S 1658 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELRCPRICAI. PEtl"I'N0. 1658
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDINGAIlDRE55: SANITARY NO. APPLICATION SUBMITTAL DATE
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O NIiR'S NAM^ PIIONE'. OMI' gCTOIi:S NA LIC�N'NO: •I� v
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�.ARCI IITECTQSNGINEER: LIC NO: ADDRESS: O ❑
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CONIAC. I'1[UNE: _ 3 BUILDING PERMIT INFO
R�/)d R O1A"^ ` 0-8-LUO ❑ Consultant Fees Paid hyApplicant(Initial) 9LDG ELIiCr PLUMB MEC
�/ lit L// 1'3/ I ' ON ❑ ❑ ❑
LICIthat I a CONTRACT'OR'S DECLARATION
1ion7 affirmtail1am Ilfhe B.amrrprovisionsof Chapter 9(commencing QTY. ELECTRIC PERMIT F88 JOB DESCRIPTION
WOZ wiW Section7") DivixionJnl IM1e Business and Rnfecsions Cale,and my license is
F_p in full force and 1'[RMI"1'ISSUANCE RESIDENTIAL'
R—L License C) Lic.M I ❑SIUWL ❑KITCfIEN RIiM01JIiL
Zed Data Contractor APPLIANCES—RESIDEN'FIAT. ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITEm DLC[AR TION
O Z y Z 1 uunderstand my plans shall be used as public reconPANELS []MULTI-UNIT [I STRUCTURAL
s MODIFICATION
F'I {tC� L¢erocd Prour i'med UP T0200 AMT'S ❑INTERIOR ❑CHIMNEY REPAIR
Q 201-UMOAMPS IMPROVEMENT
999 OW NEN-BUILDIiR DECe Cour elo ❑SWIMM]DEMOLITION PO01.5
y 6 1 hereby.(Srm That 1 am exempt tram he Co-i ns Co License Law fruffie OVER 1000AMPS [I BATH RIiMODEVkEPAIk DF;MOLITION
p(3 6 H following reason.(Semina]031 S,Business and er,de lops Code:Any city or county SIGNS Ii1,RC1'NICAL ❑f7fHER �_a_
4411 LL O yQ watch nyuisu n permit In crammer,eller,improve,demolish,or repair any slmeWre 9'i_iV�rY_L`f.--'b��
F.
pdarthslicenedpur also rgaires thovisio so for moil Perminafile icense aw(ChAterstatement SPECIAL CIRCUIT/MISC.
�} thetas is licenud pursuum to the provisions of the Comracu,r's License lsx'ICM1apter9
d'Qp�O (commencing will,Section 70fN))nfDlvision3 ratio,Business and Is lcvsion,Cade)m TEMP.M E I'ER OR POLE INST. COMMERCIAL
6 y e y that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
Section]031.5 by any applicantfor a permit subjects the applicanua a civil Penalty of IY)WfiR DEVICES
.F.
t more than live hundred dollars 1$500 Z>. ) ❑TENANT El FOOD SERVICE
Cl as owner of the pmpeny,or my employeeswith wages as theirwlc cmmpcn.wtian, SWIMMING POOL ELECTRIC IMPROVEMENT
will dollar work,and theswcwrtisnd immmdedonsffertd for car tSec.]OLL Business []OTHER
L3�^ and Rofession Code 'The Contractor's License Luse does not apply m an avner of OUTLET'S—SWITCHES—FIXTURES
properly who builds or improves thereon,and who does such work himself or through
his own employees,provided thal such im owleavms ate not intended or oRereJ for NEW RESIDENTIAL ELECfR SQ IT
sale.IL however,the building or improvement is sold within one year ofcompletion•The SQ.fT.FLOOR AREA $/SQ.f..
erhuilderwill have IM1e banes of proving that he did not build or improve for pur- p
poseof eale.). M
❑Los owner of the psis Fort;at,eselusively racracti as with licensed emilacuns m TOTAL:
croshuat Thep jest(Sit .7044,Bu,Ines,mud Professions Cade)The Continent's Lt.
rase lewder,nm apply loan ownerafpropeny who builds or improves thereon,and QTY, PLUMBING PERMIT 'FE y4 ANQrD
who comma's for such projects with a conaunar(s)licensed purse-m m the Contractor's ANS
,V
Law.
