S 1661APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY ON CUPERTINO
PLUMB MECH
BUILDING. ELECTRICAL -
PLUMBING -MECHANICAL.
PT:rr No.
1661
B UILDING DIVISION
APPLICATION/PERMIT
FEE
�
❑ KITCHEN REMODEL.
❑ADDITION
N1111.DING PROJECT IDENTIFICATION
❑MUEN-UNIT
BUILDINGADDRESS:
MEE171f.
MODIFICATION
SANITARY NO.
AS' PI.ICATIONSUBMITI'ALDAH!
i tea Yorks
ire. Dr.
0 BATH RE RTY[SiREPAIR
❑ DEMOLITION
S- /v -P8
D CIES NAME
PHONE:
CO ACTOR'S NAME: LIC NO
N/C
CONTROLa
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9�--aa�Z.—.
40 �. CJ
❑
❑ OTI LER
ARCHI'I l' T/I:NGIN3HR; LIC NO: I
ADDRF.. _, -
CONTACE
2-6 5
-,`5 —� 18
I ❑ Consultant Fecs Paid by Applicant (Initial)
1 hereby affirm that I um licensed under provisions of Chapter (meeis
with Section 700B of Division S oOhe Business and Professions Code, and myy Blicen me is
in full force and effect.
Iiccmc Class I.I,.N
Date Can racco,
ARCHITBC'I"S DECLARATION
I Understand my plans'.shnl l he it—1 a, puhl le records
Licc'vsel Penfeosional
OWNER -BUILDER DECLARATION
I hereby affirm diet 1 am exempt from the Caroni License Law lar the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to constmn,.dmr, improve, demolish, or repair any spactme
print in its issuance, also require, the applicant lot such Permit m file a signed statement
thin he is licensed pursuant m the pmvisions of the Conlmnorx License Law (Chapter 9
(comnrating wuh Section 9tf of Di,okior 3ofthe Business and Professions Code) or
chal he is exempt therefrom and the basis for the alleged exemption. Any vocak n of
Scclion )1031.5 by any applicant fur a prrnal ahc,ss the applicant n m civil penalty of
urn n ore than live hundred dollars (S50O).
I,n.nwner ofthe p -Part, It my unlployeos with wages ns their so lea opa"alion,
will do the work, and the anncuuelssol Intended nrnBeed far sale (Sec. 9144, Ilmineea
and Profuerionn Code The Contractor's License ].me docs net apply or an owner of
prnpeny who Saul Ids or improves thereon, and who does such work himself or through
hisempleyees, provided that such improvcmam rot anot intended or offered for
sale 'If. hnweveq the building or impmvemen is sold within one year of completion, the
ow net will have the burden of proving that he did not build or improve for put.
pnm of salc.y
0 1, as owner of the property, am exclusively contracting with licensed coma m
surae, the project (Sec ]1114. Bev ion., and Itofosime, Code:) The Contra md, active Laws does nom apply to an owner of progeny who hairdo or improves thereon, and QTY.
who contracts for such projects with a conlmctons) licensed pursuant to the Contractors
I.icc re I.e..
0 It exuratundcr Sec. ,B&PCforlhisremnn
Owner Date
WORKER'S COMPIINSSI'[ON DECLARATION
I hereby affirm under penalty of perjury one of the following declaration.:
0 1 have and will maintain a Certificate of Consenno self -insure for Maven Compact.
union, as provided for by Section 377 of the Down Code,
for the performance of he
work fm which chic pemat is neared.
0 1 have and will maintain Worker's Compenamion Insurance, as required by Section
1700 of the labor Code, for the perharremse of rhe work for which this Icnnit is is ... L
My W'nrlppL�_rl;Co nam Jr. ran cnnicrmrn Policynu Is nrc:
CarricrgR,lt II , policy No.:
is 9Lo„�
YYYY CERTIFICATE OF Ii 3MP I ION FROM WORKERS'
COMPENSAI'[ON INSURANCE
('('his xecl inn need sol be conmletcd d the panne is I'omne In dradodars IS I Illp
orlcsad
I verify that in the per( mmnco niche work for which this permit is issued, I shall
not employ any person in any manner so as In become subject to The Workers' Compart-
wolon laws of California. Date
Applicant
NDI'ICH TO APPLICANT: If, after making this Certificate of Exemption, you should
beco subject to the Workers Cnmpemaction pmvisions of the Labor Curie, you must
fochwrth comply with such prnvisinns or this permit shall be deemed revoked.
