S 1097 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO HUH.DINr,-E LECI RICA I-FRIM'NO,
APPLICATION/1'RRMIT PING PROJE UECIIANI IC S 1097
•RUSLI]ING DIVISION BUILDING 1'NOAECI'IDENT'IF'ICATION
SANITARY NO. API'LICI'ION SUBMI'1'1'AL UN
ItI111.DING ADDRESS: X
101363 l0lss I0989 /OSIS / o $3J' I08L1 p
WINER:.9 NAJHE: 6 ��•PHONE CONI'BAC'IOR'S NANIE. LIC NO'. NIC CONI Kill,IF
GF I'fl;(T/IiNCpINEEHV LIC NO ADDRESS: /_ 73
VI dIA`�.J�N 19{ONf::
BUILDINGPERMITIN�PO
CONTACT:
V Q•l'^I`A M f D CII
� O(� ❑ Consul[nnF Fees Paid by Applicant(Initial) BLDG ELECT` PLUMB hili
LICENSED CONTRACI'ORls ut%t,ARA'HON I _I QTY. ELECTRIC PERMIT' FEE 2Y-/ z;-"
DESCRIPTION
1 herchy affirm that I am Iiecawd under pmvidun.Of apc r 9(commencing
Oat with S¢hnn700(nul Divieinn7nnhc Hn.ine—fid Pr 'x 'I ale.a mend hwn�aix RFRIDFNT'IAL;
WooFERMI I'ISSUANCE ❑SFDWL KITCHEN REMODEL
n full force and eRecl.l..
dUU Liccn.e 1 s- I,i' APPLIANCES-RES1DENT1AL ❑ADDITION ❑PLUMBING RE-PIPE
yZ. Bac n 'atm ❑MUI:rt-UNIT ❑S"IRUCTURAL
A 'FEM' .AHAT�pI PANELS MODIFICATION
ZOyZ ImucrslanJm Lnzshal u 'r�,Ns Oil T0200 AMPS [I INTERIOR ❑CBIMNEY REPAIR
OZ-�
y1 Licensed Pr '..aon 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION QVIiR 11XXIAMPS ❑BATH REYIODEI/REPAIR ❑DEh10LH[ON
�' ad 1 herchY affirm dual 1 am ccrospd from tuc Cnnvuaor's hiccmc Law lin the ❑OTHER
X O W U [lowing reason.(Section 7031.5.Business and Pudession.Code Any city or runny SIGNS ELECI RICAL
W 3 which rcynirex a permit to construed,alter improve.demolish,or repair any 4ruaure
f-LL'NGd prion t '.: I: requires thet such dt 11signed' n suelateSPECIAL CIRCUITIMISC,
shah licensed pt to the Provisions ofth CraductoesL La (Chapter9 COMMERCIAL
Wbecmmencmgwlh Scuum]h(N)01 DIvir.bn 301 the H a,mcs:rd1 fe ss Cnrlc)nr TEMP METER OR POLE INS'('. []NEW BLDGIADDITION ❑D
n F,MOLI'I'ION
q o a that he is encmpd dremfrnm and the basis for the alleged exemption.Any violmil of
IMI'ROVEMEN'I'
-N Section 7031.5 by any applicant fur a pend subjects the applicantm a civil penalty of POWER DEVICES (ANT ❑FOOD SERVICE
me Ihxn Five hundred dollen(851X).
or
=0 ]I,u.c O,,nfdhc prnpenr.urmy emph,ccs wish wage,us their-le campensalion. SWIMMING POOL PLECIRIC C]OTHER
4. willJmhe work.andlhe.structure renol immadetmOdencol sale(Scr.700,13usinccs OUI LITS-SWI'I'CI{ES-PIXTURIiS
6 3 m and pro fcsuiun,Crude:The Cenlmemrs License Law dace rut apply m an owner Of
property who,Wild or unpnwen thereon,and who,Jars such work hinn.cHor thragA NIiW RIiSIDIiN'I'IAI.IiI,ECI'R SQ left
his Own employees.provided that such improvements am nm intended Or offered bur SQ.FI'.I:LOOR AREA $NQ,lel'.
sale.IL however,the building m improventent is sold within one year-from
the
rhuilder will have the burden Of proving that he did nm buil)Or indpnwe for pur- //^��
El ,a x..a, TO AL. 1 �9 y /
1,as Owna OI dhc Drolc'dY•um cadusivcly ttnnrunmg with IkcnscA cnnhnnors fit I{"w^R(f
cnnslmct the prejecl(Sec.VDW,Business and Pmfcssions Calc:)The Gnnc-LOrI I.i- PLUMBING PERMIT FEE late.Law JOns Out apply to an nwncr III property who builds or improves fireman.and QTY. A
Ohio commas for such projects with a contumacious)licensed pursuant to the Conbacmr's fl
Lict nuc Law, PERMIT ISSUANCE
I um exnnDd uMet Sec. .H&P C bull""'On /1
ATTER-BRAIN&VENT-"'Al ER(EA) {i IdjATIUN
Dam U
mer WORKERS COMPENSATION DECLARATION BACK FLOW I'ROI'IiCT.DEVICE("
1 hereby alirm finder penalty al'peoun,nuc of rho following declarations: C
❑Ihaveand x911 maintalnaCtAificatec)fCOnwnuO.wlfinsuml'c)r WOrkces Comped- DRAINS-FLOOR.ROOF,AREA,CONI. STORIE. TYPE CONST RUC-tR
satins,as pnrvidN fur by Section 391()sf the Labor Cook.for the performance Of the FIX'I'USES-PER'I'RAP
work for which This penal is towed.
