S 2775 (2) _ _ , _
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING..RLRCFRICAL PERNDTNO.
WELDING DIVISION APPLICATIONI(PF,RMIT PLUMBING..MECHANICAL Q
BUILDING PROJI!CI'IDENTIFICAry7 C
'fION J L 5
BUILDING ADDRESS: SANT"fARY N0. nl'1'LICAI'ION SIIHMI MAI,I li
L M ctrle� P , w 5 sols G o / 3. 2G- `� q
' OW�Ij!12'S N/yNl''N PHfINI-: �OQ C(INTRACiOR'S NAMIi: LIC NO:
.IVB NIC CON'IROLN
.n°CIII'1'1!Cl/ENGINI?ER: LIC NO: ADDRESS: %Li q I /I er ) qn� ❑
CONIAC'I': /� PHONE: (/� 6U ILDING 1117RMIT INFO
Mille- aG6 x6222 ❑ Consultant Fees Paid by Applicant(Initial) BLDG filol' PLUMB MI❑CH
LICENSED CONT'RACTOR'S DECLARATION 6 QTY. ELECTRIC PERMI"r FEE J�Ij nF.$CRIIIrT�I/C'N
Q C I hcrcby affirm IIm,I inn h,on,ed undo,provisions of Chapter 9(n+mmcncing
with Solion7ifirbof IEi51nt13nit11elimin—and Poole..To-Cod.......troy license.. pCNMIT ISSUANCE RESIDENTIAL:
FSB in full rt,anJeOkcT. ❑MTDWL ❑KITCHEN REMODEL
U F License C 36 lac.N
Fza Dme1. Contmaor APPLIANCES-RISIDPJPOAL ❑ADDITION ❑PLUhf RING RF.-PIPE
nn<e �r'� ❑MULTI-UNIT [D STRUCTURAL
�h ARCHITI!CI'S DECIARATION PANFIS
FHundm
L I cmnd my s e
Planhall bea
utl u.puhllc rocordn MODIFICA'T'ION
O Z 14 C—, UP I'O 200 AMT'S
❑IN'rIiR10R [I CHIMNEY REPAIR
r., Licensed Prolessionul 201-1000AMPS IMPROVEMENT` 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REh10DELIREPAIR ❑DEMOLITION
pp,,aiW< I hereby ammr'htn 1 a+ ,n+pI from The C.nanemre License Law for the
k a U fnllo"'Ig ba"m IScetlnn]11.3 L5 CHusint,,and 1'n I—ions Cuda Any city or cv..oty SIGNS ELECIRICA], ❑DTIIF:R
G a W y which reynires a I+cbuil It co..,true,.allot,improve,demons..,or repair any.Iruc,urc
< prioru,a,issuance.alw+rcywres the applicant for such sector to file a signed statement SPECIAL CIRCU IVNIISC.
ally— that he is lieta T pursuant to the pru,kiom of the Commao(s Ldcone law(Chapter 9
WCCO (commencing with Sectio 7000)of Division 3 of the Iftomessand Proft,simrs Code)or TFMP METER OR POLE INS'L COMMF,RCIAL:
m E o that he is exempt therchotn and the fir",for the alleged exemption,Any n vidadnof El NEW BLDG/ADDI'TION [IDEMOLI'IION
k m_t+_ DEVIC
ibu appGaunl
Section 71131.5 by any tq+plicnm lkwon
sunjcele to acted pnwlry of POWERPOWERES
W m m mom than five hundred dollar,fin
BS won ❑'I'IiNANT ❑FOOD SERVICE
1-=Q I.as owner of the norm employees with woes as Their sole core tion, SWIM Ni 1NG POOL ELECTR IC OTH- EM1f IiN'1'
F. proof' Y Y mop Y g tens ❑OTH
F will do the work.and the sTtunure is not intended or offered lot sale(See.70-14.Business
C o
a3=�°
and l f,. C+Jc theC t , :I. 1 does Golly, court.f OIITIITS SWI'1'CHLS IIX'1lIRLS
cropscrift,whon '11.nr p n - n.. d 1 .sen k 1 fformaona,lft
IT,ostrply provided that...i imp t:are not' t J Ioffered lit NEW RESIDENT'I Al.ELECT It SQ IT.
sale.IL however the building or inrprovemmntis sold within one year of completion,the SQ.f9'.FLOOR AREA S/SQ.FL
owirwi,builder will have the burden of proving That he did ata build or improve for pur-
po,e uI ualel 'IT)1'Ah
❑ I,as owner of the PruNrty,am exclusively contracting with licmmed
eonmtaorsL',
.nsmoct tauPrject Sec.7(33-Hosnesxand PmI-
nseWwdcs..,apply m an ownerof,im,eny who build,or improves hereon.and QTY. PLUMBING PERMIT FEF.
