99080027 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CJTY OF C,UPERTINO BUILDING-ELECTRICAL.
BUILDING DIVISION APPLICATIONMERMIT PLOVER NG-MECHANICAL.
, BUILDING PROJECT IDENTIFICATION
BUILDINOADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
e, GA 3 , �f
OWERS AME: I/ PHONE' CO HA, H'S NA :: LIC NO:
� L,Na✓��I/! / �„� ,�/ NAC COMROLN
CHI]EC'UHNGINEER: LIC NO: ADDRE&: ^ ❑
CD TACT: PHONE: -BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME H
❑ C� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I I �, �
QTY.' ELECTRIC-PERMIT FEE
1 nerenr arfirm hal 1 am ncenxea under pmvhmna r,r chapter 9 mnmmenehs .. !1 POR DESCRIPTION
WOO with Seainn] 00)o(Divisian3 of the Business and Prnfcssia odea dmylicenu is / RESIDENTIAL
f-ty� in full force and enact. C PERMIT ISSUANCE ❑SMWL ❑KITCHEN REMODEL
�Upp License Cln,.. Lick gl'I'LIANCIiS-RESIDENTIAL [I ADDITION El PLUMBING RE-PIPE,
Qa Date Cnntmetn
ARCHITECTS DECLA N ❑MULM-UNIT ❑STRUCTURAL
Z O VZ I understand my plata shall themed as public records PANELS MODIFICATION
UP'102W AMPS
E-��R1 Licensed Rtlessional ❑INTERIOR El CHIMNEY REPAIR
201-JOWAMPS IMPROVEMENT SWIMMING POOLS
st C papl1 Q 1 hereby affirm h��am exeER mpt LfroDECLARATION
he Contra tar's License Lax'for the OVER 10(I(IAMPS ❑BATH REMODE PAIR El DEMOLITION
Yp$, L Ufollowing rcusoo.(Sell..70315,Puxinesa unit Pm[esslnn,Codn Any city nr mmn'Y SIGNS ELP,CI'RICAL ❑OTHER
tL 31y
F. which requires a Perim,to construct,alter,improve,demolish,m repair any somme, D
1'LLOJ prior to its isauance,also requires the applicant forsuch permit to file aligned statement SPECIAL CIRCUITIM ISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chnpter9
�Qp (anarearng with Section 7000)of Di ininu9of the B-inesnand Pmfossion,Cmla)m TEMP.METER OR POLE I NST.
a a e m Ihm he is exempt hemfrom anJ the hosts for the nllegcJ exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by any applicant for a pennilsubjeniffic applicantm.civil Nmmhym POWER DEVICES
of more shun five handmd dollars(S500).
El TENANT ❑FOOD SERVICE
Cy d I,esnwncrnrho....en,orn ,Ince,with wages us their-xolerom lion, SWIMMING POOL ELECTRIC IMPROVEMENT
22 0 ❑ , g YwrP Y' b Paola Cl OTHER
p., will Pmfeggido the mk,and the he Co c is tors License Law offered of a ply to an Business
�3 m and chy he
b Code:The v,,theory License Law dyes not apply s if owner of OUTLETS-SWITCHES-FIXTURIS
property who builds or improves thereon,and who Boca such work himself or through
provided hal such improvements nl' For Nf?W ftfSID13N'TIAL ELECTH SQ[T.
his own oveseea,pnrvi pnwomen s arc not intended or [cred
ealelfh aer,leve th ng or'mp amen Id withincyear ildori prove ion,he 99 I.FLOQR'ARI?
