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CITY OF CUPFRTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT I'llUMBINC.-MECHANICAL
PIUILDIN(; PROjECP IDENT'IF'ICATION'
PERMIT NO.
MEW
ADDRIi9S?
SANI'IAR1' NO.
'LIGATION gUHM1ITAL DWIILDIN(i
)W NEWS NAME; PHONE
v Sri �ZS3' 9431.
C NI'RACI'OR'S NAME: LIC NO
NAC
❑
CON 'RO_#
CHITECT/ENGINEF,R: LIC NO:
JDRISS:
CONTACT: / PHONE:
y f} 7y Q'S fi
I/� r
rj$/
nt F
❑ Consultaees Paid by Applicant (Initial)
BUILDING PERMIT NPO
BLDG ELECT PLD. B MECH
❑ ❑ ❑
QTY, GI,ECTRIC PERMIT FEE
LICENSED CONORACfOR:S DECLARATION
1 hereby aflirni ne" I ons Ilcenosi under powslonx of Crude, 9 (unnmcncing
with Section 700(dof Division 3m he Business and P -bovines Code. and my liceme is
inllSctio antic I /N
Le'ens 'la - 3 Lee0 Zi'.3s
Dale Comma"r
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI, uryR''ITCHEN HE ODEL
❑ADDITION OV'I,UMBING RE-PIPfi
❑MULTI -UNIT �❑SHOICTURAI,
MODIFICATION
FERMITISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
PANELS
I undenoull my ptoo, shall he used as public records
UP TO 200 AMPS
0INTERIDR C1 CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
[:1 PAT REMODEL/REPAIR C1 DEMOLITION
TfIIIiR
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 ons exempt Gone the Contractors license Law for the
1 following reawn. (Section 7131.5, Business and Profe„inns Cdc'. Any city or county
which requires a permit to construct, ober, improve, demolish. or repair any structure
prior to is':: Iso re,ttims,tile applicant fsuch ormitt file a signedstatement
1 man n ono I tl C t toe
bar In, is li,enned
(commencing thSe,cti ]qq] fDivision3 of the Business dib fav, ns Codc)or
ecallelgeduexm I' (Chapter
p cmpuna Any violation of
• Ser hm�]113L56 herefrn lican Porvhpermil. he
• yany app 1 'PPlic'unrm a civil Penalty of
not more than five hundred dollar, ($500),
01, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure Is not inlendel or offered mrside (Sec. ](H4. Business
o and Profligates Code: no Comrcctors License Law that not apply to an owner (ItOU9'I,ISLS-SWITCHES-Iq
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
9 EM P. METER OR POLE INST.
R
N LDG/ADDITION ❑ DCMOLITION
❑TENANT FOOD SERVICE
IMI'ROVEMI',N'I'
❑ OTIfIiR
POWER DEVICES
-
SWIMMING POOL ELECT RIC
XTURliS
NEW RESIDENTIAL ELECTS SOFT.
• poll who builds or improve, ancestor. and who dressuch work himself or through
his own employees, provided that such improvements we not intended or o0cred for
sale. IT however, the building or improvement is sold within enc year ofc nupletlon. the
raxvr-builder will have the burden of proving that he did not Wild or Improve for put -
SQ, FT. FLOOR AREA g/SQ. FL
TOTAL:
poo, salc.l.
1, Its owner tel the propert& ant oxelusivoly vernal ing with license canno,o rs to
nsmucf me peel (Sec. 70s4. Business and Professions CeeU) File Contractor's la-
cense law docs not apply to an owner of peopcny who builds or improve, hereon. ad
who ni mael, lar men projects wins o commuter(,) licensed parsmmt tome Cannanore,
License Law.
lam exempt under Sec. . B & P C for this mown
Q O
EC 2 1 1999
VA ON
/
QTY PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
Owner Dom
WORKER'S COMPENSA'T'ION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
have and wi 11 muinlainaCcnific:ac of Cnnscm to self -imam lin Wnrkcr'x Compete-
smion, as provided for by Scelon 3700 of the labor Code, fill the performance III pre
on fur which oris pcnnil is issued.
I how
C anLutond will rminmin Wmkds Compemmion Insurance• as required by Section
9](glof lM1Ctdc, for the ryrionomecul'dne work ler whirlibis permit is issued.
