B 0475APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPF.RTINO flU11.BING- ELECIMECH'N ICACAL
EIJILDINGI)ERTIVISION AI'PLICATION/PF.RMIT PLUM1iHING-MECIIANICAL
111111,DING 1'1lOJECT I1)iiN'rll'ICATION
PERMIT N<� 0 475
SOOOI
BUILDING ADDRESS:
20 330 `_SkCYrnS Qlv C f"/n0^
SANITARY NO,
APPLICATION SU13NII TAI. DAT[
y
�A
NER'S NAME: 'ar.P({I[)Nf?',
/
it E /EN INEEU,/In J.� I.ICT'O�
1l'T
CO TR LT R'S N 8' 1LIC ND:
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CON 'IWC'C PHONE:
RU .DING PERMIT INFO
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•A��n' �i�C 41 5) J f71 � 1004
A • ,IC J -�1
❑ Cunsuhanl Fees Paid by Applicant (Initial)
BLIH' IiL[C'1' I'hIJMR MECH
F-1❑ ❑
LICENSED CONTRACTORS DF.CLARA'1'ION
I hereby amrttt mat I am u[cnxw under provisions orChapter 9 (a+mnleI IF
with Sedion]INgll ofGivision3afhe Rosiness and Profession. CnJe, and my license is
in lull force and effect.
License Cloys Lica
Dam Contractor
Q'PY. ELECTRIC PERMIT FEE
JOB DESCRIP'T'ION
RESIDENTIAL:
❑SFDWI, ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RF -PIPE
[_10111;1'1 -UNIT ❑ MODIFI UIdAI.
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
C BAI H REMODELIREPAIR ❑ Df3M01.IT1pN
DOSSIER
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PERMI F ISSUANCE
APPLIANCES-RESID17ME SAL
ARCS I I'1'EC'I'S DECLARATION
1 undersmnd my plans shall M1c used as puhl is records
PANELS
UP To 210 AMPS
Licensed Profession.)
OWNER -BUILDER DECLARATION
I hereby III! flum I n1n cscmpl front She Conira[nn'e License Law for the
following reason. (Section 7031.5. Business cal Professions Cale: Any city or [oanly
whi[h ¢yvims a permit m uimwn, alma improve, demolish, or repair nny statement
he incense imostunatto thm. e for Contromtiuofile a iccnw awJaamment
that he is licensed pursnam In the provisions of the Comracmr's License LvIt (Chupmr9
that
(c ... a ingwith Smlian]fglaJ of Ulvinon Jnl the llusincasnnA Mof...IsC, ed.
that he is exempt therefrom and the hasis far he alleged exemption. Any vinlul it of
Section 10114 by nny applicant far a permit subjects the npplilam m a civil penally of
not mom than Eve hundred dollars 6510).
Los owner of the property.nnny employees with wages as their sole n+Snlansmian,
Jo mextrucmre is Intended or offered finial. (Sec. 70,14,13 uses,
1111-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR 1101.17 INST.
COMMERCIAL:
❑ NEW BLDGIADD I' I' ION ❑ DI3MOLITION
[ X4ffTXNT ❑ FOOD SERVICE
IMPROVEMENT
❑ 0911 ER
POWER )WICES
SWIMMING POOL ELECTRIC
OUTI,H'LS- SWITCI TES -FIXTURES
LL 3
will mo work, and not
and Prof omnis Code: The Contractor's License low does not apply to an owner of
bulls. or improves thereon, trod who does such wnrk himself nr through
1
property who
his awn employees, provided that are aS such impruvcmennot intended or offered for
sale. IL however. the building or improvement issnld within one yea of completion, the
NEW RLSID AL IiLIiCfR SQ FT.
•�
S _PItPy(1{)H AHA r
D
S/SQ. FT.
ar-
ower-hudder will have the harden of proving thin he did not hui III or improve for par-
Doesale').
11, as owner of she property, um exclusively contracting with licensed commuors n+
II
MAY 0 4 1999
TOTAL:
construct She project (Sec. 1044, Husiness and I'ndec ions Call The Commcmrs Li-
se Law does not apply to an owner of property who builds or improves memn t. and
1
I;
'
QTY. PLUMHI JIT FEE
-
netsfor such projects with a rmaracmr(s) licensed parsnun to the Conrealm's
who cmm
License Law.
❑ I ma exempt under Sec. ,11 & P C far this recon
1�
u V
PERM] L ISSUANCE
ALTER - GRAIN & VENT- '
VALUATION
2V D P1 L'�
Owner Date
WORKER'Stoth,p CON Pf ON DECLARATION
SACK PLOW PR(yfT:C'I'.D ICII
Ferny
I hendwill lirmnamitcanvltyorlefcoyanc.self-ntire
CE IBJ
awalurminn.v.
