99110067 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / b I OQ
CITY OF6UPERTINO BUILDING-ELECTRICAL vI- NO.
SUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL
BUILDING.PROJHCr IDENTIFICATION
BUILDING ADDRESS: SANITARY NO A PLICAHONSUBMITTALDATE
"NF.R'S NAM': v PHONE: CO ORSNAME: LIC NO:
�f CJar' NIC CONTROL M
ARGI{IT:_.I;NG I-I:I;��/�-r`�`/Y"L� )` A IyZIS
4I- u/1LN-//CVC/�-�RIr %ov Ve �7
CONTACT -g PHONE. -C/ BUIL NG PERMITINFO
3 c-f E3Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB ME❑CH
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby arfirm Ilial I a.n Retroed anal pro.i,wm,ar ehapmr 9(eatnmencing14 JOB DESCRIPTION
OZ with Section nullpof Division 3ofthe Businc,.and Pndeaslons Ca{e.and myliccvacis RESIDENTIAL:
IB O PERhf IT ISSUANCE
full and eked.
O$FDWL C3 KITCHEN REMODEL
at-l" License Class Lot.p6VV
API'hIANCES-RISIDHNTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N6 y Datc Commmnr
IECTS DECLARATION MULTI-UNIT ❑MODIFI STRUCTURAL
MODIFICATION�7Z lundemmndm 1 I IlhmN as M1lic records PANELS MODIFICATION
OZa�-'O YPunsnm Pu UP TO 2110 AMPS
❑INTERIOR El CHIMNEY REPAIR
F4F'W Licensed Profiastlonm 201-11MM1AMPS IMPROVE 0SWIMMING POOPS
ads; OVER RWAMPS OBA ODF:IJREPAIR DEMOLITION
Yf OWNER"BUILDER DECLARATION
afsc I hereby affirm mal I:..n exempt from the Contractors Liccme Law far the
following rcacnn.(Section 911.11 S,Bnsinear tad P I ,ions Code Any city ar ttmmty SIGNS ELECTRICAL HER
Ial'31+.F' which requires a permit to construct,place 1 peeve,demolish e,repair any,uncture
F�04s prior o its issuance.also requires the applicant for such permit to rile a signed,tannenu SPEC]AL CIRCUITIMISC.
$ } that he is licensed pension it)the provisions of the Contractor's License lsw(Chapter 9
u+�00 (commencing with Section701 of Division 3 of the Business and Professions Cale)or TEFIP.METEROPPOLEINST COMMERCIAL:
c,tY c K 'hal he is exempt therefrom and the basis for the alleged exemption.Any - hien of ❑NEW BLDG/ADDIT tr ❑DF,h OLITION
'tie Sedinn]1tll.$by nnY aPPlic:mt nit:.permit snbjcdsthe applic:nn n.ncivilR tyol I.OW17R DEVICES ❑'TENANT IDT SERVICE
=� nor tie than five hundred dollars S5110). IMPROVES, l T
01,a o ra,rofthe pml¢ny,nnny employees with wage,as their sole compcnsmion, SWIMMIN 1 ❑OTHER A��.
F- will Ju the work,and the atrvcturc.enot immnded Or offered for ale(Sec.]tw.Huainmz 1
Wm and Professions Code*he Contractor's Licemc Law does ma upp o - 1
proCery who builds or improves thereon,and who docs such work h sa I gh
his awn employees,perval that.such improvement,are not inter S EN I.I_IE/R
goll FT
sale lL boweveq'bc hnlldingorimpmvement is sold within one year:,,,) SQ.FT.FLOOR .Q.FE
er-bulldn,will have the burden of proving Ihm he did not IwiW or.mpmve for par
pacem sale.). OTAL:
❑has owner of the Pnpeny,an cadusivdy comndon with liccnwd con tars m
construct the project(Sec.]014.Business and Prnfea,ioas Code:)Tae contra
FEE
se Lw docs not apply to can owner of proper whir builds or imp..cea the TY. P I
who cumnmtp for such pr jeut%with aeomnm.orl-sllicen,cdpursstammthe Conlnemr'-
Llccnse Low. PERV
C)I am esenpl under Sec. _,11 &P C
-DRAIN&VENT-WATER Uw R T
Dam ](U[/
WORKERS COMPENSATION DECLARATION H K FLOW PROTECT.DEVICE
herby chiral mai under penalty of Perjury one of the following dednm'iom:
❑Ihave and will forty eCion 37 a ofCentro In,alf
Labor Coke.
