S 1862 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CDPERTINO RU1LDING-ELECl'RICAL PE ITNO.
BI111.UING DIVISION APPLICATION/PRRMITPLUAnRNG.MIICBANICAL 1862
BUILDING PROJECT IDI:NrIFICATION
DUILDING MDRESS: [^ SANI'T'ARY NO. APPLICAI'[ON SUHMI 17AL DATE
OSSo 6e -F�e A-v�e — Cu e.,�rvo -- 1kin.�+te
OWNER'S NAM1t � Jo hN so,,
Pf10NG CONTRACTOR'S NAME: LIC NO:
NIC CONTROLp
AN CHIU'ECTiENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
6S-0- 3 Z4 ❑ Consultant Fees Paid by Applicant(Initial) 11LDG IiLECT PLUMB A1ECI]
T?00 EJ El
LICENSED CON TRACTOR'S DECLARATION Q'TY ELECTRIC PERMIT FEE
I hereby ofhrm that,con licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DAX with Section'nNhpnn)ivisiob 3o0he Bn.incomod rmlc...r Code,unduly herald is RESIDENTIAL:
FOO in full fame and effect. I'ERMI'1'ISSUANCE
ul— ❑SPUN'L [I KITCHEN RP1v10UEL
IZW I.Dateme CWsv Lia# APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
y se c. Dote Commnnr
E,Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O`^Z I understand my plans shall he used as public records MODIFICATION
OZ�q UP RE 201AMPS [I INTERIOR [I CHIMNEY REPAIR
W Licensed poor..innal 201-BIIk1AMPS IMPROVEMENT 0SWIMMING POOLS
5 Q I hereby animh that�lam�xelmp�fn'm the Conraaor's License Law for the R DECI-ARATION
OVER 100DAMPS ❑BATH REMODELiREPA,R ❑DEMOLITION
fy��dO folim ng rcnvon.(Scclear,7111.5,Rmincv,robot Prnfc..inas Code:Any city nT cnuo1Y SIGNS I3LEC'rkICA,. ❑OTHER
LLl LL y which requires u permit m construe alter,improve,demolish,or organic any structure
OQ prior orb,,uance,alnn requires the applicant branch pemm a 0leasignedsmtnnem SPEC, 'C.
that he is licensed pursuant to the provisions nl'Ihe Contractor's License Law(chapter 9
�LtJ'd0 (commenting with Section7000 of Division lof the Business and Professions Cade)or TEMP/METER DIEM COMMERCIAL•
d X Oo e' that he k exempt therefrom land the basis for the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION DEMOLITION
LL�y
Section by any applicant fora permit subjects the applicant to a civil Penalty of POW ik DE.VIC ❑TENANT FOODSERVICE
t F=Yd [ , tho hive hundred dollarsS500L
nIMPROVEMENT
asownerofhe property.many employees with wages un their sole unpuwhiun, RW INC.IN01't01.iP 'RIB '
19&
y� O II he work,andthesouetum innotimendedorolicredfor cote lSecJILW,Bm'iness ❑OTHER
til and Profusions Code!'I Contractor's License Law does not apply to an owner of of ,1 WITCHES-ITXTURIS
a 3^ progeny who hull h,or improves thereon,and who dyes such work himself or through
his own employees,provided thin such impmvemenR k dnot intended or offered for NEW RES,DIiW_r . SQ
aal,If,however,the 1) dingaimpn ve cut is m,ld within one year of eninplalon,the SQ.ET.FLOOR AREA LSQ.Fr.
,.ad,highs,will have the burden of proving that he did mal build nr improve far pur-
,a'ae of sole.),
,,as owner of the progeny,am exclusively contracting with licensed cammcmn a 'r(Yfn,,:
p
cnal mm the project(Sec.7044,Business and Professions Code:)T e Cmmeni Li-
muse Law doe,brat applym it,,own. if property who hbddcnr improve,thereon,and QTY, PLUMBING PERMIT FEF.
whocnmmmsfa-uehpmkm,vinhaemam nhrts)licensed puME 1.beC m oro
License Law. PERMIT ISSUANCE.
