99120027 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CI'T'Y OF CUPERTIND BUILDING ELECTRICAL. RM1T O.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
'r ;; BDILDING PROJECT IDENTIF'ICATION;
BUILDING ADDRESS: ' - SANITARY NO. APPLICAHO SUBM TTAL DAD
d 315 u /2 t aZ q9
OW R'SN ME: mer PHONE: COUy'JIRACT SN E: /I-_ . LTC NO:
y /`"/Y'M�C' N/C CENT
"VENGINEER: LIC At DRE.S: �� LJ
CONTACT I
PHONE BUILDING- BUILDING PERMIT INFO
ID✓- 1 y of
El Consultant Fees Paid by Applicant(initial) BLDG ELECT 'PLUMB - MECH
C `/cam-t[' ❑ . ❑ ❑
LICENSED CON IRACfOR DECLARATION Qjy F,LBCTRIG PERMIT 1'FEE
,1 hereby affirm thr e . d d p r Chapter v(commencing JOB DESCRIPTION
wag win Sacdnn 100o)o[D' Lslmn3oftnvBus and ProfaesionsCode,andmylw RESIDENTIAL:
W O p PERMIT ISSUANCE.
FIy in full force and effect. ❑SFDWL El KITCHEN REMODEL
�UF" License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
h Z H Date Contractor
,G H ECT'S DECLARATION PANELS MULTI-UNIT ElSTRUCTURAL
zOmZ nd .I all
user ielmialierecords MODIFICATION
O Z-Q _ UP TO 2n0 AMPS
�•® mensal n[:einnul - l F1 INTERIOR El CHIMNEY REPAIR
OW -BUILDER DECLARATION 201-JOWAMPS IMPROVEMENT C]SWIMMING POOLS
6 1 heresy affirm t am exempt from the Comment-,License Law for the
OVER 1000 AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION
ippiyy,� d U fallowing reactor(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER _
which requires o permit to consumer,alter,improve,demolish,m repair any sticture -
Ja prior to its issuance,also mothers the applicant for such permit to file asigned v[atemenl SPECIAL CIRCUTOMISC.
;!{y that he is licensed pursuant to the provisions of the Commclofs License Law(Chapter 9
aq0 (commencing with Section 1000)of Division 3 ofthe Businessand professions Code)., TEMP.METER OR POLE INST. COMMERCIAL:'
A. m ly that he is exempt therefrom and the basis for the alleged exemption,Any violation of El NEW BIAG/ADDITION XAEMOLITION
V• Section'11U1.5 by auy applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
W^m ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
IMPROVEMENT
SaO ❑Lothe work,the properly, rr intended
withwagesrlalei(See7,14,Business SWIMMING POOLGLECI'RIC
will doehework,and the nommrcisnot intendede offered Law
sole(Sec.1(144,Business ❑OTHER _
Faro
property
Professions Cnde:improves
License Law does sol apply to an menu of OUTLE'fSr SWI'CCHES-NIX'fURES
It,o ny who builds or improves thereon,and who does such work deed o r or Through
It,own employees,th provided r m such nchm is old within aro nae Iyearof or plediaoffered,for NE W RDSIDBNTIAL DLGCTR SQ FT.
sola lL howeve ill b bandies ader of ventent It a t hedidb t haild roimprovelfar,the SQ.PI'.FLOOR AREA $ISQ.PC.
