'IIONTAX
gnaw of APPhc: om449
renor Dam EXHAUST HOOD(WMUC) HOUSING MITIGATION PEE
IAZARDOIIS MATERIALS DISCLOSURE
Will floapplicanl m fertile building(wcuperm smmorhundlc hanudons mancrinl HEATING UNIT(10100.000 BTU)
a def eed by 0.o CuBen'mo Municipal Code.Chapter 9.12,and the 11x111.erW Svlery
Coda Section 23332(a)'l HEA'T'ING UNIT(OVER 100AM0 BTU)
❑Ye% 0 N VENTILATION I'AN(SINGLE RES ID) PAID
p
Will the am,heom ar rt to hddding occupant use e"pnpment or devices which Date keceipl
emit hurardous mr contammund es defined by me Buy Arca Air Quality Managenenl POILIiR-COMP(AIIP OR IfNI1NNl H'IU)
❑Yes 0Nn BOILER-COMB(OVER IR).411)BTU)
AIR CONDITIONIEIt
I h I dm b J ms 2550 l t der Chapter lJS tl the at'd th- ISSUANCE DA'[E
famibmidu Health&Sfety Cd S f .23305 SSI3' d 33U.1 d d he cle Td° NEW RESIDEN'1'IAI,MECII. SQ.FT. 6 — -3 -
.film
^ Ce q
build' mend h - t I, ut 1' y sinil'ry1 (IY 11eLecup nt rlYf
or the q Itxhich mu n¢t eo(v Cen'-tate
sant u' m IA 'I'(UAL: ISSUED
OFFICE