S 0179 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I-UILDINQADDJUESS�
ITY nP CUPF:RTINO BUILDING-ELEC'I'RIC.A I. I'I!RMI'I'No.
CAL
BUILDING DIVISION APPLICATIONITERMIT TING PROJECT WENT B,ic n1 7q
nuaomr,raoJ4:cn'u)e1rrlFlcn'nory
IO7Aj, &)04� , O SANITARY ND. AI'I'1.{C20S'UHhtiTTAL DATE
�NE^(OfN M/E: PHONE: ACTOR'S NAME: L �O N/C 6 CONTROL#
•ARCfI 1TiCT/ENGINHER: LIC NO: AD R S �'SG'-��yIQ �- ❑
r7:;
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IAJ[CI' PLUMB MECH
❑ ❑ ❑
LICENSE CON TRACfOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
anti bcen.ed under provisionsof Chapter9(emmneneins JOH DBSCKIPTION
�aZ Ih Scctlon 7lNXqnlOivision 3 ofine Business and Pmtcssions Code.and IuYncensclx RESIDENTIAL
n PERMIT ISSUANCE
ILL- wfull liacc unJ el' ( ❑SFDWI, ❑K1'ICI ITS REM(IUEL
Wg WyUV Caseous Clwss Lick APPLIANCES-RESIDENTIAL. El ADDITION [I PLUMBING RE-PIPIT
F d ac Dam Y' Contractor S:,,fa,Ebsts
ARCHITECTS DECLARATION PANELS ❑MUCI'I-UNIT' ❑STRUCTURAL
ZpHZ Iundeestaana,,dareshull beused-public accord.. MODIFICATION
UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
E Lqq Licensed Prnfe—amal 201-1000AMPS IMPROVEMENTE)SWIMMING POOLS
Y T X OWNER-BUILDER DECLARATION OVER 1000 AMPS [I BATH RIihIODFa/Rlil'AIR ❑DEMOLITION
IY C Q 1 hereby amen that I am exempt from the Commnm"Liccnse Law for the
KC)aU following ot(Section 7031.5.Business and Professions CWa Any city orcssamy SIGNS ELECTRICAL [I OTHER
W LL y which mquims a permit m nswd coalcor.improve,demolish,or repair any.wmum
I"00 priormitxixcturim,alvs myuimsthe applicant for such permino file a signet Ualemem SPECIAL CIRCUIT/MISC.
f try mal he is license)pursuanun me pmvisi,,nsofine Comaa<ertn License law lChuper9 COMMERCIAL:
�CLQp Icmnmcncing with Scclion]Ofk3l of Division 3nfine Business unJ Professions Csvdc)nr TEMP.METER OR POLE IN5'I.
d E e C that he is exempt therefrom and the basis for me alleged exemption.Any violation of O NEW RLUG/ADDITION [I DEMOLITION
XnLL Section 7031.5 by any applicant far a Permit subjects the applicants'in is civil penalty of POWER DEVICES ❑TENANT ❑PO(10 SERVICE
W^m notion.than five hundred dollaa(S50().
nPLUMBINGPE
iCI' C IMPROVEMENT
Q 0I,as owner of the pmPers"or my employees with wages as their sole coinpensation. El OTHER
Cmc wilt m k odd d cl inertial.,offeredfo. (Sc .7044.R '
L3�
and 1 f - :Code Th C I t L 1 t apply l d . 1%T'UkHS
Papa.ty h h I I: p :.h d h d 'I k h If d yh
his employees.provided th.: h' P I . I J I Il'rad furLIiC SQ PI'.
calx It however. he huiJn,or imp a I IJ.,Into Y' f' pl tan.theSQ I*T.I'L(I(lIt AREA SISQ.fI'.
owner-hudder will have the burden of proving that he did not build or reprove for put
-
P tic of sated,
❑ 1,as owner of the property,am exclusively emusem,with In emed cors allors In
c,,nsmnw the project(Sec.70 T Business sad Prudes....Cash 11.Cnmraran,Li- y,PAID "
se law d«s not apply as an owner of property who builds or improves thereon.and NGPE M FEE W E
who contracts for such projects with a contieclumO licensed pursuant)the Comms
License Law. PERMIT ISSUANCE
1 I am exempt anter See. .B&P C for this reams
ALTER-DRAIN&VENT-WATER IEAI Vj U .1 TI
wncr Dam
WORKER'S COMPENSATION DECLARATION HACK FLOW I'ROTECr.DEVICE CITY OF CUNERTINO
I hand wills ai under Penalty of pe jury one of the insane for declaraWorkers
Co
❑Ihave endwill muinluin'v Certificate of Consents self for W,,rAcrs Compete DRAINS-FLOOR.RODP.ARIiA,COND. Stt)Nli;s 'I'1'PE CONS I'HUCI'ION
sminn,as provided fur by Section 37M of the Lama Cavae,bar the lwdunname ol'Ihc
work for which Isis pemtil is issued. FIXTURES-PER TRAP
n 1 have and will maintain Worker's Campeawtion Insurance,as required by Section
3700of Ne Lama Cocks for the performance of the work fm which this Permit is isxucd. GAS-EA.SYSTEM-I INC.4 OUT1.1!TS OCC GROUP APN
My Worker uo rand Polie h
Carrier: "i" GAS-EA.SYS'1'F.M-OVIiR J(IiA)
,.fivoie NnY �=7j�
CHRTIPICATE OF Ii%L'MPTION FROM WORKERS' GREASE/INDUSTRL WAS TI!IN'I ERCIDIEUR
COMPENSATION INSURANCE BUILDIN .DIVISION PEES
('Ibis senion need not he completed if the pem.nis fur one hundred dollars(E 100) GREASE TRAP
or Ices.) PLANCHECK FEE
I comythm othe perfomence ofine work fmwhich mi.pennit its issued.l shall SEWER-SANITARY-STORM ITA.200 IT.