Chia Wocker'sce of
)RAINS-PIAOR,RUDE, GOND. STORIES 'TYPE CONSTRUCTION
workas provided for mi Seeman d. of the Lubar Cnde.for the performance of"c
wed for which this permit is issued. FIXTURES-PER TRAY
❑1 have and will maintain he performance
Compensationce ofaw Insurance,as required,i Section
3]Ull of the L.Mm Code,for performance of lite work for which his permit is is GAS-F,A.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carier and Policy numtx:r an'.
Carrier -.-y l No.n GAS-IIA.SYSTEM-OVER 4(HA)
CERT1171CAI'17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMISDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(Dik,ection need nm he completN ifthepc.it is fee-' hundred doll (51(r) GREASETRAP
or kss) - f CHECK PCs
Toy an'"min the perl'"aacrceofthe week for which this the it is Workers
4lshall
no'cnt In to Bcm.ne subject the Workerc'Cu.n cru SHWIIN-SANITARY-STORM EA.NNI FC � P GY E/�% lJ
employ any person In any atanner so as j t
Z Applianws of California.Umc WAI ER HEATER W/VENT/ELECTR
nt
NOTICE comesubject
APPLICANT If.Co making this Tenons Of at Exemption.d you should WATER SYSTEM/IAfiATING
F' N become subject m the Worker's Coons or this provisions of the Ldaa cede,you mus' 115 FEE
lonhwith comply with such provisions nth.,permit shall be JeemeJ revoked. WATER SERVICE.
Q
CONSTItUCT10N hIiNU1NG AGENCY NIiWN I'IAI.I'LMB. SQ.FT.
d RESIDE
U O I herthy elf roe uhm Ihvrt is a cominnion Icndin%agency fonhe perfommnee of l—Dam—Receipu.q—.
U. the work far which this permit is issued(See.30P97.Ci,C.) TOTAL:
C)U Lenders Name
Lender's Address TOTAL:
G 1 a,oify ma.I have read thio appllembn and gate ll ul the above infomwdon is BUILDING FEE
E" A correct,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UZ building enunciation.and herchynmhorna re,proanawc,ul thisciiym emcr upon the SEISMIC FEE
above-mentioned pmper for inspection purpoms. PERMIT ISSUANCE
(We)agree m wve,indemnify and keep careless the City of Cupea iso against ELECTRIC FEF:
liabilities.judgments,costs and expenres which may immty,way acme against said City ALTER OR ADD TO MECH. PLUMBING FEE
In cnnacqucnee of the granting of this rennin.
APPLICAN"r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(1010,000 CFM) MECHANICAL Flili
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of ApplicroUConms'or Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
IIA9,ARDOUS MATERIALS DISCLOSURE;
nes�cMedYs.ha Calabria Uibuilding oavpunl,mn or handle hvuMaus nautical HEATING UNIT(TO 100,0010 RTU)
W anon
as l it
ycus xh onn.n.nnmFI tsyal Cale.Chapter 9.12,and the Health and Salify
Muir
Section 25532(a)q IIIiA'1'ING UNIT(OVI?k 100.003 BTU)
No VENDLATION FAN(SINGLE RESID) PAID Date Receipts
Will thea applicant or mum building occupant use equipment or devices which
Jefindl by the Boy Arca Air Quality Mar,macm BOILER-COMP(3HPOR 100,000BIU)
Uis¢Icq BOILER-COMP(OVER 1 WWII BTU)
p Ye, C]No
I have read the hamNou,maueriaL requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE;
fomiu Health&Safety Code.Sections 25505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have c tenant,that It May respomaibiliuy to notify the Occupant
of the requirements which.nnsi he met prior to Iksunnce of a Cenil'nme of Ocrnpancy.
Owner or amhmi wd.gait Data TOTAL: ISSUED BY:
OFFICE