99090100 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q Q It 00
CITY OF CUPFRTINO BUILDING�ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGAIIURESS: / �� ES S �� SANITARY NO. APPLICATION SUBMITTAL DATE
RRTT''-1 uE. p , c/' Pm �� �s-19
OWNER'S leofr131 CA � ) 5�T9 GWoCK!'N(-}EtAllil_') 10f1,�1 -� S73 NIC CONTROL
RCHITECT/ENGINEE : LIC NO: ADDRFS$:rA41PI Sl_ &XWS �Jv ❑
CONTACT: PHONE: GlL4 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ �� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions m Chapter 9(commencing JOB DESCRIPTION
`W0Z with Section]f100)af Uivision3of the Business and Bofessions code slid mY liccnu is
Ia)DO i PERMIT ISSUANCE RESIDENTIAL:
F W I— m full Tena and eflecl •� —J
=-I- Li<cnsc Clesn •�b Lic.N ❑SIIDWL ❑KITCHEN REMODEL
yaaW Da« far Commanr�asfca� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR -PIPE
•• �- •• �r ARCHITF.CI'S DF,CLARATIaa,,N PANELS ❑MULTI-UNIT ❑STRUCTURAL
O ZNZ 1unJersrand my plans shall M:used as public«roNs
UPTO 200AMPS El INTERIOR ❑CHIMNEY REPAIR
F 4~W Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
GC W G 1 hereby affirm Thal I am exempt from the Contractor's License Law for uhc OVER IOOOAMPS ❑BATH REMODEVREPAIR (]DEMOLITION
k 3 a OF following«osnn.(Station 71131.5.Busloess and Professions Code'.Any city or county SIGNS CLEM RICAL MOTHER _
whim requires a permit to ennrtrecl,alle,improve,demolish,or repair any ebecome
trfq (- a{q
prior m mi
its issuance,also requires applicant for such pert to file a signed statement SPECIAL CIRCUMMISC.
�� that he is licensed purxuonuo the pro visions of the Contractor's License Law(Choprer9
W�OQ (connnencing with Section700(hof Division 3 office Buanes.+and Pufl,,i.sCsAc).r TEMP.METER OR POLE INST. COMMERCIAL'
a a c s that he is exempt therefrom and the basis for the alleged exemption.Any violation of -1 NEW BLDG/ADDITION ❑DEMOLITION
kms• Sectio]031.5 by any applintm for a permit xobject,thcoppleatn m a evil penalty of POWI7R DE.VICES 1-1 TENANT ❑FOODSERVICE
W..m t more than five hundred dollars(5500).
ZSp ❑1,as owner ofthe property,or my employees with wages as their sole comamotin, SWIMMING POOL ELECTRIC IMPROVEMENT
N will do thework.amillis trucmre isnot intended tendered bottle(Sce.]044,Rosiness El OTHER
W 3 a, and Professions Code.The Contractor's License Law does nor apply to an owner of OUTI.ITS-SWITCHES-FIXTURES
progeny who builds or improves rhe«on,and who decision work himmlf or through
his own cngtloyens,provided that such Improvements arc not infrared m offered forNEW RESIDIiNTIAh GLECTR SQ FT.
sde.If.houses,the building or imgmminent viscid within one ycm.fccandtfon.the SQ.IT.FLOOR AREA $/SQ.IT.
