30710APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPESRTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL.
BUILDING PROJECT IDI,-NTIF'ICA'1'HkN
/N O � � O
PERMIT NO. 30710
BUILDIN/G�ADDRESS:
,b Sl VRev
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHO
RA 'SN �''LC
NIC
CaiWROOL4gyp
(//f/fwCvyy''
,67
kRCHITECT/ENGINEER: LIC NO:
ADD ESS: h
CONTACT. PHONE::A
,
C,4
(i
Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
B1,p0 1?CECT PLUMB MECII
'y --pt` `�
LIEF?NSEDCON 'IRd tune SDECLAHAT him
1 hem -by arrnm Nm 1 am Imamned ander proviniam of chapter 9lmmmati' a,
with Secon]tM1U)af Division3afthe tlusincss and Professions Code, and mylittnse is
'oral. force ani
Dote Contrucmr
3 ])are .Class Cont,
QTY EL17CTRIC PERMIT FEF.
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
[]ADDITION [I PLUMBING RF PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR' MOLITION
❑OTHER
PERMITISSUANCE
-
APPLIANCES - IIESIDENI'IAI.
j ARCHITECTS DECLARATION
i l understand myplans shall he mad as public recalls
1
Licensed &nlesxionel
1 OWNER- ceempt RDECLARATION
C 1 hereby s(Rrm that 1 am exempt form the Cont n, Co License Law far the
de profession, Cale: Any city of county
which re moron. (Section ]031 S, Businessandmpr improve, repair any wmanre
j prim requires n permit ca construct, aper, improve, demolish file
reyoime Neappin o far such pmmit toicense Law (Chapter
Chit he its isnsedp pursuant Laon, Code) of
(omm is licensed Sectio nee the provisions ofthet e Emu tors nd Profession,
� (commencing with Seetinn]WB)af Division9nf the Buvincsa and Pmfeasions Code)o,
that he is exempt thcfel'mm and the basis for the alleged exemption Any violation of
Section ]031.5 by any applicant for a permit subjects the applicant o a civil penalty of
out mme than five hundred dollars (S500).
willas ownerof Ne'property, army employees with wages as their socixard un.mtiom,
will do the work, and the structure is not intended or offered liasele (Sec. 70,14, Dadneas
and Professions Code: The Commonest License law does not apply to an owner of
property who builds or improves thereon, and wha does such work himself or through
his own maployeea, provided that such Impmvamems arc not intended or offered for
sale. If,however, the building or improvement is sold within one year of completion, he
owner -builder will have the burden of proving that he did nm build or improve for pur-
0 os cwt).
Las owner of the pmpeny, nm itis. and contracting with licensedIhoCmam¢mrs i-
nswbt Ne project (Sec. ]044, 11usiness and 1'mfessions CodeU'Dm Connemara Li-
censeLaw does act apply manowner ofproperty who buildsorImprover thereon, and
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contractor's
Liars¢ Low.
❑lent exempt under Sea_. B& P C for this mason
PANELS
UP'I'O 21N1 AMPS
201.1000AMPS -
OVER Ifp11AMp5
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISE.
THMP. METER OR POLE INSj'.
GGMMERGIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT [I FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW R17SIDEN'IIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
DEC 2 01996
CH Ur 11Ur"thI INC
S/SQ. Pn
'
- TOTAL.:
Qj-y,- PLIIMBI Mi, FEB
PF,RMij' ISSUANCE.
ALTER- DRAIN & VENT- WA
Owner Dam
VALUATION
/^f'
wOo�/
WOIIKEt CI MPENSATIONDECLARATION
ffi
I hereby arm under penalty of perjury one of the fallowing declamations:�Y
xJ l have add will maintain a Certificate of Consent to sal6insure for Workers Compete-
nntion, as provided for by Section 3100 of the Litan Calc, for the performance of the
Vfor which this permit in ko,cd.
have and will maintain Worker's Compensation Insurance, as requircA by Section
37W of the Latin, Cale, for Ne Perfortmxn ofthe workforwhichthispennitintoied.