pu6 Id Ilk the brdc Imagingfthat hdid tbu lit or improve for par - �U
ce s , TOTAL: AUG 4
❑I a. th f th Sep property. 'v ly Pro i b with licensed conn tams u, I '1(] 9
common thep fx apply]614 B d Professions oho dsor)In.pro Comrocters L - - J 1.7 x�
camuLaw does r such hintsto an ith.cufpmperty whored for mpmves heaComm and QTy PLUMBING PERMIT FEE
who comnmta for such projects with a cnmruanr(,)Iicm,xW pursuam m the Cnnwetors Py hicen.e Low. PERMIT ISSUANCE Py
I am exempt under Sec. ,B&P C for this reason _
ALTER-DRAIN&VENT-WATIiR(EA)
DoVALUATION
lwner m
WOR KHR6 COMPENSATION DECLARATION BACK FLOW PRODUCE DEVICE
I hereby anion under penalty of perjury one of the following inclinations
I have and will maintain a Certificate of Consent o sel f-insure for Workers Compery DRAINS-FLOOR,ROORAREA,COND. STORIES TYPE CONS'IRUCfION
,inion,as provided lin by Section 3]W of ho Lobo,Code,for the pe,mm ame of the
work for which this permit is issued. FIX]V RES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as requital by Section
37W aide labor Code,for the Performance of the work for which this tis issued. GAS-EA.SYSTEM- INC.4 OUTLETS
pe Penn' OCC,GROUP PN
My Worke' Ih rand Pol'mynumbcrmc GAS Z
Carrier: �/'/my`RyY NRSrtl;ttkorriu Policy No,: ✓S ��
`T',ERTTIFICeA7'e/wOaIL'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
s DIVI
('I'bie,cation naW nor ba completed if he permit is fanme hundred Jnlb¢r,($I W) GRFiA$E THAI' BUILDINGSIONMMS-
it,less.) PLANCIIECK Il3tl
I cenifythat in theperformanceofthe workforwhich hispermit is issued,Ishall SF.WEk-SANITARY-STORM EA.206 FT.
not employ any Perron in any runner so as to become subject to the Worker'Compen- ENERGY FEE
,Z ,ohm Law,of California.Dale WATTE
ER HEAR WNNT/
IF.LECTR
Z Applicant GRADING TEE
h NOI'ICE'10 APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS rEM?REATING
a ; become snhjeen o,the Wnrker'.c Compenwlion provisions of the Labor Ctvle,you most SOILS FEE
[31 forre,th comply wiih,a,h ptaxi,ionsnr Phi,perain mil be deemWrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NIiW'RESIDEN'TIAL PLMB. SQ.FT. PAID
U C k]orw which
this pelhete is ed(See.i3N7.Cing agency[nr tho pednmmnce of ReuiptN
0 F the work tiro which this permh is issued(Sea.309],Civ.CJ
V Lenders Name TOTAL:
W Lender,Address TOTAL:
� I verify that 1 have read this application and nwm that the shove infnnnmion is - . i h BUILDING 'E
C) &n l agree to comply with all city and coutuy orditeumes and state laws ralmingm QTY MECHANICAL PERMIT
) Z building construction,and hereby romantic representatives Mhis city to curer upon the - r SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We).green,save,inde unly and keep ham,le,s he Cay oT Chanino uguitnl ELECTRIC FEE
Iiabilitiea,judgmern.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in nsequcn od-g ranting of this permit. PLUMBING FEE
APPLICA r U )ERSTANDS AND WILL CO PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.WO CFM)
MECHANICAL.FEE
SOUR C4 R, L O S.
1AIR HANDLING UNIT(OVER 111,001 CFM) CONSTRUCTION TAX
.� Sign ApplicunV name Date F,XHAUS'I'HOOD(W/DUCq HOUSING MITIGATION FEB
IIAZA 0115 MAT,iIALS DISCLOSURE
Will the applicant or future building occupant store or handle Instructions unsocial HEATING UNIT(TO IIgkWO BTU)
as defined by he Cupcnino Municipal Cod,Chapter 9,12,and the Health..it Safety
Code,Section 255320)? HEATING UNIT(OVER 100,00 DTU)
❑Ycx ❑No VENTILATION FAN(SINGLE RF_SID) PAID
Date Receipt N
Will
applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.000 BTU)
Int haxnninus air
ir contnmminvms as delined by the Bay Area Air Quality ManagementT A Ln
/
District!
❑Yes ❑No BOILER-COMP(OVEIt IW,OMIBTU)
AIR CONDITIONER
I hast eat hmallous mmennls requircmems under Chapter fi.95 of the Cnli ISSUANCE D//A��TE,,,
hmia
He & cry Cade,Section 5505,25533 and 25534.1 under and(hal if the NEW RESIDENTIAL MECH. SQ.P1.
budding ¢u 0y hast coma nit is rcsponsihility to notifytheaecupsom
,fine meta ich rbc met pn not once of a Cemil'ac of Occupancy.
OwnIN.Phruchal., DaleTOTAL: ISSUED BY:
OFFICE