S 3326 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPIsRTINO BUILDING-ELECrRI CAI, PEST NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NUICIXANICAL v 3326
BUILDING PROJEC`1 IDENI'IFICA'1'ION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
OWN1:R' NA .: fONI3: H' N ML LIC NO',
NIC CONI'HOlitit, Lp
�A HITIi T/EN INELR: IC N( DU 55: O.J 0 ❑
M\n1C d faGY e'Vf
anJN,rpcT: PHONE
HUILDING PERMIT'INFO
ry 1th Consultant Fees Paid by Applicant(Initial) BE ELECT' PLUMB MECH
\`IUJGC Kos %s- 3 9z 6 ❑ ❑ ❑
LICENSED COMRAM OR'S DECLARATION QTy. ELECTRIC PERMIT FEE
1 hercrp
hy arin lu
tont I ant licccd comer provixi:ms of Chapter 9(mmmuacfng JOB DESCRIPTION
M0.Z with Section]BBB)nfDoision 3ofthe Ltuslnessand Professions Code,ond my license is RESIDENTIAL
won in full force and 'i i'ERMI'I'ISSUANCE
❑SFDWL ❑KITCHEN REMODEL
1VV License Class Lic.ra ¢ O
i-ZW Date Contractor APPLIANCES-RESIDIiNTIAh ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
Z O'/t Z 1 understand Iny plans,hall he used ax public records PANELS MODIFICATION
OZ=� UP TO 200 AMPS [I INTERIOR ❑CHIMNEY RI'.PAIR
Licenced Rafessional 201-IXX)AMT'S INIPROV17MENr (]SWIMMING POOLS
�,jF; OWNER-BUILDER DECLAItAI'[ON DVE1000AAMT'S [I RAI 1{REMODEIJRHPAIR ❑DEMOLITION
Y w Q I hereby of rda that I am excmpl from the Coal mcmr's License Law,fur the
,llimi
0.x o U following nation,(Section 7031.5.Business and Professions Csde:Any city or county SIGNS ELECTRICAL. OTFIEN
W'3 LL ye whish require,a permit to cun,tren.ober,in iti ve.demolish,or repair any Immure
�ii•O.l prior to its iuuance,also outperm
paces the applicant such i0o fied le asignctaiddenl SPECIAL CIRCIAOMISC.
d that he is licensed pursuant the provisions of the Comracor's License Law(Chapter 9
g pyO� (emtmencing with Section 7100)ofDlvision 3of the Buoressind Pmfu,sion,Cmdc)or 'I'P.MP.Mf'I]I R ORPOLE I NST. COMMERRCII AAL,
d 0.o pp that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
iC.n t4 Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICIiS ❑TENANT ❑FOOD SERVICE
^m not Ionic than five hundred dollars S500). IMPROVIiMENT
$a$a H ❑ SWIMMING POOLELEC1RICI,as owner of thepropcny,ormyempl�yeeswithwrogesasdheirwkc�mpensation, � b<ndnd
will Bothe weak,and rhumacmroislmtintendednrnfferedfo...Ic(See.IDYL limiress s�O703R OJ`"'O f
East m and Professions Code:The Counselor's License law does not apply o an owner of OUTIAI S-SWITCHES-FIX'T'URES p wq�I
property who bond,,,,improves thereon,and who Ates such work himself or through
his awn employees, a rvidal that such impmvemems or offered lar NEW RESIDENTIAL ELECTR SQ IT.
salc.ILhnwever.thebuildingor' ..o wit uhcause mpletinn,the SQ.PH'.19.00R $ISQ.IT.
s er-builder will ha a uManor, ' that he or mild owe for our.