(have and will m,inmina Cenifcate of Cnnunt In self -insure for Worker's Compen-
sminn, ax provided fur by Section 11(0 of the IyMr Cada fur the perfnrmunce nl me
work fur which his permit is issued
DRAINS -FLOOR, HOOP, F: O D.
STORIES
TYPE CONS'I'RIICTIOP
FIXTURES -PER TRAP to
1 have and will maimsin Wndcr's Cmapensution Boma ce, as required by Section
37101 of the Labor Cade. forthe perfnnpa�rd. of the work for which this pcpal(i, .sued.
ROUP
!/
AI'N
GAS - HA. SYSTEM -I INC. 4011TI,IT[S
My Warkd'IXpgInI ON aPniky'Noy a t XKr 2 o
canis,: 1 __SS
GAS- EA.SYSTEM OVERJ(EA)
`�
3
GRF,ASIJINDUSTHh WAS'1'F.INTEItCIiI'TOH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
This section need not be conmleted lite hpermit is for one hundred doll ars 6100)
or less.) This
Icenifythm m 0saperfnrrtanem'do work 4trwhichthispermani.suad, lshall
not employ any Person in any manner so as to besubject come subjeco the Worker. Compen-
GREASE'I'RAP
FEE
ENERGY FEE
SEWER -SANITARY -STORM EA. 200 FT.
WATER I IHATP,R WIVFNT/ELECI'IR
WATER SYS 'I EM/IRHATING
,7.
Z
Z «-0
Fx
0
z
V 0
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Lr TA
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.unman laSws of QJiOnni,. Dia
Applicant 1
NODCE TO APPLICANT: IL after making this Cenif[am of I?aemption, you should
Sheatme subject o the Workers Compensation Provisions of the labor Cada Imm must
forthwith comply with such provisions or this permit shall She deemed revoked.
CONSTNUC'1[ON LENDING AGENCY
he mit i is a co (Site 30 lending agency for the performance of
Iherebyfwhich
the work for which his permit is issue) (Sec. JIYd1, Civ. C.)
IsnJer'n Name
GRADING TEE
So11S FEY
WATER SERVICE
PAID m Remila
SSA
NEW HhSIDF.Nt'IAI. I'LMN. SQ. FI'.
TOTAL
TOTAL:
Lcndcr's Address
i certify 'I'm I have read this appli[aninu and state that the above Information is
nnrect.l agree bS comply with all tiny and county otdinarm,lindmme lnwe mlainglo
building constmnion, and Barclay authorize representatives of this city to enter upon the
BUILD G FEE
Ilef
QTY. MECHANICAL PF,RMIT FEF.
SEI 11CFEE Z
PERMI"I' ISSUANCE.t
EL; 'BIC FEE
uMrve-mentioned property far inspection purposes.
(We) agrcc lo.or e, indemnify and keep harmless the City of Cupenlno agains
ALTIRDRADDTOMEDE0
LUMB G FEE
Ilabildw,,jahcorou, costs and cxparmeswhlcblnny'many wayvumeagait,l,md City
inamsegenf thegrantingSpermit.
AIR HANDLING ON]'[- la,(I(kl CPhfl
MECIIAN AL FEE
AI'PLIC U 4.YI' UNRSTANDDS AND WILL COMPLY WITH ALL NON -POINT
SOUR - EGULA5TIjj�(�IN�kSC.
AIR HANDLING UNIT (OVER WALL CFM)
CONSTRU TION TAX
w (ICI
j' n„V 5144411
II` ^^^lll J T' I_
Signs ore ofppplicnHAZAR O Dom
ion
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (WIDIICI)
HOUSING MITIGATION ITE
BEATING UNIT (TO IpI,(%O BTU)
a
Will the applicam or fwure building eecupam score or handle hazanlous material
us defined by Cupcninn Municip:J Code, ChSmmr 9.12, roil She Heahh and Svfeny
CnCod,,,11 Section 255J2(u)'!
HEATING UNIT (OVER IlN),00013'flll
VENTILATION FAN (SINGLE RESIDI
Dyes FI No
PAID
Date ece'la X
BOILER-COMP(JHPOR 100,(00BTU)
I
Will the applicant orfurore building byoccupant Buseequipmentofdeviceswhichemmt
emit huevNaus sir cnnmminuma nn Jefned by the Bay Area Air Quality Munvgmnem
BOILER -COMP (OVEN IOg000 ETU)
Districl'I
❑Yes 7 N
AIR CONDITIONER
I have real Be hicodnus materials reyuimmems under ChapmriS95ofhe Cali-
ISSUANCEDATE
NEW RESIDENTIAL. MECU SQ. FT,
form, Health & Salal,,Code, Sadons 2505, 25533 and 25.5.}1. I undersmnd that if he
building Jnee a ntlyhave nucnml, Shut in is my res mi ility mnotify thmwcupam
oghe rildi un be no prions issay,, 'metfy the canafv
LJ
(7
�` T
ISSUES) BY:
TOTAL:
Owner or marvel agent Date
OFFICE