S 2364APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUIL LING - REEK I RIC,AL
Is U11,UING 1)IVIti10N APPLICA'1'I0NITERMIT PLUMIHNG- ME,CHANICAI
/.
I hcrchy afro, that I ani licensctl Imdur provision, of Chapter 9 (mnmmncing
�Owith Scene.700) of Division 3 ofthc Rmimew and Pmfe,,mr, Code. and my Hennes is
in
full force and
UULio, Chins I,ic.a
Z Tal Il:nu Cnnhn tort
d
ARCH[ IECI-S DECLAI A'IIiT
v7i Z 1 understand my plum chat] be used as puhlic record,
to
aLicensed Pndessioral
OWNER -BUILDER DECLARATION
I Fenny amort men I am exempt t a the Conututen'x Liceme I.aw for the
LU following reason. (Section 703 1 S, Bunion,„ and 1'ndu,lom, Cude: Any city or county
a y which requires a permit m crn,tmal, alter improve, d dumb n. ser repair any mruaure
�a prim or its issuanGa. aB.ogaie,dr, applicant for such permit to file a signed snmmem
Q that he is licemed pennant to the provision, of lire Contractor's Licenw LawlChaptor9
e noncncing with Scot 7001) of Division 3 it the Business and Proldsicns Codd or
cK That he is exempt therefrom and the basis mr the alleged exemption. Any violation of
ro m Section 7031.5 by any applicant for a pemlit subjects the applicant to a civil penalty of
-. to
not more than Ove hundmd dollars ($500).
iaQ ❑ Ina oroDro
ON ppy,m
ennry employer, with wages a, their col. compemntion,
.F.o will do the work, and the s,ucurru is nm intended orllemd tor sale (See 9tw4,1u, ,
3 m and Profession, Code: The Contractor's License Law doe, not apply m an owner of
propeny who builds or improves thereon, and who docs such work hire df or through
his own employees. provided that such improvements am not intended or offered for
sale. If, however, the budding or improv'emenl is sold within one ys'm of completion, the
er-builder will have the burden of ry wing that he did not build or improve For par-
prsu of 'ale),
1, as owner of the property, am exclusively contracting with licensed cranmctom to
nm,truct the project (Sec. 70.4,11. [Business and Profession, Code:) The Crnlmnors Li -
,ow Law does not apply manownerofproperty who build, or improves thereon. and QTY.
ho ctrl Teas for enuh pmjoel, wit hanmlTeaor(,) Iiecnwd forsnum to the Cantmcmr'.,
Lin sc Law.
1 am exempt umkr Sec. . I3 & P C for this reason
nate s:
WORKER'S COMPHNSAIION DECLARATION
M1and w off ai under Certify nl" ofCon one (it the if insure,
nslowmg declaration.
❑Ihave s and will for byneCion 37M ofConBenno ode. sur the peodelare,of e
workf as provided far ni Section 3](e, of me Iabn Codc, for the perfnrman<c of mo
work for which Thi, lwmtit is issued
rv,r
M1meand willominmin eperformance
erfr mance of
lie w Irk for which
by tissued.
3](01 nfthe Lubsr Cp-udcyfnrme Perf nyncmlee or the work for which This permit is Issued.
My Worku/9CoCoca air for nJuor miner and
Policym1"li,Pef.r�'L
Carrier: ' ''Nov: ��
CER'fll'1'ION FROM WORKI"RS'
COMPENSATION INSURANCE
fl'hi,s tumnedncl her untplelicid epconi( is far sen a lurid ddollur,($1( )
or less.)
1 cenify that in the performance of Ibe work fur which this permit is issued, ],hall
not employ any Iwrnn in any manner zo as to become %objecuo the Worker' Cmmpen-
O ,7, ration I awsof Califnmia Data
O Arpream
y NOTICE TO APPLICANT: IL cher making this Ceniticate of Exemption, you .Mould
C> become subject to the Workers Compensation provisions of the labor Code, you must
D.1 fnnhwilh comply with such pmm.aom or this permit shall Be deemed revoked.
CONS] 'RUC'1'ION LENDING AGENCY
V O 1herehy affirm that ka construction lending agency for the perlornmnce of
D. F-' the work for which lhi, permit is i ... ed(See 3(19], civ. C.)
O U Lenders Name
r Lenders Address
I cenuy Bed I have orad mi, application and ,are Ibm ore above lnfornnlion is
[0./y career. 1 agree menmply with all city and county ordinances and nett, law, relating to QJ y
V Z building construction, and hereby amhorim reprewnerise, of this city to anter upon the
above-mentioned property for ionpection purpoxn.