nemploy any pervnn in any maemer.m as to bco
eme subjt
ec ,,the Worlar"Compcn- ENERGY FEE
Z sminn laws afcalifmrmu Date WATER HEATER W/VENOTILECR GRADING FEE
Z O Applicant
N01 It TO APPLICAWD If,after making this Certificate of Exemption,you should WATER SYSTEMIBEATING SOILS 1,12H
become subject ,,the Workers Compensation previsions of the Labor Cade.you mux
6i Q funhwim comply,instructs provision,or suis per shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.pE PAID
� Z 1 hereby man......hem is a concoction lending agency for the perfimmance of Dae Receipt M
LLC' the wed fur which this permit is issued(Sec.3097.Civ.C.)
O Iendrex Name TOTAL:
V lenders AJJres '1 OTAL:
L9 1 eenify mat I have read this application and ,are that the above turromtian is B
UILDING PIHi
p" s TY. MFCHANICALPERMIT FEE
V) amen.l agree comply with all city and county ordinances and stale laws mlmill m Q I!EC„)Z hadding cnr,bu,snn,and hcrebyamhorim representative.aphis city timnier upon the
aboveonvoio icd pmpcity Lx inspection purwwu PERMIT ISSUANCE Ilili(Wc)ngram Nrva inmnnily unJ kepharmless the City of Cuperlinonguinywhich miry in any way teemsagvinstsuit City ALTER ON AILD TO MEC41. FIAT' mncyuensx til the graining of this permit.
APPLICANT UNDERSTANDS ANU WILL COMPLY WITH ALL NON-POINT AIR 41ANDLINC UNIT LTO I(1IXNI CPhD CAh FIATSOURCE EGUhATION' AIR IIANDLINC UNIT(OVER 101XX1 CPM) CI'ION'TAX ofApplicandCommcmr 1)me � EXHAUST HOOD(W/DUCT) M1IITIGATION FliEHAZARDOUS MATERIALS DISCLOSURE
W,Hmaapplicamurfutum builJingceapam stem arhaile hm.Nousmmerul HEATING UNIT GO Hp.000BTU)defined by the Captain Municipal Code.Chapter 9.12.madthe health and Safety HEATING UNIT(OVIiR IIXhIXXI RTU)svk.S«tion 25532mu!� n ❑NnVENT ILA TI ON FAN(SINGI.Ii RESIDI
nam Rcccipt p
Will the applicant
ntaoffuture building byoccupant use
ByAequipmentordeviceswhich BOILER-COMP(3HP OR 100.000 BE ID
1 emit hasnrdnus air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
Ilistdct)❑Yes No
BOILER-COMP(DV(OVER IIXLIxM)❑TUI
❑
I havc reaA the LamNnw mmcrials rcywtnncnu under Cbaplcr G9$nl the Cnli- AIRCONUTTIONER ISSUANCE DATE
fu nim I Imdm&Safety Calc,Sections 25505,25533 and 25534.1 nndemwnd mw it the NEW RESIDUN1'IAI,MSCI I. SQ,TTn
buildingdocs nor currumly have u mmmn.that it is my nepor%mili.y,tonutifY thclsvvuum
of the rmryimments which must be act prior to issuance o1'a Cenit3anc fit Oe'ulamcy,
Owner or authorized agent Uwe 'I(TTAL: ISSUI?U BY:
OFFICE
OF
NF Cfip y
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--AU above sign design&art wodo m belong to SfGN9 EXP SS .Cm isProh3ded. ALL RIGHT RESERVED.--
waEyPREM nm. CO. pScal : Noted Drawn by
•8 EXPREM : g_21-97 I Drawing
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"All above sign designs&art works are belong to SIGNS EXPRESS MFG.CO., Any duplication is prohibited ALL RIGHT RESERVED."
n 10871 N. WOLFE ROAD, CUPERTINO ma i Cxmm mirm co, Scale : Noted Drawn by
2446 MERCED AVE.,SOUTH EL MONTE,CA 91733 Date : 6-7-97 Drawing #
818.443-3333 ' 818.443-1615(FAX) APPROVED BY :
STATE LIC.#554097 0 U.L.APPROVED#E-119586 .—