S 1936 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELE(a'RICAL PCPs f NO, 1936
BUILDING DIVISION APPLICATION/PERMIT PLUMRINO MECHANICAL l`J
BUILDING PROJECT'IDI?NI'IFICADON
BUILDING ADDR SS: X SANITARY NO. 7AjPTLICAI ON SUBMITTAL DATEn2 O WPs �cr r -q- 7 -g
NAME; PHONE: C IOR'.q NAME: LIC NO:
r• -q 1 A_ NIC CONI'HOLX
a ARCHI'I EMPEN(INEER: LIC NO: ADDRESS: / 4„' 711:7 ❑
'ssq LFI 4. Cv r. -fl S-F `f
CONTACT': PHONE: HUII.UINC PERMIT INFO
112
f -�� ❑ Consultant Fees Paid by Applicant(Initial) BLDC TiuiCT/ PLU❑Mx ME❑CIi
(CENSE ,CON IAACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hreny is fm.mal 1 am licensed undr prods,e,or chapter 9 fn()...ananeirg JOB DESCRIPTION
pazwhh Section7AXI)idDivi.lon3()Dhe Business and Pr()I'esxi()n Coda and any license is � � s5"O RESIDENTIAL:
'00 PERMIT ISSUANCE�W- in full force andcfRa ❑SFDWI. ❑KITCHEN REMODEL
Circa
Cls La
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIE-PIPIT
i-Q Ww Date Court
ARC]11*1 ECT'S DECLARATION [I MULTI-UNIT ❑STRUCURAL
F-D w PANELS MODIFICATION
z py a
I undcmnd my plan,hall ba used as punlit record,
p Z%JO UPTO200AMPS A{pi'�IOR El Cl IIMNEY REPAIR
F�1=W Licensed Pr..lLS
' ar
esetd 201-1000AMPS IMPROVEM17NT SWIMMING POO
�y�j OWNER-BUILDER DECLARATIONOYER IIXIOAMPS ❑IIATH REMODF.I/REPAIR ❑DEMOLITION
o C 6 I hereby aRmo that 1 am exempt from the Comments,License Law for the
3 LL FU- following reams.(Section 7031.5.Rosiness and Professions Cede:Any city al county SIGNS ELECTRICAL ❑OTHER
Lz. hich y permit t e n Tru T h r p r Y.I Imre
X�O hath licensed p stra the prvrrluc m'I ` hpc nlslLicenseLaw g I(Chtpter9 SI'IiCTAL CINCIIIT/MISC.
W 00 (cemmencingwth Section IINNOolDivision 3ofibe Br.nes,and Pndessons Code)or 'PUMP.ME PER OR POLE INS'P. COMMERCIAL:
6 a py Ibut he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION E]DEMOLITION
W^N Seemn 7031.5hysny applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
t mom Than five hundred dollars 05(10). ❑TENANT [I FOOD SERVICE.
F C ❑ I,as owner of the pmpeny,nnny employees with wages as theirseleennipenution, SWIMMING POOL FLE(TRIC IMPROVEMENT
will do the work,and the suclum N nor intended or olrcred for sale(Sec.70,44,Business ❑O'fHER
and Professions Gale:The Cnnlrunor's License Low does not apply In an()want of OUTLETS-SWI'I'CI IES-FIX'I OWES
6'3^ property who hailds or improve,threat,and who does such work himself or mmugh
his own employees,provided cent such improvements me n.l intended m offered for NEW RESIDENTIAL ELECTR SQ E'.
sale.EL hownxr.the building.,improvement is sold within one yearof comn pletiothe SQ.FT.FLOOR AREA 5/SQ.TE
er-haildcr,will bate the hoiden of proving that he did nm build or improve for Par-
Ivan
of snlc.l.
