S 3888 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINrO BUILDING-ELECTRICAL. PERMIT'NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMB ING.MECHANICAL C' O O O
BUILDING PROJECTIIIENTIFICATION J O O O
BUILDING ADDRESS SANITARY NO, APPLICATION SUBMITTALDATI
/013( LINDA 111xs%A Aci✓e (p 2- QIP
OWNERS NAME. _ � PHONE: CONTRACIOR'S NAME: LIC NO:
�4 / Q, EAT SONil N& P�0 N/c coN'rkol.a
.�
ARCH CENGINEER: LIC NO, ADDRESS: fI $ 6 A41W.1 r *.aid
❑
77 S "'r. 9.5''i�y3
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ l ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT 'EE
I hereby union thin I.m licensed coder proeixhtn.of Chapter 9 o'ontmetciag JOB DESCRIPTION
O¢Z with Smtion70Yh.f Division3ofine Business end Pndecsinn Ctde,ardm Iicensc iv
ul0 y PERMIT ISSUANCE
C W U in PoII force and effectd -O y j ry $P„WL ❑KITCHEN REMODEL.
IVU Licenxn Cla ' C -J I,ic.a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PBE
hZW Doc - Commaor
Z O`I_G2 Rshallh use DECLARATION ❑MULTI-UNIT El STRUCTURAL
m Z understand any)tuns shill be used ox public records UP10PANELS MODIFICATION
4)C_ UP 10 200 AMPS El INTERIOR CHIMNEY REPAIR
F-EQ w Licensed Profo.ined 201-1000AMPS IMPROVEMENT C]SWIMMING TOOLS
OWNER BUILDER DECLARATION OVI!R HMAMPS ❑BATH RF,MODEVREPAIR C]DEMOLITION
K�
U 1 hereby.(firm on I am exempt fn n the Cssions o :AnyC Law fur the
d O y U following reamn.(Seaton]OJLS.Nosiness and Profusions Code:Any city or county
SIGNS ELECTRICAL ❑OTHER
which acquires u permit m nnrsouct,alcor,improve,demolish,or repair any swcture
prior to its issuance.atm requires We applicant lbrsuehperntit In file.signedstamnKnt SPECIALCIRCU1T/M '.
E sf} mat be is licensed paummemth,provisions of the Comtmetors License low(Chapter 9
III C, (commencing with Section]0O)of Di vision]of the Business and Professions Coma, TEMP.METERLF,INST. COMMERCIAL:
m 1 e C that he Is exempt thend t n and the basis for the alleged cxcntptbn.Any violation or ❑NEW BLDG/ADDITION ❑DEMOLITION
x so vi Section 71131.5 by any applicant for a permit subjuts the applicant to a civil penally of POWER DEV ,S ❑TENANT ❑FOOD SERVICE
cat more than rise hundred dollars($505). IMPROVEMENT
=Sp ❑ Lns owner of nhc pntpcny.or mY anpinyecs wlm wegee us their sole comcemntlnm, SWIMMZ;
)POOL ELECTRIC [I OTHER
F will do the work.and the structure is not intended or offend for xalc(See,70f Business
W 3 and Professions Ctdc:The Contractor's Litems Law does not apply man owner of OUT :TS-SWITCHES-FI%T'URES
propcny who builds or improves tbercon,anti who does such work himself nr Ihmugh
his own anployees,provided that such improvements are not Intended nr >14
RE!ill) 0 SQF
vale.If.hox'evo.the holding or impromalk wild within..ywrmminndeuan.the SQ.FI'.FLOOR AREA $ISQ.FT.
er-builder will have the burden of proving that he did not build or improve for put-
pn cofealc.).
