S 3356 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEBTINO Bljll,DING-RLE.C'FRICAL 1 H�ITN°. 3356
BUILDING DIVISION APPLICATION/PRRMIT PLUM NG-MECHANICAL
BUILDING PROJE,CIIDENI'IF'ICA'I'IIN
BUILDINGADURESS SANITARY NO. APPLICS110N S1111h11'ITAL DAPI,
)WNER;S NAMI7: PHONE: CONI' ACIP 'S NAM 1
NIC CON gItULM
I' :CT/H :INlHHR' LIC NO: AORE.S'. •�I7• ❑
CU '1'n C PUONE: HLI DING PERMIT INFO
. // copy
❑ Cunsultanl Fees Paid by Applicant(Initial) 13 E1.13a] PLUMB MECH
�Ls co ❑ ❑ ❑
LICENSED CONTRACT ORIS DECLAkATION QTY ELECTRICPERMIT FEE
1 thereby affect Chat 1 ma fcereed trader pevkrm ioof chapter 9(emnmend^g JOB DESCRI VRON
A 0.O Z with Seernn 9aro)of U vi-se 3 al he it ine,s aml11f.ian,Code,n^d,ay license ix RESIDENTIAL
W O PliliMl'I'ISSUANCIi
�U� infull
ccl.and effect. 3 ❑ADDITI ❑PLUNIHINNRMODIih
aVU License Cla,s 1.i<.N APPLIANCCS-RESIDEM'IAI. ❑ADDITION ❑PLUAIHING RI PIPIT
QD:,Ie Cnnl,unCar
�m tCHITECICS UI!CLARATION PANIiLS ❑Ml1Cl'I-UNIT ❑SI HUCI URAL
F-,n Z I un craun m I h ll be used as public records MODIFICAI ION
O�
y P war,a UP 10200 AMPS
(]INTERIOR ❑CHIMNEY REPAIR
Lice.,wal Professional 201-1000AMPS IMPROVEMENT C]SWIMMING FOOLS
�� � OWNER-BUILDER DECLARATION OVER IfXOAMP$ ❑HA'I'R kCMOUEfJRIiI'AIR (]DEMOLITION
C 6 I hereby olfinn that I ani auntpt Iron the Cantrosm.rs License Low far me
'La(�i V following reason.(Section]031.5.Boniness and Professions Code Any city or county SIGNS ELECT RICAI. ❑(Yf IHR
u13 U.i¢- which requires a perms to construct.vier,improve.demolish,or repair any sauc um
prior ta itsalso 4 to IPI 1,intfill 11 fernal II III le a signed.IminentSPIC I A L C I RCUI'1/MISC.
that he i0wervedp a It the anwision,ofth Cart L : Lme(Chapter9
Wa00 lcommenc n6 with S<e,na 7")ofDivision 3o1"The BnnesvdProfession,Cedc)or TCMP.MITER OR POLE INSr COM
FR 1 1:
L y a y that he in exempt Iherelim^and the basis for the alleged e,wri ion.Any violation of ❑NEW HLDG/ADDI'T'ION ❑DF:MULI'fION
XLL�4y Section 70315 by any applicant fir,a Permit subjects the applicv^no a roil penally of POWER DEVICES ElTENANT El SCRVICE
not more than five hundred dollen(5500). IMPROVGIHNl'
DLm owner of the prvpeny.or my employers with wages as mcirsolecompe^smion. SWIMMING 1
F'1=.� wi11d^the wank,and mcamenue is mr memedondfemd far,ale(vsies
i70,14,Ren , ❑aft lliN
13 m and Professions Code The Contractors License law does not apply m an mother of OU'11.ISf5-tiWITC111S-Irl%'1' RIS
properly who builds or improves thereon,and who docs such work himself or through
his awn employees,provided Ihm such Intproveamuls am mol intended or inhered Tim NEW BESIDES PIAL ELECI'R SV b
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ,F-C FLOOR AREA $/%Er.
"buiWcr,will h ivc the nnnlcn of proving that he did net build or improve for put.
'oeol
❑ 1,as owner of the pr,pcny an exclusively connecting with licensed comrucmm to
msl mel the preject,ply our Itusincsnroddywhsinas Cad....po C,Illem dxLi-
selawdaasnm:TPlyloan with
eof Papery whosedporhnpnncs Contra.und Q'I'Y, PI,UMI3ING PI3RMI' FEIi
who common for such pmjttts with a nmmnnortO licensed Punuanl m the Contractor's
License law. PIiR MIT ISSUANCE
❑Iver cxcmpt under tis. ,It&P Cfanii....no
\CI'ER-GRAIN&VENT- AT' Is VALUA'T'ION
Dam
/]
W'ORKIiR;S COMPIiNSN'ION UECLAItAIION BACK PLUW I'kO11iCT.DIi17 V ICIi ij�O QO�
1 hereby atliem under penally of Perjury one of IM following declarations: Y
Ih:wcand will maintain aCenlficmcof Consem to self insure lin Wader's Compen- DRAINS-FLOOR.ROOCAREA.CoNO. STORIES TYPE CONS'IAUCI'[ON
cation,os provided tar by Section 371X1 it the lahor Code,for the perfonaunce nt tn,
zwork for whielt This malo.issued. FIXTURES-PER'FRAP
I hove and will malmain Worker's Compensation Insurance,as required by Section
39(Xlof the laMtr Code,for the perlonnareef the work for whmlidn'Pcrnti t.,theft. OAS-FA.SYS'I'EM-1 INC.4OU'FLI;1;S OCG GROUT' AIN
MYWo ��1(X�In' cr and folic" t GAS-HA.tiYSTLM-0VF.R4(EA)
Carrier C C Wiry No..
