S 0779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0779 7�7 A
IIUILIIhVG PRUJF.C'1'IIIERI'IP'ICATIUN O 1 1 IA
tiANI TARY N(1. APPLICATION SUBMI'PI'AI.DA'1'li
BUILDING ADDRESS,.
l 3-2�
CTOR'S NAM is LIC NO: NIC CONI'Rol.N
ARCHITHCDENGfINEEK: I AUDRE55 t y ❑
rho
CONTACT. PHONE: BUILDING PERMI'1'INPO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IJ_E PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLAKATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm Nm I um Iicer,J under pnrvisiuns of Chapter 9(commencing
Wd'Z tb Semion7(XXPm Division 3 ol'Ihe Entire,and l'rnl'o,ions Cnde,undl^y license in F 1 T
IA
F12 wa full force.. A PERMIT ISSUANCE SI:DWI- ❑Kit'CHEN RIiMQUIiI.
CSF r^ C APPLIANCES-RESIDENTIAL ❑ADDITION ❑1'LUM61NG RE PIPE
Q U I L¢enec Cl a k
NaW6 Ume Commcu'r ❑A1ULThUNIT ❑STHUCTURAI.
ARCHITECoSDECLA A IO PANELS MODIFICATION
CFt2Z I understand my pleas hall be used as publ is records UP TO 200 AM I'S
Z-'a QIMPROVR ❑S CHIMNEY MING POOL
rot: l Licensed l'ndewional � 201-10X0AMPS IMPROVEMENT SWIMMING POOLS
-4 7 OWNER-BUILDER DECLARATION OVER 1000 AMPS [IBATH RFMOUFIIIIF:PAIR [I DEMOLITION
C W Q I hereby affirm Nmu
al I acmpt from the Comeaaor.License Law for the ❑OTHER
1x O6 U following re.wn.(Section 703 1 S,Business and Profession Code:Any city or county SIGNS ELECTRICAL
W'3U.vF which requires a Permit m con tmcE alter,improve,danNinh,or repair any stmetut,
I_iiv�OCA prior I :: n.1. 4 .th ppl If hpermu fi 'g J,tlement SPECIAL CIRCUI'1'IMISC.
5p�y)Y (hell II ((ap " C t e ndPr l %ions Code)our TEMP M1:1'1iR OR POLE.INST. OMMFR CCL;
ypQnO (commencing vi th th Section 7000)of DivFnn3sof f Ns.B
66 e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NLW RLUG/ADIJO'ION ❑UIiMOhIT10N
Section 7031.5 by any applicant far a permit subjects the applilmdul.civil ImIll of POWER DEVICES ❑TEN ANT ❑Fool)SERVICE
t me than five hundred dollar,(5500). BMPROVF 11'
otT
E=C ❑L as owner of the progeny.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC C1 OTHER
will do the wark.mdthcd.,Imc as not intended ornheard outside(So,.70.14 Business goryLETS-SWI"(CITES-FIX'1'11HIIS
and ProfcxsimI,Code:The Connacia's License Law docs no(apply m un awn✓ ,I
aprogeny who Wilds 9r improves(hereon,and who docs such weak eanhrough NEW RESIDENTIAL ELECI'H S
his own cmployccz,provided then such impmvenscnu arc not intenddedd in or offered for SQ.try.FLOOR AREA SSSQ.1'I'.
sole.IC holdet( building or improvurcent is within one year of completion,the -
tomer-tmilJcr wilt have have Ne burden of pmvin6 that he h he JiJ not hill or improve for pur-
po.a nr.mle.1. TOTAL:
E] L e owner of IM na,"y...n,exclusively contracting with lieunscd cormemr,In.