❑ m PERMIT ISSUANCE CSI V
laenempT ander sec. .B&rerorthia mason VYCfYII -
OwnerALTER—DRAIN&VENT—WATER(EA)
Date VALUA'T'ION
WORKERS COMPENSATION DECLARATIONBACK FLOW PRCnC`E.DEVICE
I hemM1y uRnn under Penalty of perjury one of the following
declensions:
❑ I havcand will maintain aCenilicateof Consent oself-insure for Worker's Contpen- DRAINS—FLOOR,RODE AREA,COND.
sector,its provided for by Section 3700 of the hMsr Cede,for the performance of the STORIES TYPE CONSTRUCTION
for which'his permit is issued FIXTURES—PER TRAP
wu I have and will mninlain Wmkees Compensutlon Innamnce,as required by Session
3 od'the"Kit Code.for the performance ofthe work for which
This Permit is issued. (IAS—IIA.SYSTEM-]INC.4 OUFLETS OCC.CROUP AI'N
My Wnr scot pS�ylry gcay4 fc carie indPol poky No.Y�a_I pan t���l GAS—EA.SYSTEM-OVER4EAI
Cant kmc 1'I LCGI
CERTIFICATE OE EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(Thio mesion need not be,completed it"the permit is far mne hundred didlam S1Out BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCIIECK EEE
I cenify'has in he performnt. fthmit e work far which this peris issued.[shall
not employ any penes in any manner sa as to account subject o the Workers'CantPen_ SEWER—SANITARY—STORM EA.200 PT.
,Z talion Laws nl'California Data ENE RGY H17
77 O N01;am
A"IWATER HEATER WNENT/ELECTR GRADING FF.f:
a 5 NOTICE TO qPo the Work H,Co making this provisions
s.1 of Exemption, ,y should Wq'rER SYSTEM?RF.ArING
Fes ' heamtc comp[bject n the Worker's pa Compensation provide-s ulThc LaMm Code,you matt SOILS fTiH
Ir.) fraMwilh comply win such provisions or this permit shall IN,Deemed revoked. WATER SERVICE
Q
'z CONSTRUC'T'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
L)0 thereby affirm that There is a construction lending agency for The performance of Dale ReceiptM
LAF the work for which this Permit is issued(See 3097.Civ.C.)
0 L) Lender's Name TOTAL:
Lenders Addow, TOTAL:
H 0. 1 cenify'hut 1 have read this application and same hot the aha va information is BUILDING FEE
.w rn conoel.I agree m comply with sill city and county unin ma,and site laws odmog na QTY. MECHANICAL PERMIT FEE
L)z building convrucliome-d hereby amhaire mpresenmlives of'hisci'y,m emerupam the SEISMIC FEE
aMrve-mentioned property for impaction purposes. PERMIT ISSUANCE.
(We)vgo.m ease,indemnify and keep harmless the City of Culwnlnn against ELECTRIC FEE
liabilitics,judgmems,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the go This perm 1. PLUMBING FEE
APP AN 1NDER5'L D NII WILL COMPLY WITH ALL NON-POINT AIR HANDLING11NIT('fO IgINNICPM)
S RCIiR IL,\TION MECIIANICN,FBE
AIR HANDLING UNIT(OVER 10,11(X)CFM) CONSTRUCTION TAX
re of Ap c.V(a sir l Date IiXHAUS'r HOOI)(W/DUCT)
HA ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the nppliwn
or future auiddl ag occupant store orhandle hnzardoas material HEATING UNIT(TO 100,1X10 BTU)
as def neJ by 0¢Cupcn nn Municipal CuE,Chapter 912,and the Health and Safety
Code.Section 25532(.)] HEATING UNIT(OVER 100driI BTU)
E]yes ❑Nu
VBNTILA'1'ION PAN(SINGLE RIi51U) PAID
Will the i limn or rumm Fdeine co Air Quality
Elate Receipt A
pp Wilding use 'urJcices which HOILER—COMPIIHPOR IfN),g108TU
emir ictzaMom air conmminancs as JefineJ by The pay Arca Air Quality Manngcmem )
Ui,lriel'! TOTAL
Yes ONo BOILER—COM PfOVER IW,IXX)BTU)
I hove reed the hnmnlom malcmd,mquirtmens under Chapter 695 rad"the Coll- AIR CONDITIONER ISSUANCE DATE
Food-Health&Safety Code Sections 25505,8533 and 25534.I ondentand this,if the NEW RESIDENTIAL MECH. SQ.FI'.
Willing doesnot coma have-Iran-',that it is my mspa nhility m notify the occupant
of the na,monme t,which must be mel prior m issuance raf a Cant fruit,of Occupancy
Owner sir authorized-gem Date TOTAL: ISSUEDBY:
OFFICE