S0001B0312 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CI)PERTINO BUILD ING-ELECTRICAL PERMIT N f
BUILDING DIVISION APPLICATION/PERMIT 112
vLuntxlNG.-MECHANICAL SOoo�
BUILDING PROJECT IDENT'IF'ICATION
11UIhIlING ADDR135. SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'St PHO - CO TRACT{�R'.'N E, LIC NO. i
Colll...11l.....VVVVVoIliAo �� (7[ N/C CONTROL#
ARCIII'I'EC[/ENGINEER: LIC NO: ADDRESS ❑
CONTACT. PHONE: f BUILDING PERMIT INFO
.x-/33 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUIvIls MECH
❑ ❑ Ly ❑
LICENSEDCONTRACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hcrehy of ion dim I am licensed under provisions of Chapter 9(commencing
0WOZ with Section 7003)orDivision 3 of the Brearessaml Promwions Cole,and my hcen;e is RESIDENTIAL:
PERM]T ISSUANCE
F U U im1'ull forceanddfccg Z ❑ADWL ❑KITCHEPLUMBINREMODEf.
aUU Liccns.Cl,. Lick APPLIANCES-RESIDEN'p1AL El ADDITION PLUMBING RF,-PIPE
yZW Date Genesee
ARCHITECT DECLAR ❑MULTI-UNIT' ❑STRUCTURAL
F y Z 1 understand my plans shall be used es public records, PANELS MODIFICATION
0z�OUP TO 200 AMPS ❑IN'T'ERIOR El CHIMNEY REPAIR
M Licensed Prnfis"canl 201-I000AMPS IMPROVEMENT SWIMMING POOLS
;
OWNER-BUILDER DECLARATION OVER TWO AMPS ❑BATH REMODEIJREPMR ❑DEMOLH'ION
y W Q I hereby affrmt that 1 am exempt from the Contractors License Law for the ❑GI'HER
d U following reason.(Section]0315,Business and Professions Code Any city or county SIGNS ELECTRICAL
which rewires a Permit to eonamer.cher,retailer,demolish,or repair any santclern
Fs r0.�nC)< pot t t '..- l rq 'th applicantf - hPermit l 1l 't dmale Hent SPECIAL Cl RCUH'IMISC.
' gyp. mail I' d0) n th . fm C t t L Law
(Cbnptcr9 COMMERCIAL:
�aq0 (seam enc'ngxilhSwt nn 9fg0)nfDviinn5ofghc novices f..- nx Cnle)or TEMP.METER OR POLE INST
Q.1 ca (co be is exempt therefrom end the hails for Ne allege)exmttplinn.Any vinlodon of ❑NEW BLDG/ADDITION ❑DEMOI.ITION
�mN Section 91131.5 by any applicant fora peruchadseem them, ¢ineivil penalty of POWER DEVICES ❑TENANT ❑h00D SERVICE
LI.....
main claim Imo hundred dollars($500)
IMPROVEMENT'
CZQ 01,as owner of the property,or my employees with wages as their sole complainant, SWIMMING POOL ELECTRIC
CC22LL� will do be work,mtdlhc.stimpl re is not intended or offered for s,In(See 7dIG,Business ❑0'fHER
Lam antl ProPossinne Code:The Contmemrs L ccnm Low doth not apply to an owner n[ OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself air through
h'o own employees,Provided that.such improvements are not intended or MTecd for NEW RESIDENTIAL ELF.CTR SQ PI'.
sele.If.have...the buildingo—apawement is sold within one year or computer,the SQ.FI'.FLOOR AREA 5/SQ.FI'.