CONST RUCTION I.ENDING AGENCY
I hereby Wfim Ilial thena is n constmction Iendi lig agency for IIIc pert'ommnce of
clic work I'nr which this perim, is ii,c al IS.. 9099, civ, C.)
"Oder', Name
Lcoda,, Addnas
1 unify chat 1 have read this npplicuciun and state that the abuse ii forn ntion is
correct. I agree to comply with all city Intd county oN'mences and lace ..sea b ing to
building conviction, and hereby umhonse reprexntaives of this city to enter upon the
aMwc rationed propcny for inspection purposes.
Ilk) agree to save, indemnify and keep hanalea the City of C.,tromn .gains.
li.bilitiea,judgmemo, coos rend expenses which may in any way accrue agairs, said City
in con,sp era of the gmming of this permit.
APPLICANT D'DERSTANDS 'D WILL COMPLY WITH ALL NON -POINT
SOI112C1! ONS.
HAZAR DOHS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle Menelaus mmerial
as defined arch, Corsicana Municipal Code, Cbapmr 9.12, and the Health and Safety
Cade, Section 25532(a)T
O Yea FNo
will the applicant or future building occupant use equipment or devices which
emit haaedous air contaminants as defined by the Bay Area Air Quality Management
Nodal!
[I Yu -I No
1 curve retld lie hawclous..... 1,64ls reap/...mens under Cherie, (.950 (lie Cull.
11lnda I Italic & Smet Gale, 9cctlnml 255115, 25599 and 25514. 1 oalcoand thus it the
hnilding doedy,have a cytplt, thaylt is nmy rc.pnrrsiM1ilhy m nndfy the uccrmant
L'LE(i PERMIT
PERMIT ISSUANCE
APPLIANCES - RCS I DEN'1'IAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAI-
SPECIAL CIRCUS UNUSC.
TEMP. MITIiR OR 1101.17 INST.
POWER DEVICES
SWIMMING 1'O01.Ii1.1!C'1'RIC
OUTIATS - SW ITCHES -1'1X7
SQ Ff.
I'LUMBINO PERMIT
PERMIT ISSUANCE
ALTER - DItAIN & VIiM' - WATER (HA)
BACK FLOW I'RDI'1iCE DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
FECTURES - PER TRAP
GAS - EA. Sy I'T:M-I INC. 4 OUTLETS
GAS - IiA. SYSTI7M-OVER 4 (IIA)
GRF.ASF.IINDJJSrI'RI, WASTE INTERCEPTOR
GREASE 'I'RAP
SEWER - SANITARY - STORM EA. 200 Irl'.
WATER HEATER W/VENT/F.LF.CTR
WATER SYSTEM/TREA'1'ING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL. PERMIT
PERMIT ISSIIANCE
ALTER OR ADD 10 MECH.
AIR HANDLING IINI'1' TI0 SO draft CEM)
AIR HANDLING UNIT' (OVER 110,0(0 CFM)
EXHAUST IIUOD(WIDIICD
HEATING UNIT fro 11010,000 BTU)
HEATING UNIT (OVER Shoal 13TU)
VEN'TILAI'ION PAN (SINGLE RFSID)
BOILER -COMP UHP OR 100.000 BTU)
BOILER - COMP(OVER I00,0(x)BTU)
AIR CONDITIONER
NEW RESIDHN'I'IAl. dIFCH. SQ. EL
OFFI
FEE
BLDG ELECT
PLUMB MECH
❑ ❑
Pg) ❑
JOB DESCRIPTION
RESIDENTIAL:
FEE
0SFDW1-
❑ KITCHEN REMODEL.
❑ADDITION
LUMBINCRE-PIPE
❑MUEN-UNIT
STR
MEE171f.
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
0 BATH RE RTY[SiREPAIR
❑ DEMOLITION
❑ OTHER
F
COMMERCIAL:
❑NEWBLDGIADDITION
❑DFMOLI'MON
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTI LER
SQ, IT. FLOOR AREA SISQ. FT.
FEE
r�d
VALUATION
STORIES 11 TYPECONSTRIICT
BUILDING DIVISION_ I_TES
PLANCHECK FEE
ENERGY FEE
GRADING PER
SOILSFEE x
_ //ISSUF. AN DATE
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A -"rO
ISSUED BY: I.
PAID
LL RKCipIR
IDEAL
BUILDING F.
FEE
SEISMIC PEI:
ELECTRIC
PLUMBING FEE
MEE171f.
iCHANICAL
VCRTRUC'ION'IA
HOUSING MIT'IGAT'ION FEE
MSIR Date Benin,4
F
_ //ISSUF. AN DATE
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A -"rO
ISSUED BY: I.