I.nro
s owner of the property,am exclusively contracting with licensed contractors to TOTAh
instruct the propeda(Sec.IDLL Business and Professions Cale:)The Conuactor'e Li-
st,LewdoesnolapplymamowneeofpropenywhnM1aildorituprovssmorenn.and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contrachols)Iicemed pur,mem to me Curad ctors
Licence L mv' PERMIT ISSUANCE
1 ant Cscmpt under Sea ,If d P C fill this reason
ALI'1!R-DRAIN&V HNT'-WNI ER(EA) VALUATION
Owner Date tt
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(J(ECI'.DEVICE YS�' dJ
I hereby till ai under pendny of perjury enc ill the fallowingW Worker,
oe:
,El I.am,us and will far by St,Cent 37M of he LitlloCode.for for Wmkcr'.C,apen-of
DRAINS-IIAOR.ROOF,AREA.COND. S'IORIE$ TYVE CONS'TRUCfION
scion,as provided fur by Scaian]](p of the Indsr Code,for the perfonnana of the
Ktar which Ibis rennin is issued. FIXTURES-PER TRAP
have and will uta rm in Worker's Cmnpersation Insurance,as required by Section
of the it
Code,for the performance of the work fare wshiicchy this
�Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTI-MS OCC.GROUP APN
My Told Policy
Caner(—'sr ,, _gyPs Pol cy No:7noo A e GAS-EA.SYS'TEM-OVER4HA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' CRI!ASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IBES
Glinsw,diounned ant be cnnsplded it thepannin is h,onulmodruddollars($IW) GREASE TRAP
or less.) PLANCHECK PEE
I certify(bat in the perfmcremcco(the work for which this permit is issued, hall SEWER-SANITARY-STORM EA.20514.
Z py person any manner so u. t m w the Wnrkurs'Conq,wm- ENERGY FF.F.
nntnnt to any t '1! ygtf.tet
O Apcnlnws oCCellfomi.,D eY — Wgl'I!R HEATER w/VIiNt/P.LIiCfR GRADING FEE
z Q NOTICE
N(IIICH'1'O API'LICAN'I':IL adten . tug nhlx Ccrtificvm of Exempunn,you sM1nultl WA'I'1!It SVS'TI!MTREATINO
become .bjcel In the Worker',Compenadinn provisions of the labor Code,you mull SOILS PEE
fanhwith comply wimsuch provision o,,his permit shall be deemed revoked. WATER SERVICE
Q
7Z CUNSTRUC❑ONL;ion leGAGENCY NEW RF.SIDI?NTIAL I'LMN. SQ.FI'. PAID Date Receipt#
1..) Thereby aRrm thauhert co
isanswnion lending agency for performance of
r the work for which mix psoril is issued(Site3(9],Civ,C.)
c U Lender's Name ,'t TOTAL:
r Wlenders Addrtss TOTAL. �7'S
C real this applicmion and stun mot the about informminn is BUILDING FEE
0. 1 cenify that 1 he
4 correct.I more to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL,PERMIT FEE
U Z trithirt...mction.and herebyamhoti,u clmesentmives ofmis city men¢r urym the SEISMIC FEET
above-mentioned property for inspection purposes. PERMIT ISSUANCE.
(Weagree m save,indemnify indemnify tied kap hamdnrs me City of Catamount tnt againsELECTRIC PEE
l
Iiahilities,judginems costs and expenses which may in any way acme against suid City ALTER OR ADD'IU MI!CH,
PLUMBING PEE
inconsequence of the g.man, ifthls permit. sf e5
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10.001)CFM) MECHANICAL EEF,
SOURCE REGULATIONS. q
0C
'17 AIR HANDLING UNIT(OVER 10,00 ) CONSTRU TA
7
Signawrcot'AlrlieanUVontouaor Dam I!XIIAUST IIOOU(WIUUCT) HOUSIN GATIG Eli
HAZARDDUS MATERIALS DISCLOSURE
Will lheappllcanl orfuwm building occupant store or handle Imeantas material HEATING UNIT(TR)TIN). IU)
as donned by the Cap, u Municipal Code,Chapter 9.12 anal the Hcnlnh and Safdy
Cede,Section 25532(.):' �j��, HENI[NO UNIT(OVIi W,0S0 BTU)
�Ye` e'er t VENILM ION P (SINGLE RESID) PAID
Will thea applicant or future building uccu ill use c t m device,which
Date Raeipt p
PP 6 pa .Air n BOILER- MP(3111'OR 100.000 BTU)
emit hmmdous it contaminants as defined by the Bay Arca Air Quuliry Management TOTAL,:
District t Yes BOLL/-COMP(OVER 10,011)BT U)
❑
I have read the Intrudous mntenuls or ulm umas under Chapter 6.95 of the Cali- CONDITIONER ISSUANCE DATE Q (].
ino is Health Aa Safety Code.Section 25505,2553)and 25534,1 understand that it t NI!W RESIOI!N'1'IAI.MLCII. SQ.PI'. Z (_.7
building does not cuncmly have a tenon,that it is my responsibility to notify me occupvn
of me taquiremcnts which may t ruJnoiss eofu Cenificarcof(Xcu
Owneroramo Mag I Date I TOTAL: ISSUED BY;
OFFICE