instruct(he project(See.70W4,Business and I'ndexsio I,Code)111.Con(mcna's LP-
cerise Law cars not upPlytoamnwnen,fpmpcny who build,or impmves0mrcan,and QTY. PLUMBING PERMIT FEE
who camosen 0,r such projects with n commmmis)bca-nsed panuant u,the Contrecmr s
License Low. PERMIT ISSUANCE
ma
rod,am npt order See .B&PCfor this rcav,n
ALTER-DRAIN h VENT-WA'1'IiR IEA) VAL W\'I'I(IN
Owner Data
WORKER'S COM PL'NSAI'ION DECLARATION 13ACK FLOW PROTECE DEVICE
1 berchy affirm under penahy of perjuryoneol he following.1111mmionr
I have and will maintain a Cenificate of Ccmenuoself-insum for Workers Compel- DRAINS-FLOORROOKAR FA.COND. STORI[.ti 'TYPE CONS'TRUCIION
cation,as provided for by Section 3700 of the later Code,for the Performance of the
work for m
which his pe (it is issued. Fl%TURI'_S-PER TRAP
E]I have and will maintain Workers Compensation Insurance,as required by Section
371X1 o1 the Lahr Code,Ga the perGnmarce of the work for which in,,perm it rs issued GAS-EA.SYS'I EM-I INC.4 OUTLETS OCC.GRUMP APE
My Wnr "ko/nCf,nlpcnsali Inuu nc^cnrzicrand oliy icy bwm: GAS-PA.SYS'IEMOVER4(CAI
CvnicnPolicy Nn.:
CIiRTIFlC O :%EMPI'ION PROM WORKINL'TER.' GREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEI3
(Tbissection need not becamplexdifthe permit is fnraaehundreddellam(SIW) GREASETRAP PLANCHECK PER
nr less)
Ioy alylhatlnthe anyalnneTnl the brklirt which othirehis prothe on is swod,I Workers
Compel, SOWER-SANITARY-STORM[A.21X1 FT. IiNIiRGVlyili
nodemployLeYu,I ulifinin unYnmm�msr,as(olscconusonjmuotheWorAcMCompen-
z snfinn Luws al Califnmiu.Date WATER IlligT EH WNENT/Ii1.liCfR GRADING hlili
z Applicant
NOTICE'f0 APPLICANT':If,after making this Cenif<mc of Exetnptian.You should WATER SYSTISMITREATING SOUS FEC
a , become subject y it Wofhds Comas or this s mail steal of one Lahr Cede,you must
a n.a
forthwith comply with such Provisions or this perms shall be deemed revokal. WATER SERVICE
z❑ 19UU
CONSTRUCTION LENDING AGENCY NLWRESIIIEN'I'IALPI.MB. SQ.I'I'. Dam R-111 N
L) O (hereby affirm than there is a co^slmction lending agency]or the perfrmanecof
D. Ne work for which this pemdt is issued(Sec.3(N7.Ci,C.) TYPAL:
0 E" Lenders Name TOTAL:
W Lender's Address BUILDING FEE
I mnify that 1 have read Iho.,henner and sme that the alive inrommtion Is
rail c neer.I agree^,comply G,E all city and cnumy ordimmec,ant atale Iaws rcmdag to QTY. Mf3CHAN11 At-PERMIT FEE SEISMIC FEE
C.) Z handing cons(nasion.ant hereby au(horize reprcscntativm of)his ei(y m Inner upon,the
alive-mentioned prnpeny for inspection Purosew'e. PERMIT ISSUANCE Ii1,ECfRIC IT!li
(We)agree to we.imletnnify and keep harmless the Ciry of CuProme aFainst
liabilities,judgments,costs and engenses which may in any way accme against said City ALTERORADUTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.00ICFM) MECHANICAL FEE
SQURCE REGULATED S
� AIR HANDLING UNIT(OVIiIt 10.000 CFM) CONSTRUC'TIUN'TA%
�y n
B^
re^ APP icon C^mrnctA ��1 I-ate— EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the application,future huilJin6 secupnm.wnre or handle huaallous matarial HEATING UNIT(TO 1011.000 BTU)
to der ed by he Cupenim,Municipal Code Chaptcr 9.12,and the Hellion and Safety HEATING UNIT(OVER IIXI.IXX111'....
Coda SCC(Inn 25532(W1
❑Yesx]Nn VENTILA'1'IUN PAN(SINGLE RESIU) I'AI)
T_
Date Rcccipt N
Will the applicant nr future building armiga il use equipment or devices which BOILER-COMP(3BP OR Ift"BTU)emi
t hazardous air contaminants as refined by the Bay Area Air Quality Management TOTAL:
�Ldixsn(A
BOILER-COMP(OVER IfX1,IXXI BTU)
s Fl No
AIR CUNUI'l'IONER ISSUANCIi))ATE
c read the hamNous mumriuls rcyuirensms under Chaptcr b.')$of the Cali-sn(Safety tlyha e B tans 25505,2553)and 25533.1 understanatIeNEW HISIUIiNTIAL MECl1. SQ.PI'. os not currently love r Ienant.Thal it is any rtponsibiliry m nmify Ihc occupant
mcnB which must h trent prior m izwoncc of a Ccnifcme of Occuparxy. _T�
NarizW agcn( Ilam U IAL: ISSUE[)BP. r
OFFICE