owner-huilder,will have the buNen of proving that he did not hvild or improve for par-
pose if owner
-
❑1 f the Property I i 1y contracting with I' a d o [m mry i- atlji)TAL
consumerb project- (S ]0448 : sande be.� .CJ )Th C fact rs Li-
cause
a
.cans Law does tapply t fp pay n buildsp :th nand QTY PLUMBINGPER!! FEE
who Ra,achP liters with acam t r(s)Icersed pursuant to the Contractors
License Law. PERMIT ISSUANCE
L] 1 am exempt under Sec. ,B&P C for this reason -
' Owner 'Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
AM WORKER'S COMPENSATION DECLARATION /�f� 1
BACK FLOW PROTECT.DEVICE W
Ihamity andwill rmorder a Certify of perjoryeneofthe lf-insmfollowing
or derliWorker S Co
ch,as and will maintain Section
Certificate700 of film
Lab r Cede fi re for Worker's ce of(beoper- IJRAINS-FLOOR,ROOF,AREA,GOND. STORIES l'YPE CONSTRUCTION
asoma,as pmvlded for ai Ss Isom J1011 oY the Labor Code,for rho pmfnmmnce of the -
C]I forhave
eared will
armad it is issued. FIXTURES-PER TRAP
❑1 offhand will ode,fon Wodm'r Compensation work
hie. h his permit
ermby Section
My Wrke Labor
penaion the
surancPerformance r and Policy
for thispermitisissued OAS-EA.SYSTEM-I INC.40UTLBTS
UCC GROUP AI'N
Ca Worker's Compensation Insurance carrier and Policy number arc:
Carries ' Policy Na: GAS EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSfL 357 `
(TM1Lssmtimn need not be'rumpSletTr4IOifN rINSURANCE-
pSeUemRiAl iNt CfoEr• GREASEINDUSTRL WASTE INTERCEPTOR
a."BUILDMC DIVISI
oehundeddollan($100) CRGASERAP ON PEES
orles.)
PLANCIIECK FEF.
Icenifythat in the Perforreanceofthecorkforwhich thispermit ismued,I,mH SEWER-SANITARY-STORM EA.200 FT.
net employ any person in any manner so.,m become subject to the Wmkers'Compen; ENERGY FEE
z, satior Laws of Califomic,Date O WATER HEATER WNENTULECTR O Applicant I GRADING FEE
tiNOTICE TO APPLICANT:If,after making this Certificnle of Exemption,you should WATER SYSTEM/T EAGNG SOILS FEE
H become subject to the Worker's Compensation provisions of the Labor Code,you most
WA forthwith comply with such pnwisionxor this permit shall be deemed revoked WATER SERVICE -
z CONSTRUCTION LENDING AGENCY NEW RESIDENDALPLMB. SQ.Cr. PAID
U O thereby affirm that there ieawns[muion lendin6 agency for rho performance of Data Receiplb
W H the work for which this permit is issued(Sec.3091,Civ.C.) ' -
OLender's Name - m".�,.�TOTAL:
rW Lender's Address TOTAL: i`
E+ Ps 1 verify mail have read this application and state that the above information is - - - B D NG FEq,j�
y amraat.1 agree no comply with all city and comity ordineoce,and spun Iowa reining to QTY. MECHANICAL PERMIT EFE��E
-
V z bung cnnswdion.unA M1ereby uothorize represena[ives of lM1is city to entenrpan.he S 1 M_ICF E
ahove-mentioned property for inspection purposes. PERMITISSUANCE(We)agree to save,Indemnify and keep formless the City of Cupenlno agalnn &CTRL11eMlldw,Judgments,cads and expenses which may in any way accme against said City ALTER OR ADD'TO MECI I. EING FEEin onseuence of the gran' g' this permiAP�URIND WILL COMPLY WITH AL NON POINT AIR HANDLING UNIT(TO IQOOOCFM) A[a'!,AQ 1 FED
SO _
QZ AIR HANDLING UNIT(OVER Ill,(It10 CPM) CONS'1'RUC'1'IOF
Sig t ppll nUCo acro but; MXIAUSTHOOD(W/DUCT)
HA RD S MATERIALS DISCLOSURE HOUSING MITIGATION FEE
XIIlthe apPlicaI or are building reacting store or handle hazardous material HEATING UNIT GR)100,000 BTU)
as defrul by the Cupe Municipal Cade,Chapter 9,12,and the Health and Safety
Code,Section 25532(x)^ ��� � HEArRxG UNIT'(OVER 100,000 BTU) -
❑ '_
Ycs
�1 VENTILATION FAN(SINGLERDSID) PAID -u
Will the applicant or Tenure building occnpamt use egnipmem or devices which Date Receipt k
mil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(3 UP OR 100.000 BTU) -
isomp? TOTAL
E-1 Yes - BOILER-COMP(OVER 100,000 BTU)
I havemed lheh malmallsrequirementsmuse Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
7building
orma Health&Safety e,o ' s 25505,25533 and 25534.I u ersp d Thal if the NEW RESIDENTIAL MECH. SQ.FT.h m en4 that it is my respnnsibilityt hoof rho aeeupom fprior toissuenaeoPo�a 'f mem cy.
Q ne r' thanxed agent le TOTAL ISSUED BY
OFFICE