owner-builder will base the burden of proving that he did not build or improve for par- ^-`-•�„��.�-�`�I
pose of sole.). 3 r{I
❑1,as owner of fine progeny,am exclusively contracting with licensed contractors to OTAL:
consumer the project(Sec.91 ,Business and Professions CodThe Contractor's /�
00 e:) 1\1
cense Law doer nm apply to an owner of property who builds or improves mercnn.and QTY. PLUMBING PERMIT U
who contracts for such projccfs with u Conuactons)licensed pursuant o the Contractors G 1999
License Law. PERMIT ISSUANCE D SEP 1 a
❑ I am exempt under See. ,B&P C for Nis reason Gr
OwnerDate ALTER-DRAIN&VENT-WATER(G) 11 TIVALUATION q
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTIiCT.DEVICE �0
❑�
I herehy affirm under penalty of perjury one of the following declarations: I J
Fl nave and will ineirodo CenlBcateo[Cnnsem utsd[-insure for Worker's Cromer. DRAINS-FLOOR,ROOF.AREA,COND. POI
S'TORIRB TYPE GDNgTRGGTIQN
onion,as provided for by Section 3900 of the labor Coda for the performance of Our
wo k for which this perms is issued. FIXTURES-PER TRAP
1 have anti will neurtain Worker's Cool frowtion Insurance,as squired by Section
Ml offle Labor Code.fee he perfrraarmuff he work for which�this p.if iiss i/ssyued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP c qPN
Cy Wmke's Co pens - Insur ttcanierriloley No,: [ga�'v.._ GAS-EA,SYSTEM-OVER 4(EA) •� ( tJ
CERTIFICATE F EXEMPTION FROM WOR KER S'
COMPENSATION INSURANCE GREASEHNDUSTRL WASTE,INTERCEPTOR
(this section nein nm the et il'IM1e punnit is foronu M1unJred Jellarn(Sl W) BUILDING DIVISION PEES
or less.) GREASE TRAP
1 certify that in the performance of the work notation this permit is issued 1 shall ENERGY FIE FEE
bol employ any pernmm enymennersoasht h,c.mcsuhjen to the Warton'Compcm SF.WIiR-SANITARY-STORM EA 200 FT.
ENERGY FIE
z .-tion Laws of California.Dae
0 O Applicant WATER HEATER WNFJ.T?;LECTR
GRADING FE
h NOTICE TO APPLICANT.11:afar making this previsions
n s of the
(Labor ion,you should WATER SYSTEMRRPATING
? becomesubjectm the workers Compensationprovisions of the Imedr Cone,you most SOILS FEE
� Glnhwirn comply with such provisions or this permit ah:Jl Its,deemed revoked. WATER SERVICE.
a �
CONhem is alONLtionlediAGENCY NEWRESIDENTIAL PLMR. SQ.FT. PAID
U O work
whichby th the them irsued( ee,3097,nrling agency far gerfnnnnnce(if
v¢ ReceiptM
LL. F" the work 1'ar which thin permit is issued(See,3ty3].Civ.CJ
s 0 Irani el.Nesta TOTAL:
U Under,Address TOTAL,
Fr-' C 1 certify that 1 have mad this application and Aare that the above information is BUILD]
V) correct.I agree to comply withal]city and enumy ofinanees and state laws relining tp QTY. MECHANICAL PERMIT FEE
U Z building amstmerion,and homy authorize representatives offs city to concretion the SEISMICFl
nNommentioned proper,for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupenum against PERMIT ISSUANCE ELECTRIC Fq
Iianililics.judgmcntn,costs and expenses which may in any woyacamc;gc.m,tmld City ALTER OR ADD TO MECH.
in nsequnnce of the gmming of chin tworn. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CPM)
SBUNCE F, NS � MECHANICAL FEE
AIR HANDLING UNIT(OVER IQ00(]CFM)
11 CONSTRUCTION TAX
Signature of AppremoUGmlraclor Duro EXHAUS']']IOODIW/DUCT)
HA9,ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant smrc lir handleharardous material HEATING UNIT(TO 100.000 BTU)
ns def tri try the CuPur inn Municipal Cede,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? HEATING UN]T(OVER 100.000 BTU)
L]Vic ❑Nn
VENTILATION FAN(SINGLE RESID) PAID Date Herein
Will the applicant or ferule building occupe
ant use quipment nil devices whim P
mit hmardous air contaminants as defined by the Buy Area Air Quality Managemm�t BOILER-COMP(3HPOR 100.100 BTU)
District? TO AL:
E)ye, [3 No BOILER-COMP(OVER 100.000 BTU)
I have read the hazardous maeialsnequeemcnts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA�
fomia Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. Sp.FT.
building docstrot rruntlyhaveatemmt,Nuliiismympornihilltyronnrifylhcoccupant
Of F hicl hmu.slbemelprinrmissuanceofa Ctnin/ p1�pille, /y
. ev6 - ❑r ora«ihnnredlage_nt` 9 SIC TOTAL: ISSUED BY: ✓��NT��
OFFICE