❑ L a,o oun of Ih.pmpeny,arta exclusively conducting with liumsed....auctions(11 I"
construct tiro project(.Sec 7rna,Business and Pioruselan,Coda)Tho Can....tar's Li-
cause Law does not apply to an owner of property who holds or improve%thereon,and gry.. PLUMBING PERMIT FEE
who comrade for such projects with a enmmemrts)licetned pursuant to the Comreamh
Creative Law. PERMIT ISSUANCE
l am exempt under sec. ,B&P C for this reason
Owner Dale &
ALTER-DRAIN VENT-WATIiR sp VALUATION
�/ O
Wm under
SCOMPENSATION DECLARATION BACK ROW I'R(YTF:CT.DF,VICIi l
I hand w affirm under penalty operjury one of the following dation',.Co:
❑on.as and Provll ided
for
SectioCertifiable 7Mif theedll.ulf-in sure for performance
of the
DRAINS-IROOR,ROOF,AREA,COND. STORIES '1'YPIiCONSTRUCTION
nation.f as provided for by Section 3?fN)of the In Md Calc,for the prtormance of the
work hit which this permit is issued. PI%(DRGs-PER TRAP
❑ 1 have and will nminmin Worker',Cumpenanin i Insurance,as required by Sccti.n
3900 til the ladinr Crede,for The parfurmunne.lube work limwhich thin pernail is icued. GAS-EA.SYSFUM-I INCAORY1'1.1 OCC GHOUL' APN
My Worker's Conlpensmion Lrsnrxace carrier and Policy number oro:
Carrier: Policy No.: CAS-EA,SYS'f1iM.OVER J(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSI%INUI1S1R1.WASTE INTERCEPTORCOMPENSAHON INSURANCE OR DIVISION PUBS
(Thi,,reindneed not bccnmplcnd Pilot rmi
pet is fortune hundred doll...(SIM) GREASETRAI'
,it leve) P NCIiPAKITTi
Iccnifymal is the perruniance or hework fmwblch this peeNl is lsvaed,l shall SEWER-SANI'LARY-STORM ITA,2INIPP. X-�
I employ nal rein any manner sa nthr� M1je.uo the Wnrkc,,Compere- ENERGY F17E 3-` 'V
z ,,fan Law,,jjyyyF�j�11""��'1 r,}ys,. �,Ly MU
zO Applicam `a n �- WATER HEATER W/VENT/EI,I:CTN GRADING FISH 1 1A
N NOTICE A PIT ICANT:If,after making this Canifcme of Exemption,you should WATER SYS ItMP RHATING
F bmome euhje'l To the Warkols C...nNosmion ranonions of the Labor Cock,you most SOILS FEE
fa fonhwithc.mply with such provirians er this permit dell bndeamed revoked. WATER SERVICH
d
CONS'1'HUC'fION LENDING AGENCY NEW RUSIUEN'TIAI.PLMH. SQ.PC PAID
Z I hereby affirm that There is a construction lending agency for the Performance of Dat ReceiplX
U
U O the work far which this permit is issued(Sec.3097
.Civ,C)
0 E-aLender's Name TOTAL:
U Lender's Adder TOTAL:
�-a a
[rI unify Thin have read This uPPlicudon and nmm Ihat the,hove infnrnmtion is BUILDING FHT'
to
scatter It".to comply%ahnll city and county ordinances and state haws rotating to QTY. MECHANICAL PERMIT FEE Q
U z building cnnswmion,and hercM1y awhonzerepresenmtivu til mix city nunuir upon the SEISMIC FF.F. '0
above-mentioned property for inspection purposes. PERMIT ISSUANCE (/�
(We)agree to save,indedmify and keep handless the City of Cuper inn against ELE C s 7-
Imbibaies,juJgmeats,coslsanJ expenses which nary loony way secure againm.wid City AINER OR ADD TO MECH.
in asequence of The granting of tbi.s permit. PLUMBING F
APPLI 1'❑NDIIRSTANDS AND WILL COMPLY WITH ALL NON-POINT ALIT HANDLING UNIT(10 R1,Qy)CPM)
SOUR IEGUIXTIONS MEC LPUE: s,J
6?j& 9 AIR HANDLING UNIT(OVER 10.1MMI CFM) CON,TRUCION'TAX,
Sighoune lifAp ' nVCommctor true RXHA US'I'I 100D OVIDUCT) HOUSINti ITIGAl 10N FEE
HAZARDOUS MATERIALS DISCLOSURE -
WIIImeapplicatit or future huildingreciponl suite or handle hmualmn material ORATING UNI'f(TO❑10,(0()BTID
as defined by the Criterion Mirrici al Code,Chapter 1).12,an I The ITudth mm Safety
Cale,Seclion 25592(.)? 1IHATING UNIT(OVER I(group It'IU)
E)yes VENTILATION IAN(SINGLE RECID) PAID
Date ReceiplX
Will the applicant or future building macupanl use equipment or devices which
and hazardam sir contaminants s defined by the Bay Area Air Quality Management BOILER-COME'ChHP OR 1 W,rXN)B'ru)
District?
❑Y.s kfNn BOILER-COM 11(OV UR I train ITT]])
I have uiad the hazardous nmterims reyuiremems under Chapter 6,95 of The Cali- AIR CONDITIONER ISSUANCE DATE.
brain Health&Safety Code.Sections 25505,8533 and 25534.T understood that if the NEW RESIDINUAI.MECH. SQ.PT.
build does not currently ea a tenant,that it is my rupmsibiToylon if Ibe upon (� o
of l I mems whit oust he met nor to isspanca of a Cenifca kgu/1: c
Owner raudar agent C/DOOW TOTAL: ISSUED BY: —"(+
OFFICE