❑lam cis emptrCh "'s=. _B&rcfor this reason
e4AAS
ALTER-DRAIN&VENT-WATER(EA) VALUATION
0, �
• WORKE :S COMPPISSAI ION DECLA RAAI'ION 1 BACK FLOW PROJEC-E OHVICii
I hereby union under penaltyof perjuryone dithe following decldr oat:
I have and will maintain a Cordillera of Consent mselLiboim lin Worker's Common- DRAINS-FLOOR,ROOF.ARBA,COND, SIORIES TY PE CENSER UCr10N
sation,as provided for by Section 3700 of the Labor Code,for the peffarmance of the
work fur which this permit is issued. FIXTURES-PER TRAP
Fl 1 have and will maintain Workers Compensation Insurance.as required by Section
37M of the labor Cale.for the Tzdnrmuneeof the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 DOE LETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number area
Carries Policy No.: GAS-EA.SYSTEM-OV17R 4(BA)
CER I'IFICA'I'1i OF EXEMYI'[ON FROM WOR KFIS' GRLASFJINDUSI'RI.WASTE:INf1iRCGl'TON
COMPENSATION INSURANCE BUILDING DIVISION FEES
Cum,section neednuh M comp,endlittle permit is Boone hundred dolam(5100) GREASETRAr
or less.) PLANCHECK FEG
I cedifythat imbue perfamanec affirm work forwhichthis permit is boreal,I shall SEWER-SANITARY-STORM EA.207,4.
not employ any person in any manner so as m bewsnte subject a the Workers'Comped. ENIiRGY FEE
P n laws of Califnmia.,lmc WATER HRAFER W/VEN'DELECHt
O GRADING FEE
mho
Q A plicam
NOq'ICIi TO APPLICANT:II;afar making this Cunifciee of Ilxcmptien,you should WA'1'I?R SYSTEM/IREA'1'ING
a ; becomembjeet fa the Worker's Coillamooninn provisions of Ne Ealy,Code,you mus SO,ISFEE
Forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
aQ
� z Chante RUCTIONLPIJD,NGAGENCY NEW RFSIDGMIALPLK113. SQ.fI'. PAUL Da¢ Ree
V Q thereby uflirm that isxcnnntmnian lending agency for 0e porrfamhance of 't#
the work for which this permit is issued(See.1099.Civ.C.)
Da Lenders Name TOTAL:
Lender's Addrcs.s TOTAL:
1 certify that I have read this application and roma that the above infamafion is BUILDING PEIi
_s taA torah.I agree to comply with all city and county ordinances and sate laws relating it QTY, MSCI IANICAL PERMIT FEE
V Z building consmction,add hereby authorize representatives ofhbis city its enter upon the SEISMIC FIE
above-mentioned prepedy for inspection Purposes, PERMIT ISSUANCE
ENJ
(We)ngree td.mve.Iademmfy and keep beanies.the City df Ggwrtlbb against ELECTRIC FE
Iidulid.,pedgmems,casts and expere.which may,any way acerae,gainsaid City ACITR OR ADD TO MECH. PLUMBING FEE
in anesequete,t to gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To I0,gI0 CFM) MECHANICAL FE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signuarcdf Appli,moCcdrucar Dua EXHAUSTHOOD(W/DUCO HOUSING MITIGATION TiE
HAZARDOUS MATER,AI ti DISCLOSURE
Will the applicant(it future building occupant ounce or handle hazardous material RENTING UNIT(TO 100.000 BE U)
us ddibed by the Crta,rh n Municipal Code Chapter 9.12,and the Headlined S fe(y
Calc.Section 25532(a)? HEATING UNIT(OVER Edisto B"N)
❑Yea El No VRN'TILA'FION FAN(SINGLE RESIDE PALM
Will thea licam or future building f use t or devices which Droa Receipt#
PP Eby then co Air
BOILER-COMP(JHP OR 10(1.010 BELL
emit District?
hazardous air vamnminamx nx defined by 0c Bay Arca Air Qublity Management TOT -
Disrim? BOILER-COME'(OVER 1 00,0)0 BTU)
i]Ycs Fl No
I have mad the hazardous materials requireaabt umlef Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia Death&Sal'my Code,Sections 25505,25533 and 25534.I undersand mat if the N17W RESIDENTIAL MECH. SQ,FT. 7 O
bui,dingdoes not currently have a tenant.that it is my ms,xmsib111hy to notify Ne tecupom
of the requircmems which n.rot be met plat m issuance of a CeniOcsa nl0cmile ncy.
Owner or authorised agent Done TOTAL: ,SSUED HY: s
OFFICE