My Worker's otpemminnl once ca er vnd Policy numherarc �f
Cnrrler:l1 Palley NO.:�
E CA OP EXE PN INN FROM 4OR,KE�25'
COMPENSATION INSURANCE
(Thin section need not he completed if the permit is before hundred dollars (E IaO)
or lass)
of thebecomewhich this pintrthe W isissued,Compel.
Loy any Natinthe pea-ftomany
not employ any person in any manner see m m become subject m the Workers' Campen-
action Laws of California. Dam
Applicant
BACK VLOWPROTECT.DI;VICC
DRAINS- FLOOR, RODE, AREA, CORD.
STORIESTYPECONSTRUCTION
- •
FIXTURES -PIR TRAP
GAS-EA.SYSTEM-IINC.40UTLETS
OCC. GROUP
APN
GAS - EA. SVS'fP.M-0VER4(BA)
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
_
OREASETRAP
PLANCHIiCK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY PEE ,
WAI BE HEADER WNENTMITCTR
GRADING FEE
NOTICE TO APPLICANT. If, after making Nis Cenificme of Exemption, you should
became suhp,O torte Workers Compensation pravismm of the labor Code, you most
forthwith comply with such provisions or this Fermitsholl he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there i.voconstrunion lending agency fur Ne performance of
the work for which this permit is tasted (Sec, 3097, Civ. Cd
Landers Name
WATER SYS'I [IMOREATING
SOILS PER
WATIiR SERVICE
PAID
- Date Receipt#
NEW RESIDENTIAL PLMII, SQ. Fr.
TOTAL:
1<nderI A
TOTALcro:
ally t
1 ceni(e that I have read thirty and
nate that the starve lawsrelmia, is
rec0lagrcetocoinply with all cityand amntyordinmsof and city toentrupon the 1.
buildingconstruction,pm,m herebymnhonprposes.mvdves of thiscity to corer upon the
abase -mentioned to save for inspection keep h.a'
(We) agree m save, indemnify end trop harmless the City of Cupeninn against
Iiabilitiea,judgmem..cord and expcmcs which may in any wayoccmcagainnt,aid City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
\¢nnTi'untracLt=or CLQ
BUILDING FEE
e
SEISMIC FRP.
QTY MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ELECTRIC FEE ,
ALTER OR ADD TO MECII.
PLUMBING FEE
qlk HANDLING UNIT (TO Ig000 CPM)
MECHANICAL FEE
AIR HANDLINGUNIT(OVER 10,000CF1,O)
CONSTRUCTION
CONSTRUCTION TAX
NTAXNFEE
S re of Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfrtme building occupant store or handle hmaardous maeflal
as defined by the Calendar, Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 255326a)]
r-1 Yes C1 No
or
Will the applicantinfnts asure building occupant use equipmentor Management
el hazallous air contaminants an define) by the Bay Arca Air Quality Managmnem
�Istri0t7
❑Yax Fl No
1 have read Ne bmardous materials to under Chapter 6.95 of the Cali-
requirements Z533a p
folia Health & Safety Cale. Sabana 25505, isa y and 25534. I I lifand Nut if the
buildingpmenot ,a,hicyhave. tummy thath in my is,of. biitytoeofythen.., t
of Ne teluiremm�ta which mon he ten prim nt issuance of u Cenifcme of Occulnncy.
EXHAUST HOOD(WMUCI)
•HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Dace, Receipt#
VENTILATIONFAN(SINGLERESID)
BOILER—COMPORPOR 100,000BTU)
TOTAL:
BOILER - COMP(OVF,R IINLOW B'fU)
AIR CONDITIONER
ISSUANCE DATE
,
ISSUED BY:
NEW RESIDENTIAL MI CH. SQ. ET.
Owner or authonzed agent Dote
TOTAL:
OFFICE