S 1642 5 _
APPLICANTTO FILL IN IDISE BALL POINT PEN ONLY
CITY OF CUPEHTINO BUILDING-FLHJRICAL I'E ITNO
BUILDING DIVISION `A I'LU311tING-MECIL\NIC.\1. 16 4 2
BUILDING PROJECT WENIIFICA'r111N
ADDRESS: ''.t., <_., SANITARY NO. APPLICATION SUBMITTAL DATI
:2S DE+✓►PsTE1Z AV6 ,vr ►►.rpt C A S i 6 1 in
I�tRr'S NA 1E: ^L 11 SS`` PHONE' (ONIRACU R;S NAM"f'��I,-`1 1r �LrIC NO. rI
cur I - ( \ w3.0 1� G JJ NIC CONfIt(ILM
AHCHITECI/EN( NIII;R: LIC NO: A H15S: ❑
S $ WWcMESTEP.AJE J99
COMACT: � 1'IIONI_ BUILDING PERMIT INFO
I ❑ Consultant Feet Paid by Applicant(Initial) /B�CLLDDGG E E(L T_ PLUMB MECO
LICENSED CONTRACTOR'S DL'CLARATION QTY ELECTRIC PERMIT FEE ( IB DFSC
I it,"b,affirm Inns I a...Ecenurl unver provhir-of CF,"1)&mnneo,ong JOB DliSCRIPIPION
C)wZ with ticctinn](10M1)ef Division Jaftle Bu.incss aaJ Ytufcaiuns Codc.enl mY liamcis RESIDENTIAL
WOO PEHMF ISSUANCE
H _F in full force old etibct. ❑SFDWL ❑KITCHEN REMODEL
QLiana Ch- la
Q i Owc Crrllr,m APPLIANCES-RESIDIAL [:]ADDITION ADDITION PLUMBING RE-PIPF
CL
ENT
ARCfIIIliCTS DECIAHAfION ❑MUhTI-UNIT ❑STRUCTURAL
PANELS
1" MODIFICATION
Z-
Z O,r�Z lel tendm plans: Ilh w<dwpuhlic rtaoNs
OZ�-� �/ UP1i120EAMPS ❑1NIP.RIOR 0CHIh1NEY ftPP,\IR
F`_I"' ioxnaJ ltofasio.ml�� ell-H*X)Alsl IMPROVEhfENT E]SWIMMING POOLS
OWNIiN-❑UIhUIiR UECIAHATI(lN _ OV1iR I"AMP5 ❑BATA RIJN JjIiP<\{Ti ❑I)FA101.ITION
y C G 6 1 hereby,eflirm that I am acme from.the Conasctor's beans,,law for the nQ�/��
>(3 iL U Iull.wing reason.(Section 911)13.Bueincvs and Prom ano.e Core..Any city or county SIGNS ELECTRICAL ❑OI'HIiR
LL] W which reyuim a r it In eonorecr,titer,imsier,JetmliJl,or repir u:y Hommo, ��
,E]�0� priorm aN.Itiarla also«quits th,.1ficvm R,lach pemtirm Rk a siynd amntmn SPECIALCIRCUITIMISC. V
i`"} IMt he is lienal gvsuanttuthe pms�sien+nf 1110 Con,mcttr's License law((Iwptt9
W�QO COMMERCIAL:
C latmnx:e,tero,ln4.cnnn]golilf,lei:for the le Husi rcasmdon,Any
Cnlnl nr 'CEMP.MEI1Jt OR IK1LE INST.
L a e z Nat ro is camp therefrom esti th bei+for Nc dlegN arnpnion.Any l nilly of ❑NEW HhI>r/ADDITI(1N ❑F11.D SERVE
Xml+. Set.fiirLS M1y vnyapplicumrorwpcnui,.mhjcnslhappLcanlmueivil pcnelD of POWER DEVICES ❑TPIJANT ❑FOODSERVICE
FZY
not rose Nan nom t,hr, mldmy
zlollanzy ple
d OLae maes(Nopmpnny.rxcntpinysw'nh wagesa,dlrmu..
tcicnrnruelI
un, SWIMMING%K .ELECT RIC IMPROVHMENT
t a will do E.ewrr/.,Std Neorecture is rm interi rvonemd fu sale(Sce.91W.B-f— ❑OTHER
Wwd Prnfc aonx Ctxlc:The Gtmracmm r'e Liecna law doe.. only to a,owner of ouTTTs-SWI'fCIIP19
S- KTUHLS
prvpeny alto huids 9r improv.thimmin ed whr t wch wcol,himself or Nmugh C.
his own cmpinyeew,pmvi"Hear sash in,,orr,ols am not intcrdcal on offend fns NEW RESIDFI D TIAL ELECT R SQ 14.
at,,,If.hawevcr.He herding or impnwccent is n.WwiNinore yevof.rSetion.HcSQ.IT.FLOOR AREA SISQ.Ff.
owner-huilJer will have Ih herdcn of roving that he AFI not Whi on i.nprove for for- P A l 4
rtsc ofvkd.
1,as water of 11,oro.pm,.no,cadusicely lona-fir,with hecocn
d cnmc,rrm
a TOPA L:
construe,IM project(Site.704-1,Bonott vel ProfeaianN Core:
Conommr'I Li- �1AY 11
eta law Gcs nm Py 1. o.of pn,my who hulldenr imProo-lhaeon.cod QTY. PLUMBING PERMIT FEE ^�
who contacts for arch ojets with a cmtmelons)licensed pmvuant to Re Commune x C y
Beene law. PERMIT'ISSUANCE - it` V1-
(] Ismiontoander See. .B&IPC h.r in,m n UVr
ALTER-DRAIN&VENT-WATER(EA) VALUAVIW
Ower Dam
WORKERSCOM%iNSAT10N DF,CL%RATION RACK ILOW PROTECT.DEVICE
L hcnhy adirm un.L:r penalty of perjury non(A IM1c to Uwiny daelactuncr r.
