S 0433 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-F]LECTRICAI, PERMIT NO.
BUILDING (VISION APPLICATION/PERMIT PLUM1181NG-MF.CIIANICAI. S 0 4 3 3
BUILDING PROJECT IDENTIFICATION -
BUILUINGADORES''S SANITARY NO. APPLICATION SUBMITTAL GATE
�NU CONT R'�NAME: —I - LlC No
0��2/
gggg !� NIC CONTROL,
�A CHITE /ENGINEER: LIC NO: A/gjt-c. XWb�1l4r A+iE fill?j� I J ❑ -
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herchy uffrm that 1 um licensed under prnvixians of Chapter 9(comrtmncing JOB DESCRIPTION
RWZO with Section]011(17 of Divi=ion3uf the Business and Pmfexsions W�and/nylianuis RESIDENTIAL,
O LS/O PERMITISSUANCIi ❑SFDWL ❑KITCHEN REMODEL
n full force and cffe .
aW�❑] Licema Lic.M�O APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMB(NO R6PIPE
Fa- µ� Dote Camnchn t I
F. y s ARCHITECTS DECLARATION PANELS [I MULTI-UNIT []STRUCTURAL
MODIFICATION
Z O o Z I urderslund my plans shall be east public blic records
OZ4UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
r4F� Licensed Nufessioml 2111-I000AMPS IMPROVF.MF SWIMMING POOLS
Sy .•.•11 OWNER.BUILDER DECLARATION ❑BATH 1/REPAIR ]EMOLITION
OVER IIKKIAMPS
6 1 hereby aff rd that I am exempt from the Contractors License Law for the OI'
O y U following roosan.(Section 703 1,5,Business and Pmfiasaons Code:Any it,or comply SIGNS ELECTRICAL
3 LL which requires a permit to constmn,alter imports.demolish,or repair any strcare
prior toils iuueme.also"at.,heapplicant it,,such permit n file a signed smtemem SPECIALCIRCUIT/MISC.
� } that he is licensed pursuant the pmvismnxnf the coal.,,.sLicen,e low(Chnpar9 COMMERCIAL,
ommencing with Seatinn]000)of Division Sof the Business and Probssiunx CWe)or TEMP.METER OR POLE INST. I
d 6 o (cthat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section]071.5 by any applicant for apermit subjects the applicant uacivil penalty of POWER DEVI' ❑TENANT ❑FOOD SERVICE:
nut more Nun five hundred dollars($500). IMPROVEMENT
~ZQ ❑I,asownernfthepropeny,ormyempinyeeswilhwagesustheiratslecompen,atiun, SWIMMING INTO IC
yf�0 [I OTHER
will do Ne work,and the structure is not intended or offered far sale(See 7044.Business
u1 and Professions Code:The Contractors License law does not apply m owner of ownof OUTLETS-S W HES- RES
n' propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
Jr.if,however.the building or Improvement is sold within one year of completion,the SQ'FT'� LSQ FT
owner-builder will have the burden of proving that he did not build nr improve Int pvr- c �[p
posenfxole.). YEP 3
I,us menet of the propeny,am exclusively n,mmning with licensed enntrecmn m IILIIa
mr.mct the Project(Sec.70H4,Business and Professions Cake:)The Commmor's Li-
cense Law does not apply to an owner of proper,who builds or improves thereon,and QTY. PLUMBING P.R FEE /s s
who contracts for such projects with a corltractons)lmansed pursuant the Convectors CITY Ur UUt-rri INN
License Law. PERMIT ISSUANCE
Iumesmas oder Sec. .B St P C for this reason
ALTER-DRAIN&VENT-WATER(GAJ VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the 1'olloming declarations
Q lhavmnd will muinmin aCenifcatenf Cnmum ro selGinsumfor Worksrs Compete DRAINS-FLOOR.ROOK AREA,CLING. STORIES TYPE CONST'R13CTION
smion,as provided for by Section 37M of the Latin,Code,for the performence of the
work for which his Permit is issued, pl XTURES-PCR TRAP
❑1 have and will mainain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work for whicht upcmal issued. GAS-EA.SYSTEM-I INC.4 OUTLIOS OCC.GROUP APN
My Works o Pa u ea c 'er and Policy
Cartiee��Policy Nn.:
GAS-EA.SYSTEM-OVER 4(IiA7
ER'1'I'CCO OF COMPENSATION
NFRAN WORKERS' GREASI9INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE —BUILDING DIVISION FEES
(This section realist betaropletW ifthe permit is boom hundred dollars($IW) ORIiASL TRAP
PLANCHGCK FEE
or less)
I certify that in the performance ofthe work for which NSTORM
is permit is issued. SOWER-SANITARY- EA.200 FI'.
not employ any person in any manner sec as to become subject to the Workers'Compen- - ENERGY FEE
Z ration laws of California.Date WATER HEATER WNENT/F.LCCfR GRADING FEE
0 Applicant 1
y NMICI7 TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEmn-REATING SOILS FEE
a ? become subject to the Workersabo
Compensation provisions of the Lr Code, most e,you
1,. fanhwith comply with such provisions or Nis permit shell he decmeJ revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RLSIDLNTIAL PLMR. SQ.FL PAID
D
Ihercbyaffirm IN,them iso construction leadingagency for the Performance of na ceipt it
11.r the work for which this Permit is issued(Sec.3097,Co.CJ
TO'T'AL:
O ULender,Name TOTAL:
[Ll lenders Address BUILDING FEE )
4 I certify Not 1 have read this application and arra that the above information is
CA correct l agree to comply with all city and county ordinances and state laws calming to QTY, MECHANICAL PERMIT FEE SIiISMIC FEE U Z buildingconmrctim,and herehyamhodm represearabo esnfthis city menarupus the
show rmamead propeny fott in tion purposes. PERMIT ISSUANCE ELECTRIC TLE
.(We)agree m vete d nify and keep harmless Nc City of Cupcnino against
liabilitics,judgments,rn apcnsax
which may in any way mere against said City ALTER OR ADD TO MECH. PLUMBING FEE
in comequmtce t o this Mrmit.
APPLICANT NI .COMPLY WIT LL NON- AIR HANDLING UNIT Ob 10,000 CFM) MECHANICAL EF:
SOURC LE ,��
AIN HANDLING UNIT(OVER 111,000 CFM) CONSTRUCf1 AX
Si at of ppliwMContmcmr Dore EXHAUST HOOD fed/DUCT) HOUSING MITIGATION
HAZARDOUS MATuternw ISCLOSURE
Wlltheapplicamorfutumbildingmeup tstoreorhandlchuaudnusntaterial HEATING UNIT(TO 100,11011 BTU)
as defined by the Cupanim,Municipal Cale,Chapter 9.12,and the Health and Safety HCA'fING UNIT(OVER 10(hlNla RTU)
Code,Section 25532(a)]
(]Yes FIN. VENTILATION PAN(SINGLE RESIU) PAID
Doc Remipl N
Will the applicant or future building numpant use component or devices which EAIRCONDEMONER
OR IORNOBTU)
emit haamdnm air conmminams m defined by the Bay Area Air Quality Management TOTAL:
OisvimT R 100.01X)BTU)
Oyer ❑Nn
I have read the harardams arreials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
foria Health be Safety Code.Sections 25505,2553)and 25534.I understand that if the ECH. SQ.FT.
building does not currently have a tenon,that it is my responsibility,to hurt,the occupant
ofthe requhemcrim which most be tram prim to issum¢e-1 Certificate of Occupancy.
Owner oramhoW daagent Data TOTAL ISSUED BY:
OFFICE