24315 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preen Identification PE]LWTN -
BuildingAddddress: /�
1.► ba6 6-aYlfe-A V40 LMH 315
am: one:
Henry Ch:h-NeH K;44 �3f) CITYOPCUPERTINaBUILDING DIVISION
Convector.Nerelsk d Ile,Na APPLICATION /PERMIT
QW BUILDINGFl=CA PLUMBMGMECHAI.'ICAL CATEGORY CONTROLY
Architect/Engineer. Lie Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERh11717ISSUANCE fAl ❑
LICENSED CONTRACTOR'S DECLARATION
IkrSectioirm O)ofhat am Hcensofthe mvwmno(Chapler9(mrmnm APPLIANCESRF9DENTAL BD65CBETION
Ingwlth in
In.
dMan3ofthe Busircsrand Prolesdon.Cade,and {"1
ik<ve b in fu0!Dene and dfect. PANELSTAa
License ClaO L{ea
Date Contractor
ARCHITECTS DECLARATION 701-1000
�Z I understand my plavB m
.kbe used as public mrda OVERIU)(J 'S S/SQ.Pr.
fna0�qD PUTER
. Lkxnaed Professional SIGNSE EC RiCAI,
� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
P �3 h mby alO mthat I am exempt from the Contractor's Licerue LAW for the
Doenoqfollowingreason.l5enion70315,thienuM
aPmfubvCode:Any city ar ATE
rM cw tywhb mquU apem wmvtruMl ter,4 pr ,demoWh,orrepdr TEMP.METER ORIOLE QJS7.
qq .nyalructum prlmto vK
its leae,aqutra
lsorethe.ppliaut for m
such pedi to
.l5 file a signed Materrent that he is lionesed pursuant to the provisions of the POWER DEVICES
Ctrs
onctur'sLlc.Lsw(C10 er9(coeurendn�withSection7000)ofDlvi-
G bn3oftheBurness.ndPm(embvCode)orhkb hxrom.nd S NA POOLETECIRIC VALUATOR _
a <S the basis for the alleged exemption. Any Wdatbn of Section 70715 by any
appllontfor.pemm b)enathe.pp"l tt.ad 1pevhydnacnnrethao 1177-E1SSN77Cff6FA�T1RF3
five odreddolW(5500/. -
a.owner of the property,or my,employees with wages as their sole NEW RE4DFNMLELECTR SQ.Fr. S WFS TYI OO1JSTRUCMN
7� pevrtion,willdo theworkancithestructumbmt intended or offered for
p vle(See70Zlhtelneaaand Prd®ions Code:lhe Contactors flame Lw
.had.pply to.n owner d pro ugh hn. W lropIcy mprwn tkrton,and
whodaesauchwvr teid throughNfow .Ifhowe,rerthedthat ildingh OCCCROUP RES LINTS
impmvemntiamwtIntendedwrofcdpleale.t hw -bthebuildingw AL
Improvemerdbmld wbhinone7carofmmpldbgtkowner-Wllderwlll knee
t nlenofpecoingthnkdid notbuldorlmprovefapurpo.eofsa)e). QTy. PLUMBING PERMIT FEE
[_J L••wner of the Property,am excl.ewly�truting with licensed FLOOD ZONE APN
mntanors to mvtrun the project(See 700 Buereseed Profesbv Code: PERMrr ISSUANCE
Th Contractor's Lianas Law does not apply to an owner d property who ALTER-DRAIN 4 NEM-WATER(FA)
br Ods or Improve thereon,and who mw.ds for such p(ojecu With
rynt[actaW Hanrd pursuant to the Contractor's Liana Law. BACK FLOW PRO"fFi—I'.OEVICE FEE SUMMARY
LJ 1 .m exempt under Sec B 4 P C for this moron
DRAINS)FLOOR ROOF,AREA,NND. SANrrARY Y_ N_
Owner DamRlCm'r a
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I haw a certificate of consent to se0-bwm,a a MURES PER TRAP SC[1OOLTAX Y_ N
anl0ene of Worlen Compensation lvur.nm as o rtifled copy thereof 5m RD=F
38M,Lab C.) GAS FA.SYSTEM-1 INCA OUTLETS PARK FTE Y_ N_
INky a GAS F.A.SYSTEM-OVER l(FA) RECE]Pr
Cr ny BUILDING DIVISION FEES
CedlOed mpybhemby fumbled. GREASE/INDUSIA,WAST:INTERCEPTOR PLANCFIECK FEE
Certified copy b filed with tk dty lvpedbn dhdsion.