71e,orp'loyany
CERTIIHCATli )P EXT: I'l'IONIRUM WUkKr:RS GREASP%INDUS"rRLWAS'IEIN'I'FRCI?PIOIt02. COMPeSA'1IONINSURANCH BUILDING DIVISION VEM
(Da-,eioanced anhecomplredBum,permit i%krn^chundreddolla GO00) CREAM:IRAI'vs1'LANCIIECKIIJi 3 0
I cenlly that in the permmene wChc work for which thispere iiis issued,Inhall SEWER-SANITARY-STORM EA.210 Fr.l't'rsnninnnymunnersoustobtiamesuhjeclmtheWorker,'Continent- ENERGY Sr 20
Z codon Law'xof Cairn niit Owe WAI'FR HEATER WAVE NIiLliC 1'It GRADING FEE
Z O Applicant
NOTICH TO APPLICANT:If,after making this Cediftcale of Iixemption,you should WAI ER SYS"1'FM/1'RHAT
H h SOILS FIE
heconic ubni'cetat ic Woker's Coiisiann ofthe Labor Code you nnut
forthwith comply with such provisions orchis pearnilshal he deemeJrcsokeL
WN!12R SERVICE)
.L CONS'1'RUC'f10N LENUINOAOI!NCY NEW RF,SIDENTPAI PLMB. S B LAID
UO I hereby affirm that there is a construction lending agency for the Performance of J �-Xf1 G .. Dam RccciptM
the work for which this permit is ismcd(Sec.30G.Civ.C.) \IGv 4
OUheader',Nome TOTAL:
Lender's Address ` 'I'OT'A L:
1 cervi I Ina,I have mai this npplicmion end,,are then the above information iv BUIL 1
Vl correct. agnea mso.tq,ly aim nu sty and mumy onlinunccs nnJ cath laws rcladngm QTY. ME CI NICAI,PERMI FCC
U z nuilJing mnumaion.and hereby umhori'sereprcxenmtives of mi,city to ether ulsm the SES P o O
above-mcmiumd pmfaif^r imfec,ion purposes. PERMIT ISSUANC ELEC plili
(Wc)agree m all.indmnnily unI keep nartnlesx the City u(Cc,.,ao 1,un l
habil'nictijwlgreci ensu and cspemes which may in any way accmc against said City AiA ITR OR ADD'IU MECII. It. GI]
in nw,ucncc af,Ite gramin,of This permit s
APPLICANT UNDERSTANDS AND WILL COMPLY WI 111 ALL NON-POINT Alit HANDLING UNI'I'(To 111,(0X1 CFM) MECIIANICAI.IPE
SOURCE R1iG TUNS ) '
/�/�Q� fs AIR HANDLING UNIT(OVER I(hIMM1 CFM) CONSI'R PION TAX
Signummof Applicv factor I, v�14])am HXHAUS'f 11000(VTUCI) HOUSING M IGA'1'I(IN FEE
HAZARDOUS MAITRIAI S DISCLOSURE
Wi11the nppllni I of Entire building occupant uorc or handle hawardaus material IL17ATINC,UNIT(10100,M)BTU)
as defined by the Cul<ni^n Municipal Cod,.Chapter 9.12,and the I1ea11h and Safety
Godo.Section 25532(v)" HEATING UNIT(OVER Ian ago BIG)
E3 Yes No VI!N'I'I IA'1'ION FA N(SINGLE RHS IU) PAID
Date ,Receipt%
III the applicant or future building occupant me"apmem of devices which COMP(dTTP OR 100.000 P'I'U)
utcit hwnnlnus air aunwmi nom,as Jclined by tire BOILER-
e Bay Arca Air Quality Management
District! BOILER-COMP(OVER IBlLWO B'I LB
❑Yes Fl No
At It CONDI UON HR ISSUANCE DAI E
I have recti err hvsardnus nuncrinls rcyuircntcnu ander Chi(s05 of the Ceti-
fnmia Health&Safety Cole,Sections 23505,25533 end 25534.1 undersand that if me NEW RI MDHNTI AL MECl1. SQ.PC
hulld'mg Auer not curved,have u mna th that it is my msl,ansi hili,y,o nastily the occupant V
of the ma,du menu which mu.a Centel it In Issuance of v Ceniliczm of(V eafrare. ll
Ownenn uuthnn/W upen, Wit, I(YEA I,: ISSUED BY:
OFFICE
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