My Wurk'C mnce e. and Policy
pRA1NS-FLOOR, ROOF. AREA. GOND.
IT T.4
'TYPE CONSTRUCIIC
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. Int Ol FTS
GAS-. SYSTFM-OVER
fiA(E
;m
Cartier:_,, IPolicy Nrr.:
CHRTII4:AIE OVEXEMIMON PROM WORKERS
COMPENSATION INSURANCE
GREASEINDUS'On. WAS' FE IN'IPRCEPI OR
BUILDING DIVISION PIiF.S
GRGASETRAP
PLANCHECK FFE
(This,enionncenotbccnmplendifthcpemnakfurene M1mdreddollars(SIW)
or le".)
ectur which this a islouCl.Inn.mil
Nexnthe an, oreamcoflhcwork
Toy on, that
not employ any fierson in tory manner so as to became mbjauo the Worker,' Compem
Z, amino Laws of Califomia. Dam
SCWIiR-SANT FARY - STORM IgA. 2001 I'I'.
ENERGY FEE
WATER HEATER WNENF/ELECIR
GRADING FEE
2 Applicant
NOTICE TO APPLICANT: If, after making his Cenille nc rf Exemption, You should
account subject to the Worker's Compensation provision, of the Labor Code, you must
r fnnhwith amply will such pmvmams milli, pcom, ,bill he deemed revoked.
WATER SYS] IiMORFAIING
SOILS FEE
WATER SERVICE
PAN
NEW RESIDE TIAL PCMB, SQ. FL
ZUmc
CONSTRUCTION LENDING AGENCY
tiIhemny union that them isanm.amdiun lending agency for performance of
the wad for which his Permit is issued (Sec. 3097, Civ. C.)
Rcccipl0
TOTAL:
jLenders Name
Lcndcr'x Addmss
1 cenny that I have read this application and ,one mat the above inlatmmiun is
A correct. l agree In Comply with all city and county ordinance, and state laws reningm
',Z building constmnion, and hereby amhorizerepresemddves of city tet enter upon the
uMwe-memiorod propcny for insparmrn pugxtse,.
' d ily a keep hammscre the City of Copartner against
cx may inany way azcrvc against seiJ City
TOTAL:
THAI DING FEE
QTY. MECHANICAL PERMIT f'Eli
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR AUUTO MECH.
PLUMHING FEE
rnhich
Ins of t.'AM D WILL COMPLY WIT II ACI, NON, POINT
)H.
W
AIR HANDLING UNI'I'(TO I0.x)0CFM)
MIiCIIANICAI. ITE
AIR HANDLING UNIT (OVER 10.000CPM)
CONSFRUCIONTAX
EXHAUSTHOODIW/DUCT)
HOUSING MITIGATION FFF
S roof Applicam/Copowtor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the upplieun jointure building astern, store or hondlehauWous mantled
as delinal by file CupninU Municipal Code, Chapter 9.12, anti the houlth and Safety
HEATING UNIT(TO 100.000 IFFU)
HEA:rING UNIT (OVER 100JRX) BTU)
Chic, Section 25532(0)!
❑Ycx R17”
7C
PAID
Dam Receipt N
VENTILATION FAN(SINGLE RES
Will the applicant or future building occupant use ryuipoem or devices which
nit hexa ti air cnmaminants u, dlfined by me Hoy Area Air Qu,fity Management
BOILER- COMP(3HPOE Ia0.g0)BTU)
TOTAL:
• ,
Ii(11hI:.R-COMPOVER ItID1001BTU)
)IstriuR
ye, 7y�(/
AIR CONDD'IONER
ISSUANCE DATE
ISSUED HY
1 havt re char ., n m' , equircmenu under LTOPtCf 6 95 of the Cali-
arty t 2 05, 25597 and 25534. 1 undcrsland that if the
fon a Heads] Sc
mi ingd 11 cc Idhal if is mY mspon,ihiliry mntnify acupm
rcqu em u t to unceafaCertil Enzd ¢i on i
e w
NI?W RBSIDE N'I'IAI. MECII.
TO'I'AI,:
Owner m inu m led agent Umc
OFFICE