who contracts for such projects with IT comracmgs)licensed pursuunuo the Contractor's
License law. PERMIT'ISSUANCE
❑ l..tn va rept under See ,11 N It C for this reason
ALII7R-BRAIN A VENT,-WAI'HR(EA) VALUAI'ItIN
Owner Doc
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(YrECI.DEVICE
1 hereby affnn under Penalty of perjury one of the following dcclumuff ns: <
r I have and will mnintain a Cerificate of Consent in self-insure fur Workers Colvin. DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCTION
,niton,as provided tut by Section 3700 ufthe[sbor Code,for the perlhrmanccaf the
work for which this lie nntt is issued VIX'I URES-1117 R I RAI'
E]1 have and will maintain Worker's Compensation Insurance,us required by Section
37000 the Lo Cade.Ino theperfomu ttof The wad 4orwbich,hispermitisissual, GAS-EA.SYSTEM-I INC40UTLEfS IZIGROUI' -W'
My W'orkeI our ansae.. Once c: ,ic.and Policy u bet arc: GAS-IiA.SYSTIiM-OVF:k 411iA)
ol,
Nc.
Carrico CHR'I'IIICATP OPT!%IiMPfIOINYI ROS' (044,!&COMPENSAI ION INSURANCE' GHGSUINDUS'1'RE,WAS'll!INTIiRCEPIY)H RIIILDING DIVISION IIifS _
('Mt,mesion need nm Re cotnplmed tithe permit is for one hundred dollars(S 100) GREASETRAP
or less) I'LANC111iCK IFIi
I terrify that in the performance(It the work for which this pennn is issued.Islall SHINER-SAN[TARY-S'IORM IA.2(a Fr.
n.I....ploy any person ..any mannTonon,In become suhjcct m d
the Wocrs'Cntnpen" ENERGY IFIE,
Z mion Lowe of Colaurnia.Date WATER HEATER W/VENT/ELI!CTR
z 0 Applicant GRADING PEE
NOTICE DO APPLICANT:If,after making This Certificate of Exemption,you should WATER SYSTGM/rRIiATING
`Na SOBS FEE
FNN heroine nuhlecT m the Worker's Comp.In Ili, provisiotrs n e do,Lob+.Qdc,you most
tor(1 11, (Imply with xuch pmvisiunn orlhix pcnnh.ehull nc JmnmA mvnkcJ. WA'f13R SL'RVICI!
d Q PAID
7Z CONSTRUCTION LENDING AGENCY NEW RESIUIiN TIAL PLMB. SQ.17L Dote RecelprTo
L)O IherchYaffiren that there isaconswninn lcndingagem,1 I the performance of
W e+ the work(..which this Pc aril is issued Nce.3(N)7.Ci,CJ
C U London Name TOTAL:
Under,Addneex TT 1'IA 3 . 00
r W I ccrlify that I have need this applientino and%late that The above information is IiU11.DIN( Flili
a
F to rortcct.l agree mcomply with all city and county oNinuntts and slam laws refining to QTY. MECHANICALPERMIT FEE
40-
U Z, buBdie
in,,um ion,and hm hereby amhoricetepmoaccudvcs of city enter-11a'he SIHSAt .
ab.vcnteutiened properly for inspection pur,v),cs PERMIT ISSUANCE
(We)accent anvc,indcnmily t I IT,larntlms Ile Cl y ul Capella agaitul Ii1.11 Il?li
IiabRbdns,judgmc....cnx..and cspenms ohknmry in any way.come agincra said Cl, At:[ OR At)[)TO MECH. PLIt 11 NG FEH OO
onscyuenccn Ill L'mn' g.nni.pemrh. I
APPLICANT Jf HS NDSAp")WILLCOMP YWITHAL1.NON-POINT AIR HANDLING UNIT(TO Ift,000CFM) MEC ANICALI,:.
SOl1RC AI' .3,T/. J
31syI9_l_
!VE"�Floyf
LERLSIL
.INN ) CU "TNUCfI(1N'I'AX
Sig urc of Applicant/Commctor Care HOOD(W HODS GMITIINHONFEE
HAZARDOUS h1ATi' DISCLOSURE
Will the applicant or future buildingooctsamoom or handle hnmrdous..mend it I'U)
a.nemrea try sun cnPenim+Mnnic' .tl ct><1n,clap..,9.12,and me Hetdtn:rand stiety
Coda Section 25532( 000 BT
�Ycc Nn IRLSIDI AID Dme Receipt or
Will the applicant(IT future building occupant use equipment or devices which XXI BTL1wetnil h..eanluus air,ornanmi ams ax shined by the Bay Arra Air Quality Management DtsviaP .)00BTU)
❑Yes zzo Ll S
Ince , hv:Waus nu¢nak uunder Cha nor 6.t)S of Thc Cali- AIRCONDITIONER ISSUANCE DATE
n rcymmnxn i
forma 11 S. y CnJe, inns 255(15,25533:md 25534.I unJcmand,ha,it the NEW RI!SIDEN'1'IAL MECIL SQ.IT.
nutsli ...e ..r t n I nm+dn,'I,louonIylhe Ior...pant
n tvol
em enrae nope t l
..Ione, cA..gem V a,c 'TOTAL: ISSUED BY:
OFFICE