ser-bollde will M1nve the barren of proving that he did not build air top...c for pule
pose of side). TOTAL:
0 I,m ewneror the property,am exclusively contracting with licensed emrmmtm or
construct the project(Sec 7RU,Business and Pronasions Come:)The Commmtr;Li-
clause
i-
c seLaw does not apply to an owner of property who build,or improves Immune and QTY, PLUMBING PERMIT FEE
who contracts for such pmjems with a eanvrec res)[messed pursuant m Ota Commons s
Inccnsc law. PERMI'LISSUANCE b+ O
1 am nxempt under Sce. .B&P C for this reason
ALTER-DRAIN&VENT-WATER NA) VALUATION
Owner Date
• WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I herby affirm under penalty of pe Jury one of the[,,]lowing dwlumtinns:
E] Ihave and willmaintain a Cersf....ofCmema.self-insom for Worker's Compen- DRAINS-FLOOR,ROOF,ARE A.GOND. STORIES TYPE CONSTRUCT ION
lion,us provided fa by Section 3701 Labor Code,for the p.dormenee of the
w k which this pammit No-ed. FIXTURES-PER TRAP
or M1avc and will ecure in Workers C......am Insurance,as ramal by Section
391#lol the Lobar Cndu,fnnh.perfonnvn ofmbe work far whi,b,his permits;island. GAS-EA.SYSTEM-]INC.4 DOITETS OCC.GROUP AoV
My Work Cri enMtirn m i'tt r' m'c esti (ivy Ne. GAS-GAS-EA.SYSTEM-OVER 4(EA)
Cardec a it Pand Polr 1 WC �l V`/daMl
CERTIFICATE.OF EXEMPTION PROM WORKERSGRF,ASETNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(His rection need not be completed ifthe permit is fomes hundred dollars($100) GREASETRAP
PLANCHECK PEIi
css.)
lay city that in the anymannrsoas twrnkfo[suich ject In Permit ikso'Cissued,I shell S LR-SANITARY-STORM F,A.2110 Frf.
urn cmtloy dry person in airy manner soas m become subject m IM1c Workers Compcn_ ENERGY IPE
Z Idiom Laws ur Ce if in ia.Date WATER HEATER WIVEN'UELECfR Os�Q GRADING FFP.
N NOTICE TO APPLICANT':If,alive making this Certificate of Exemption,you should WATER SVSTENVIBEATING
(~
cremate subject to the Worker's Cumpensaron provisions of the Labor Code,you must SOILS FEE
�+ ti fnnhwith comply with such provisions or this parnit xhall be deemed e..okc& WATER SERVICE
i Q
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,ET. PAID
Dai¢ Rcuipl#
U kf..w ichthi the them isucomwetienlendi,agency for performance of
W P the Work(or which this permit scented(Sec.30yd9,Civ.C.) TOTAL'.
0 U bender's Name IOTA
} [LI Lcndcr's Address BUILDING IEE
1 eerily thin 1 have rend this application and state that the above information is
Ta/] come.,I.,me tocomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z bu]Iding consmidime.eadhereby amhorc,.mpmsemmlvonofthis city menrerupon the
abnve-menti,,ned property for inspection purposes. PERMIT'ISSUANCE EL17 PRIG FEE
(We)agree to save,indemnify and keep harmless the City of Cuponinn against
Iiahilities,judgmenbs,ensu and expenses which may nany way aceme mairal,do City ALTER OR ADD TO MECH. PLUMBING FEE
he consequence of IM1c granting.f this permit.
APPLICANT UNDERSTANDS AND WILI,COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGUI.RDONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONS"(RUCTION TAX
Signmurc of Appliwnl/Convnnor Date EXHAUST HOOD(W/DUCT) HOUSING MI'I]CATION FEE
UA7ARDOUS MATERIALS DISCLOSURE
Will theappliwnt or future building occupant store or handle hasarrous materiel HEAI'INC,UNIT(TO 100.000 BTU)
it,dcllSed by the Cuperino Municipal Code Chapter 9J2,and the Health and Safety HEATING UNIT(OVER 100.000BTU)
CN.,Section 25532(x)"
0Yes NV F.NTILATION FAN(SINGLE R ESID) PA )�
Ume Receipt
Will the applicant or Lamin building occurring use equipment or devices which BOILER-COMP OHP OR 100,100 HTfA
mit hamrraus nh eonteminams re erred by the Bay Area Air Quality Management
Doric[! BOILER-COMP(OVER 100.1100 BTU)
Yes No
AIR CONDITIONER ISSUANCE DATE
I have end the axardtns m:nennls rcgniremenu ander Chapter 6.95 of Call-
forma l l alth& afct 'Wc.SpLons 25505,25533 and 25534.1 underaand that if thc NEW RESIDENTIAL MECH. SQ,PT. Y
huilJl n� end have o lennm.that it is my respnnsibilhy In notify thc oeepleat
Mthe c ulr rot v' h nustbemetp....ur issuance of a CeriEedc If Or y.
G as or calmiu agent at TOTAL:
OFFICE