p� u of sale.),
❑1,as r of the p avidly contracting with in, ontramers o TDI'AL:
cen<we the pacjul ISe. e Business and Naftali.: s I trvcmr's Li-
.clawJocsnmappl o ncrLM'prop6ny�tle� y m s arrom.rl QTY. PIA GPERMIT FEE
who 11) cstursuch or wid}y mmmdni�n(s)liccn. pnnuam ot1 omnmtors
Liccns Law. PERMIT ISSUANCE
lam exempt under S .11&11C fn 'his reason
ALTER-DRAIN&Vii - ATERf:A) VALUATION
Owner 3
WORK( RATION HACK FLOW I'ROI'ECT.D'VI i DOD
Thereby alLrtn undo na ty of perjury one ollhe Billowing Acdamdions:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Comped. DRAINS-MOOR,ROOR AREA,COND. STORIES TYPE CONSTRUCTION
xodion,as provided for by Session 3700 of the Labor Code,far the por ornomcc of the
work far which this permit is issued. FIX7'U R ES-PER TRAP
❑1 have and will mmimain Worker's Compensation Insurance,as testified by Section
3700 of the LuberCale,for the perfornmnce of the wok for whidnhi,entrulls issued. OAS-HA.SYS'FEM-I INC.40UTLF1S (ICC.GROUP APN
My WokcCs tin I nsurance Garband Poli eygy�tw,karc.at' v� (�
My Wd.k, �. 1 .1 GAS-IiA.5Y5TEM OVERJ(EA) -`
CERTIPIC TE OP I?XFiMfTI( PItpM WOR ERS' GRIiASIJINUUS'1'RI.WASTEINTEkC13PT012
COMPENSATION INSURANCE UILDING DIVISION FEES
(This section need not Fv completed if the permit is for one hundred dollars ISI It GREASETRAP
PLA Ior less) C [.
I certify that in the performance of the work for which this permit is issued,(shall SEWER-SANITARY-STORM EA.But FT
nm employ any person in any manner na as la to,o me subjecno the Workers'Coratem. bay .F. o
Oz sation Laws of California.Date WATER HEATER W/VINT/IHJiCTR
0 Applicant GWe G1FEE
y NOTICE 10 APPLICANT':If,after anking(hie Certlfcam of Escanditsm you should WATIiR SYS'I IM/TREATING
!Yi become whitest to the Workers Compensation provisions of the Labor Code,you must soil ItiP.
forthwith comply with such provisions or this portal shall be deemed cevoked. WATER SERVICE,
d Q
� z CONSTRUCTIONLENDINGlending
AGENCY NEW RESIDENTIAL i'LMH. SQ.FT LAID Dam RecciptN
I hereby affirm that there is a ewmsction lending agency for the Performance of
L) he work lin which this period is issued(Sec,3097,Civ.C.)
LL VLenders Name
{2J Lender's Address �- TOTAL:
y 1 certify thud I have read this applienion and swte that the above moorti onion is ItUll.l ill
y curca.I Duel,comply with all city and county ordinances and state laws reining bt QTY. MECNANICALPERMIT FEF
V Z building construction,and hereby aathonae representatives areas city to enter upon the SEI C ?EE
above-meminned potpeny tax inspection ourrysscv' PP.RMI'I ISSUANCE
(Wc)ugneu,save,indemnify and keep harmless the City of Cupenion against li 'f CPI(,
liuhiliries,judgmema,cons and expenses which may inanywayaccrueagi instseid City ALI[LR OR ADDTO MECH.
in mta,mmeofare grumi ag of tbi' crntit. P. I NG Plili
APPLICANT UNDERS'1'AN S j.L COM II WITH AI L-NON-POINT AIR HANDLING UNIT(TO DI,OfO CFM)
SOl1RC!R1 IILATI l MSCI ANICAI.TEF.
/J,_
_�Z�� AIR II ANDUNG UNI'I'(OVIiR 10,000 CFM) CO "1RUCHONTAX
Signa pelican Conmamr 4 Date I7 EXHAUST HOOD(W/DUCT) H SING SH rLGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the...Bear,ar fitvrt building rtcempanl sorenrlmndle hazardous material ARM ING UNIT TO 100.0111,BTU)
as defined by he Cupenim Municipal Cate.Chapter 9.12,and the Breton and Safety
Coda Section 25532(3)7 HEATING UNIT(OVER 100,000 B'I'U)
❑YesjNo VENTILATION FAN(SINGLERLSID) Lou ReceiPl#
PAID
Will the applicant r Ibmrc building oeempanl use equipment or devices which
emit havardmo, it containment s defined by the Be,Arca Air Quality Management BOILER-COMP(311P OR 1(0.0011 BTU) AL.
Dlnnna'1
Yes BOBAiIt-COMP(OVER 100,000 B'll,t)
❑ No
1 hove rend dhe rotor tem nmteriuls reluircmainx under Chapter 6.95 at Cali- AIR CONDITIONER 1 (SSU E DATFrs n
Ibmia idulth&Sm��ntl,
Caste,Scei s 255(15,25533 and 25534.1 umerstsnd dritt i lI -— NEW RFSIDPNT'IAL MECH. SQ.FT. / Z Z I yi///(•Jxie
hni lding iI chove est. hat it in spnnsibdi - upant
+dobe eta ' n 1pnn,m' + crllh3�i{y n�� yyrdyy
Own nm igen Date TOTAL: ISSUED BY:
OFFICE