CERTIFICATE OF E)(EMMON FROM WORKERS' GRFA''"E TRAP PAID sZ
COMPENSATIONINSURANCE gEWFRSAMTARYSTORM EA 20�r Date Reeej tit
(Tdseectbn need nal k complded b theperrNt b for ons hundred dollars
(SIM)alss.) wATi HEATERw/vEN/Fl Fs R ' ENERGY FEE Y N
I artily that b the performance of the wak forwhich this permit is Issued.
I.kll net employ any person to any manner o as to become subject to the
wATFR SYSTEM/TREATING
Wa4en'CompewtbnlAws ofUWanb.Date PAID
C• Z Applicant NEW RF9DFNITAL PLMB. SQFT. Date Reoei t#
Z O
NOTICE TO APPLICAM:IL•fler rnaWeg this Ccdiflateof ExemptloR you
should home wbpet to the Wodmrs'Compensation provbbv of the Labor TOTAL:
N Code,you nwslforthwith comply wRb.6 provisions or this peme shall be
W G deer ed revoked. -UUILDING FEE
aCONSTRUMON LENDINGAGENCY SEISMIC E
Inerebyx(Orm Huttkm bamvlvnlon lcndingsgcvy fartk pertortry ELECTRIC PEG
7 Z arta of the workfor which this pemut is issmd(See.309/,Civ,C.) r TOTAL
V O Lendds Name PLUMBING FEE
LL I— Lendce.Addrm Qct'. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedlfy that l leve mad this application and Mate that the aboveWor ton -
bmnme
rm .I.gtocoreply WhhaBcttyandcounty ordinanasandetatelaw. PERMUISS'UANCE FEES PAID:
>. S CA rdatby,
i ng to bu lldIng construction, lumauNoZ repnyeniathms of this
F Z ety to enter upon the abovcmentionad property for Wpsetion purports AUPRORADDTOMFGH.
Cwe)a&.to sw,i"emNfy an d lo'ep harmless the City of Cupedino Date Receipt#
V .gaWt HabWtles,ydgriems,".and expenses which may in anyway amus AER HANDLING UNrr TO 10,000 CPM) SUBTOTAL:
against aid Cay in consequence of tk granting of tit•permk. ,
MR HANDLING un7 (OVERlB,aoocEM) CONSTRUCTION TAX
/D
7 i
igiuvfl1rfF&Appgant/Contrana Dale IXHAIhT Ht70D(W/DUCT) CONS'ITiUCI-I TAX PND:
HASH RDOUSMA .part ISCLOSURE
Will the applicant
nedibmeupbuild Municipal
Mom handlehazardous the I-SATING UMT(TO 100,000 Bft!) RecYl t#
materh l ar dtfiSalety bye Soct1.2oo24)? lCode,Chxptcr9.12,and the
Health and Safely Cade Se No 75532(x)7 HEATING UNIT(OVER 100,000 BTI!) TOTA
❑ Ye rL��No
W01tM1e applbMor futumbu0ding ampant arae ryulpment«devlaa VENMLATION FAN SINGLE RESID) ISSUANCE DATE
which eMt kardous eb mntamwnte as deflvd by tk Bay Area Air
Quality Management Dbuict? BOILER-NMP PHP OR l00,0IU BTU)
QNO
Fll
kvemad the ha,,andou.materials requirements under Chapter G95 of B0ILER-NMP(OVQt100,000EDU) O
/l
Ik OHlndomla l le.hh 4 Safdy CWd ,S«Uona 25505,25533 and 255M. I �
understand that ifthebuildingdoes not currentlyve haatenanL that ltbmy, NEW RESIDENTIALM110i. SQ.Fr N
rmpovBUitytonaifythe«mpaMdtherequlm ..whkhnu rct - N
prior to bsuavc efa Centa ste of occupaney. CI1 r
i Vf TaUr
\�/ v
Ownerorautharb iagent Date
TOTAL ISSUED BY.—
OFFICE COPY
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