I have find will mainmin Warkar's Compensation In.wrunce,as requirtd by Smion
3]1X1 of the LaMn Conic Br the peAnrmuar invariant the work tin which thin pcnniusiswnl, (iAS-IiA.SVSTIiMI INC.JOUH.FTS OCC GROUP ANN
My Works' CnPd�'ma�top lm rano and PulieY nlyl)Mrlyf.i 20 �, GAS-EA.SYSTEM-OVER J(EA)
Cwricr: /(�.V Fahey rvn.:.1�f/--4IT]ff�L
CER�TILTCAT E\EMP•1"ION FROM WORKERSORGSI%INDUSTRI.WASTE INTERCEPTOR
COMPENSAI'IONINSURANC1i B 1 >I, VI. )N PEES
(This tum ncnl not he comple¢J it he pe0 istin Onchundred Joll...D ishl UREAS,OUIP PLANCHEC'PBII
Or less.)
Toy any
dpenuld in performance nOM1c work lbc,or dhispcnnil isismed,lehaE SIiWLR-SAN ITARY-$'IORM IiA,]1X114. IiN1iItGY I'lil
not employ any penult in any mooned s �n tuC"Ildc wb¢n I�hc Worker(Compc'n-
z• wdinn Wws of Nlihmtia.Oalc `7 WATER IIfiAI'IiR WIVENT/IiLECfR GRADIN 'IiE
zQ Applicam
N(yl'ICEubj ct to t]CAN Phe Wink IL Coe staking This Cisions Of Of I1-din inn,you should N'ATIiN SYSTIiM?BEATING SOILS FLIT
I-" baro,Ith carried,
the Winker thi,Permit hal Of the decimal
Circle,Yom unall
W hmhwi@comply wish such Pmvisiun>Or dais pcnnn shall be doodled revoked. WATER SERVICE
Q
ow'
CONSTRUCTION LENDING AGENCY NEW RISIDIiNIIAI.PLMIf. SQ.ET (NIU Oat RccclplM
U cc) I hurcby Of 1imthat dwruls u I l"Octien flooding agency fur the paEm"Ineof
[I. the work Por which this permit is i...cd(Sce.3097.Civ.C.) TO'I'AI,:
Q ULender's Naas T( L:
UJ Lander"little, BUILDING HE 2 L
1 verify tha I hove nxJ(hie xpplicmion and acre that the aMwe infnrmainn is
Frns g TY. MECHANICAL PERM IT FEE
N nmad.I egrce m comply with ell oily unJ county aJinnt sand store Q SEISMIC Igili
U Z building construction,and hereby authorize mpmsematives of yhmnteru e
aMrvomentioned properly lir inspenian ryvponcs PERMIT ISSUANCE -5,5, o ELECTRIC PEE
(We)agree to save,indemnify and kc raes duthous o
le City O galmt
Iiubilitiex,jud,lundI.cnas and eaten ich may in any eme against said City ALTF.RORADDTONWCII. �� I'LUh1H1N0 FF,L
in conuquence of the grutnin ds pe.,Ill.
APPLICANT UNDER. DS AND W MPL 'H ALL NON-POINT AIR HANDLING UNIT(101(1,000CPhB M[CIIANIGh1'lili f 0
SOURCE REGUL S. /
AIR HANDLING UNIT(OVER)ILIXNI CFM) GDNS'TRI1G'T1DN T'A%
arum canuetilutifilem, /Bac HAHAUST I IOODIWIDUM) HOUSINGMIUCIAIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Willds.pplicimnrlumrt building Occupant sande Ohnialle h...Nuus nrelerlal HEAI'INO UNIT CIO IINLINNI(ITU)
as defined by the Canadian Municipal Code,Chapter or 12 and the Pleahh and Safety HEATING UNIT(OVER I0E,000 BTU)
CNe,SOcEnd 255321x)?
❑Ye, EJ No, VENTILATION PAN(SINGLE RESID) IAIU
Bate Receipt X
Will the applicant or future Wilding Occupant use eyttipmen,ar devices which BOILER-COMP(3HPOR 1(0,1X()BTU)
unit h:vnrdons air conaminands as Jclined by te hBuy Area Air Quality Management TOM
District? BOILER-COMP(OVER 100,INg H'1'U)
E]Vice ❑Nn
AIR CON DI'HONI;R ISSUANCE DATE
1 have read the ha>aNnus rdwterials rtquimrnentx umk,Chapur b.95 Of d"e Cnb- l
(oust,HcalO&Safety Cock,Sta 255115.2,55791nu125534.1 rmdcmm�J dha if the NEW RESIDENTIAL MECIL SQ.FE 6 ^ 3 O.- �.//
building docs am currently have a tenant.that it is my responsibility to moody the Occupant V
of the requ nndcros which nuut be act prior to issuance Of a Certificate Of OccupaneY.
Ow ner or authori rcl agent Dale 'f TAL: ISSUEDH O `
OFFICE
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