%-1 will rtarinbine Ccnifawco/Crnscm owl(=trwurt far M'aAdsCm.pcm DRAINS-11.gJRRODFAREA,COND. STORIES 'FYPBCONsfRUC1'"
wfion,m pnnihJ far by Smux.1901 of IM1c labra Code,Gr th penorummu of the
_ corl,(rr which Nix pc mar,iEoa,,1 F[XTRES-PER TRAP
❑ 1 Amo mal will nwinm[l.Worker I Compm.wtion Ina.mncu,m nyuitnl by Secl inn
17do of de lmor Cori
'far tleppcdomnwec MEe w'arA fm which t`, pennit.a isoact]l.� GAS-FA.SYSTEM-I INC.A OUTLETS OCC.GROUP AI'N
� Cuder ^ MTV U1LPdieY Nrn���• •����-•MICATE GAS-EA.SYSTISLOVF,Ra(FA)
CER' OF IiKEMPUON FROM WORKERS'
COMPENSATION INSURANCE � � GREASE(INDUSTHL WAST1i INfIiRCETTOH HLDINr DIVISION FP.ES
Cfnisaction recd nm hecno"Ller if then-iris Lr one hundm :a
l dalla (S 100) GREASEIRAP
m less., %ANCHFC .04
I certify that in ole lerfmormi of the work for which this Penni,i s Casual.lxhal l SEA LR-SANI'RRY-SOIRM FA.200 FT.
nu cmplov stay pnvm in any rrmocr mu In Net me subjeel to the W'eAcri Con cn. ENERGY .f.
Oz m,irm lawsofc,iramia.llme WATER HEATER WNENT/ELECIR GRAD R'
z Appicm,
rNOTICE TO APPLICANT:If,aner making this Ceni(m of Exemption,Yon should WAI LIR SYSTEM?RI'.AHNG
I s ? hit suhlecl to Ih Wxkce,C'ornlensation pnrvisims of Ih lahn code.yea man SOD
L�Ld "
forthwith esrolY Jdsuch Parvisionstr Nis pmnit,foll ho,limed!mvrkcd. WATER SERVICE
Q
� CONSTRUCTION LEAGENCY NEW RISIIIP.MIAL 1'Lh1H, SQ.FT PAID= z Ihcrehy atdnn Nm Vry
them is a cunstction tenting agency forth m
Pede .wtee of Dwe Hmeipl>
U O_ He war,fa which this Femur is roared(See.1(0),Civ.C.)
F' Doctor,Nantm TOTAL:
O U I<nlcr'sAidm,, TOTAL
1J
} La that HUII.1 NG FEE
F+ l acnll'y IM1UI have trnJ IM1Ia oppliculinn and sl:ec that Ile uMve inhxnwtmn s
V�1 cnmxL l agrm to carol ofrill city and cannty own and mm laws mlatingm Q'I'Y. MFCHANICAL PERMIT FEE
kiildingconwtuction,and Uemhy aelluxize represenm,ive ollhokc,menterurmde SEIS IC FEE
ho,oentimM Pnyeny for impztim pmts as. PERMIT ISSUANCE
(Wit ogre to save,iidcnmify mal Aep M1unnlaa the City of Ceresin"ngdma ELI?.CHIC RE
liahilitics,jwlpmrot+.cons etd expemcs which nary irmy why cera,egnm1 aid City AUITR OR AIIUT(I MHCH.
agwnce of Nc gw lin,of his Pcmdf PIT MBING FEE
APPLICANT ON DE RS'I A NILS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10,000 CFM)
SOURC ULATI $. MI :HANICAI.IFE
AIR HANDLING U NF(OVER I0.010 CIM) C( SI-RUCTION AS
Siym�iturt art ApplicaMGm,rmux J — Dum FAHAUSI'HOOD(W/DUC7O HO SING MITIGATION FEE
I IAVARDOUS MATERIALS DISCLOSURE
WE the applicant or future Noldinerccupun store or handle ha,,nhres nominal HEATING ON IT U O 10 ON)BTU)
m tkftnl by no,Cuprnirm Munlcilvl Crdc,Cnartt 9.13,mad the Ileallh and Safety
Cock.Section 2551200 HEATING UNIT IOVEB 100,1101 BTU)
Ycs 0 No
VE.YI'ILATION PAN(SINGLE RES ID) PAID (A¢ Reccip�
Will the applicant or future heiding oavpam ua equ form,or kcica,which
on ha-,d,,.,air cmtannmml,ns JenoeJ by Nc Buy Arta An,Quality Mun,,con tut I1(IILI?H-COME'11HP LIR 101.fMX1 NTD)
u
Vee ❑Nn IIOIhIiR-COMP(OVEH I01.IMq li'i'U)
I lave mriddw M1wnnbux l.wuniuls mluimnenN mdcr CMpat 6.95of tux:Cah. AIH CONDI HONER ISSUAN ?DATH
fcrnin IRw,r&Ssfny Cock.Section 255n3.23511 and 2 YW.l unktsurvf Hot if not NIIV RESIDENTIAL.hfl.Cll. SQ IT.
hJlding A�.el cumndy hwc n lenont.IM,it ir.ny tivrr.n.bility m Ielify the orcvpanl
M the mluimnerus which rota k rte,prim In i.wmec orf•Cmifa„•of(kvvparcy.
Owtlu a auNnnr 1 ugcn, Ilmc TOTAL: ISSUIiD BY:
OFFICE