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99110030H� ow zz Fbo ga W ,1IOa F u.0 z'� a ml�❑ a c I � aL- a3 APPLICANT TO FILL IN CITYIIF CUPFRTINO BUILDING DIVISION 2.r. SSS' b 4101'f NAF, ov L 4 WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING - ELECTRICAL. APPLICATION/PERMIT e--2; M L -f, CN.M, 6'f 8 --471IS % �h� � G<7 PQ2..'iiNO � Cd -C./ �'OYLiL11A M RIl1]B:kXX 'fes / ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT I hereby omrn that I am licensed under provisions of Chapter 9 (commencing 99I10o3O wish Seninn]0007 of DlvisionJ ofthe Business end HofnxionsCodc, and my license is PERMIT ISSUANCE in full force and effect. PERMIT NO. License Class Licp APPLIANCP_ti- RESIDENTIAL. NITARY NO. APP .ICATI 5 ITTAI ARCHITECPS DECLARATION PANELS 11-5-Q NIC ❑ OTHER UP T02(XIAMPS COPGROLIf 1 have and will maintain Worker's Compensation Insurance. a, required by Section 370 ofthe Lahr Code, for the performance of the work for which this permit is issued. GAS - EA. SYSTEM-] INC.4 OUTLETS My Workers Compensation Insurance artier and Policy number ere: Carrier: Policy No.: BUILDING PERMIT INFO 'fes / ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT I hereby omrn that I am licensed under provisions of Chapter 9 (commencing _ wish Seninn]0007 of DlvisionJ ofthe Business end HofnxionsCodc, and my license is PERMIT ISSUANCE in full force and effect. BACK 11 -OW PROTECT'. DEVICE License Class Licp APPLIANCP_ti- RESIDENTIAL. Uaa Commnor [I INTERIOR ARCHITECPS DECLARATION PANELS I understand at, plans shall be used as p dlie records ❑ BATH REMODELIREPAIR O DEMOLITION ❑ OTHER UP T02(XIAMPS Licensed Proficonnul OWNER -BUILDER DECLARATION 1 hereby offrn that I am exempt from the Contractor's License Law for the Following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to consumer. alar, improve, demolish, or repair any >trumurc prior ro its issuance, also mgnims the applicant for such permit o file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter9 (Commencing with Section 70(k) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basic for the alleged exemption. Any violation of Section 7031.5 by any applicnm for a permit whjeem the applicant to a civil penalty of n Imomthan five hundred dol Inrs($500). I,usownuof the pngany, r is employees with wages r theirsola acmpensiness will Pr be work, anile: he structure is not am)mendedor offered do for sale(Saopply to an owner es .adpro Professions Calc: The Casthers's License Law does not apply s if owner through � 'z progeny who builds or improves thereon, and who Jas such work himself or redfor his own employees, e building that such mentis old w am not intended or offered for sale. If, M1ower, will me have building en of parents improvement is sold within one year of completion, the owner -"do.), will hoc Ne burden of proving Lha he did not build or impale for Pur. Elo,snleJ. 1, ns ownu of the property, not exclusively wn0ating with :)cussed mmtmcosv uo construct the pm)ul (See. 7044, owner and rty who mu Code:) The es thereon, and ase Lear dax not apply je an owner of murrey who bend, m improves thereon, and QTY, who contracts for such projects with a wntractnr(s) licensed pursuum to the Contractor's :.)cense Law. 1 am exempt under Sec. . B & P C for this mown SIGNS ELECTRICAL. TEMP. METER OR POLE INST. POWER DEVICES JUL SWIMMING POOL ELECTRIC NEW RESIDENTIAL ELECfR SQ Per. RI ISSUANCE ATTER-DRAIN&VENTAT?A U 0 Ihuchy affirm Oat them iso conswnion lending agency far chepulonnuncc of CF F the work for which this permit is issued (Sec. 3197, Cly. C.) OU Lender's Name r Lender's Address I conify this I have read this application and sora that the above information is F N Correct. l agree to comply with all city and county ordina ses and state laws «lacing to QTY U Z building Conscience, and hereby auNmiu repmumutives ofuhis city menterupm the FEF. JOB DESCRIPTION (Owner Date ) ❑ADDITION WORKERS COMPENSATION DECLARATION BACK 11 -OW PROTECT'. DEVICE ❑STRUCTURAL. I herethy nffrm ander penulry of perjury one nl the following declarations: DRAINS- FLOOR, RODE AREA, COND. [I INTERIOR I le caadwifrntinrninu Cullfcurc of Cansenun nil-im'nrefor Worker's Cme,cn- IMPROVEMENT sudor, as provided for Try Section 3700 of the [..he, Code, lin the perfommncc of the ❑ BATH REMODELIREPAIR O DEMOLITION ❑ OTHER work for which Its p .it Noisier. FIXTURES - PER TRAP 1 have and will maintain Worker's Compensation Insurance. a, required by Section 370 ofthe Lahr Code, for the performance of the work for which this permit is issued. GAS - EA. SYSTEM-] INC.4 OUTLETS My Workers Compensation Insurance artier and Policy number ere: Carrier: Policy No.: GAS - EA. SYSTEM -OVER 4 (EA) CERTIFICATE: OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFJINDUS'FRI. WASTE INTERCEPTOR GREASE'1'RAP (This section need not he completed ifihepernit is for one hundred dollars Sigh n hsaJ SEWER - SANITARY - STORM FA. 200 Fr. I Certify Farm the perfmrmance refine work for which lhisperran is i ... ad, Lbrill not employ any pent a in any manner so as as become subject to the WorkersCompen- WATER IIEAT17R WHEN DELECfR Z,Z o union laws of Califomia. Data Applicant to a ^ Q Z NOTICE TO APPLICANT: If, afar, making this Cenificme of Exemption, you cluadd become subject to the W'orkeh Compensation provisions of the Labor Cade, you must Renhwith Comply with such provisions m this permit shall be deemed revoked. CONS'I'RUC'I'ION LENDING AGENCY WATER SYSTEMOREATING WATER SERVICE NEW RESIIl1iN'I'IAI. PLMB. SQ. PT. U 0 Ihuchy affirm Oat them iso conswnion lending agency far chepulonnuncc of CF F the work for which this permit is issued (Sec. 3197, Cly. C.) OU Lender's Name r Lender's Address I conify this I have read this application and sora that the above information is F N Correct. l agree to comply with all city and county ordina ses and state laws «lacing to QTY U Z building Conscience, and hereby auNmiu repmumutives ofuhis city menterupm the FEF. JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑KITCHEN REMODEL ❑ADDITION E) PLUMBING RE -PIPE. ❑MULTI -UNIT ❑STRUCTURAL. IianhunC, judgment s, co.matd .,a a, which May In any way acerae against xuid City MODIFICATION [I INTERIOR El CHIMNEY REPAIR IMPROVEMENT E3SWIMMING POOLS ❑ BATH REMODELIREPAIR O DEMOLITION ❑ OTHER SOURCE REGULATIONS. EW BLDG/ADDITION ❑ DEMOLITION TENANT ❑ FOOD SERVICE IMPROVEMENT' ❑ OTHER SQ. FT. FLOOR AREA I LSQ. IT. FEF. VALUATION l ce j 3 SZ2 STORIES TYPE CON5IRUCfION OCC. GROUP .y © APJJU PERMIT' , I i FEE Signature of Applicamu Cnnwcmr Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant nr fulum building necupam sore or handle hamNous matedul as dcfned by the Cupenlnn Mmo,, al Coda, Chapter 9,12, and Wo Health and Safety Code, Section 25532(:)'1 E] yes 0 N Will the applicant or future building occupant use equipment or devices which mit hmardous air Courtrooms as defined by the Bay Area Air Quality Menageneat District I r7 Ya, Fl No 1 have read the haendous materials requirement, under Chapter 6.95 of rhe Cud - fame Haddi & Safety Cnde, Sections 25505, 25533 and 25534. 1 understood Not it he building Joe nomumtn1ly have o record, that it is mym,,x,dM1iIity m notify the sa.,a, of the requirements which oast he mer prior 10 Ixauance of a Cen flame of Occupancy. AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST'HOOD(W/DUC ) ,HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000111'U) VENT ILAd ]ON PAN (SINGLE RESID) BOILER - COMP UHP OR 100.000 BTU) BOILER - COMP (OVER 100.000 BTU) AIR CONDITIONER NEW RESIDI71oflAI. MECH. SQ, IT. TOTAL: OFFICE I BUILDING DIVISION FEES PLANCHECK PEE ENERGY FEE GRADING FEE SOILS FEE PAID Date Receipt# BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE I HOUSING MITIGATION FEE I I PAID. - Date Receipt # ISSUED BY. JANCE DATE 6,-.d0 above mentioned property for inspection purposes. PERMIT ISSUANCE (We) agree re save, iadaumfy and keep harmless the City of Cupenino agoirrst IianhunC, judgment s, co.matd .,a a, which May In any way acerae against xuid City ALTER OR ADD' 10 MECH. in consequence of the gaming of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO Iff"CFM) SOURCE REGULATIONS. Signature of Applicamu Cnnwcmr Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant nr fulum building necupam sore or handle hamNous matedul as dcfned by the Cupenlnn Mmo,, al Coda, Chapter 9,12, and Wo Health and Safety Code, Section 25532(:)'1 E] yes 0 N Will the applicant or future building occupant use equipment or devices which mit hmardous air Courtrooms as defined by the Bay Area Air Quality Menageneat District I r7 Ya, Fl No 1 have read the haendous materials requirement, under Chapter 6.95 of rhe Cud - fame Haddi & Safety Cnde, Sections 25505, 25533 and 25534. 1 understood Not it he building Joe nomumtn1ly have o record, that it is mym,,x,dM1iIity m notify the sa.,a, of the requirements which oast he mer prior 10 Ixauance of a Cen flame of Occupancy. AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST'HOOD(W/DUC ) ,HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000111'U) VENT ILAd ]ON PAN (SINGLE RESID) BOILER - COMP UHP OR 100.000 BTU) BOILER - COMP (OVER 100.000 BTU) AIR CONDITIONER NEW RESIDI71oflAI. MECH. SQ, IT. TOTAL: OFFICE I BUILDING DIVISION FEES PLANCHECK PEE ENERGY FEE GRADING FEE SOILS FEE PAID Date Receipt# BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE I HOUSING MITIGATION FEE I I PAID. - Date Receipt # ISSUED BY. JANCE DATE 6,-.d0