(We) agree m,save, Indelnmfy and kcep uumlc,s the City of Cupenlno ugnitnt
tubi l itim, judgments. cola and exlwnw•, which Inay in any way an me agoiml said City
in nwqu.ncc it he gmnfng of this pcmnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'rll ALL NON -POINT
SOURCE REGULATIONS.
Sq numm of APPlicanl/Cuntre cmf Dam
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant or furore building occupant Nom or handle broardou, material
as defined by the Copenino Municipal Code, Chapter 9.12 and the Health and Safety
Conte, Section 25532(a)'f
❑Yes 0 N
I Will the applicant or future building occupant use equipment or devices which
learail baimcmus air contaminants a, defined by me Boy Area Air Quality Management
Di,aricf!
❑Yes No
1 have read the harardou, ntmmals ropmuca mhm We, Chaplvr h.95 of the Cali -
mount IRuth & Safay Code, Sevin- 25505, 25533 and 25534. 1 undcnlunsl thin if me
handing down nor annually Imv.0 10nnnh thin n ie my rc,pon,fallly,, unify the occupant
oft ho rWmrmuru,, which yu,l cInel prim to marrice of a CcniEnllcof Oealpancy.
ri
Cunsultent Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201 -VM AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. FIT I KR OR POLE INST
POWER DEVICES
SWIMMING POOL 12LECIRIC
OU FLEES - SWITCHES - FIX "t
NEW RESIDW'TIAL I LFCTIR
`T Ah:5-7-70
S 2364
PLUMBING PERMIT
FEE
SANITARY NO.
APPLICATION SU13M�I'PIPAL L
ALTER -DRAIN & VENT'- WATER (EA)
❑MULTI -UNIT
N/C
CON'1'ROLA
DRAINS- FLOOR, ROOT', AREA 'ONl
C/
O s3C
UILDING PERMIT INFO
IMPROVEMENT
HSL -DG/ ELECT PLUMB MECH
u
FEE
`T Ah:5-7-70
Lff, 5SJ
PLUMBING PERMIT
FEE
PERMIT ISSUANCE
❑ ADD] TION
ALTER -DRAIN & VENT'- WATER (EA)
❑MULTI -UNIT
RACK FLOW PROfEC'1'. DEVICE
DRAINS- FLOOR, ROOT', AREA 'ONl
C/
O s3C
FIXTURES - PER TRAP
IMPROVEMENT
GAS - EA. SYSTEM I INC, 4 OUTLETS
Zo
GAS - EA. SYSTP,.M-OVER 3 (EA)
❑ a] HER
GREASI%INDUSTRL WASTE INTERCEPTOR
veaac�
GREASE'IRAP
SEWER -SANITARY - STORM F.A. 301 FT.
COMf7ERCIAI;
WATlilt II I TATER W/V HNTIELECTR
❑NEW BLDG/ADDITION
WATER SYSTEM?RIiAI'ING
[_1 TENANT
WATER SERVICE
IMPROVEMENT
NEW RESIDENTIAL PI,MB. SQ, FI'.
[:]OTHER
TOTAL
Lff, 5SJ
MECHANICAL PERMIT
FEE
PERMIT ISSUANCE
❑ ADD] TION
ACI ROR ADD TO MECH.
❑MULTI -UNIT
AIR HANDLING UNIT (10 10.00) CFM)
AIR HANDLING UNIT (OVER 10.001 CPM)
0NERIOR
EXHAUSTHOOD (WIDUCO
IMPROVEMENT
HEATING UNIT (TO 10).(100 BTU)
Zo
HEATING UN1'1'(OVER 100,001BTU)
❑ a] HER
VENTILATION FAN (SINGLE RHSID)
veaac�
BOILER -COMP (31111 OR 100.00IITID
BOILER - COMP(OVER IMON) RTU)
COMf7ERCIAI;
AIR CONDI f1ONER
❑NEW BLDG/ADDITION
NEW RESIDENTIAL MITCH, SQ. PT.
[_1 TENANT
FICE
JOB DFSCRIPFION
RESIDENTIAL:
MEC11ANICALFEE
❑SIUW1.
❑ KITCHEN REMODEL
❑ ADD] TION
C3 PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL.
MODIFICA'T'ION
0NERIOR
[I CHIMNEY REPAIR
IMPROVEMENT
C]SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑ DEMOLITION
❑ a] HER
veaac�
COMf7ERCIAI;
❑NEW BLDG/ADDITION
[I DEMOLITION
[_1 TENANT
❑ FOOD SERVICE
IMPROVEMENT
[:]OTHER
SQ, FT. Fl AREA
Z �� .SFflcR..L
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FI:E
Pd1E
PLUMBING [ZEE
s OJ
MEC11ANICALFEE
J
CONS'] RUCHON'IAX
HOUSING MITIGATION FEE
PAID 1l—_;?y z9t7 083 '
Date Receipt#
ISSUANCE DATE nn
d1