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BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL SOOOI 12 1
BUILDING PROJRCI'IDENTIFICATION
Rl11LDiNGADDHIi.SS: SANI'T'ARY NO. APPLICAI ION SURMI MAE.DATE
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9 RPS
O NER'S
NAME 1'IIONI?: CO '12A"I OR'S AMIE IC NO
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DIT '` LIC NO: ADDNF.SS
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PHONE: �' CA IS]3i1 BUILDING'PERMIT INFO -
MK- N 71 e-W6,AVI VI Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB MECD
S— 31- c�
LICENSED CON'I'RACTOIi'S DECLANN'ION 1QTY, E1;81"TRICIPERMiT , FEE
I nereny af)rtn mat 1 a1n lmen,ea under pmvi,ions of shaper 9(caminencing JOB DESCRIPTION
�I+JOp aZ with Sc Iim700mdIDivi,bm3uphe Rosiness and Prnlessions Code.an mylicensc i. RESIDENTIAL:
PERMIT ISSUANCE
Fly.. inculi force and ellect ❑SFDWI. [I KITCHEN REM1fODEI.
<UU Li,enw Clues p AI'I'LIANCIiS-Iil?SIDEN'I'IAL ' ❑AUDI T[ON El PLUMBING RF-PIPE?
FZUL Uum Commdor
Fo al ARCITI° TSDIiCIARTIO PANELS MODIFICATION
H<y ❑JIJLTI-UNIT ❑
ZOm ❑INTIBLOB ❑CHIMNEYRI 'A
IROZ40 UPT02WAMPS
I
, I es irnul 201-❑NNEAMPS IMPROVEMENT' E]SWIMMING POOLS
OWNI?R-IIDILDIiN DECLARATION OVI?R 1000AMI'S ❑BATT I REMODEL/REPAIR El DEMOLITION
d' 6 i hereby:Jfinn that 1 am exempt front the Convacmr's License Law for the
a•OyU following (Section and professions Cwle:An 't t ❑of-DER
l� g reason y city or county SIGNS ELECENICAL
R W� which requires a permit to construct,alter,improve,demclish,or repair nay sruc rre
�e7�Q prior to it,is,uurce,oleo reyuircs the applicnm or such Mrmil41 file aaigneJ SLamnlem SPECIALCIRCUIUMISC.-
@,l�} thin he is licensedpulsuamm ihc,m,ixmr,oB the Cmnrimotl License Law(Chapter 9
w C0 (connnamagwith Section 7010()cf Division 3mmm Himme,sand Professions Code)al TEMP.METER 0IVJ NST. COMMERCIAL:
d C I that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C2 DEMOLITION
r li Section 7031.5 Eby any appI wind for upemtil mhjens the uppliecorma civil Frank,or POWER DEVICES - EITENANT ❑FOOD SERVICE
�>. nl ncom than five hundred dollars($500).Cz6 ❑I,usowner of ltid progeny.or myemployeeswith wugesaslheirsnlennnpeosaka, SWIMMING i'OOLELEC'IRIC IMI'Hf3Vl?MENI
'
0 will do the work,and the structure is not intended orNTereJ bursate(Sec.AW1,Rome" El OTHER
6'3 m 5nA Professions Qule:The Cnmunor's Littnx Law dnen not apply m un owner a OIITLFTS-SWITCHES-PI%TI1RC
property who huilds oi- mprovcs thereon,and who dues such work bimsclrapthrcugh
his own emplcyec,,pr died that such impmvcmeals ors not immrded or offered Int NEW WIN'I'IA EI.EC'I R SQ Ff.
sale.If.however the building or improvement is sold within one year ofcmnpletion,the SQ.FE FLOOR AREA SISQ.IT.
nenbuilder will have the burden of proving that he did nm build or improve for pnrin
-
. pnwc of sale.). _
I.a,owner d Lha property,tun excloolvely contracting with licensed"'court nrs m OT
mdmn the projem(Sce.7044.Rashness and Profession,C1xle:J The CunOacmr's I:r - ..
se law dons not apply to an owner of property who builds, impnrves Ihercon,and QTY. i" - MBIN PERbI1T •FEE
whorcmnmcts forsuchprojectswith sConfiset o)licensed pursuanuothe Comrecmds '�
License Law. 1117RMIT ISSUANCE
El I no exemp�drder Seo. ,B&P Cf or lhismn,on
Date ALTER-DRAIN&VENT-WATER(Ck) VALUATION
WORKER'S COMPENSA'PION DECLARATION RACK FLOW PROTECT.INIVICB oO
I 10hereby;than ander Rnal ty of perjury ore or the col lowing dcclurnt Ions'
I havodnd wi 11 mai ounce Cort ideate of Con,en1.sell'-insure for WorkersCamper DRAINS-Fl.t( ROOF,A & ND' S'IORIE. 'TYPE CON S'I RII CTION
1
smion,as provide)for by$re11m13IIXE of the labor Cole,for performance of the
w k for which this permit is issued FIXTURES-i' AP
I have and will Inaimam Workers Comperwtio,Insurance,as required by Section
.7 0nrlhe Labor Code,for lhope,formam.eof the work for wag., i,is 'ed, OAS-HA.SYS's I IN(' ( L T. 9 OCC.CRIME. APN
MyWinwCo p a� ncecwTieraiid No.yher GAS-F.A.SYS' -OV: 4(I?A)
Carrier. Kl
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASUINDU. L WASTE INTERCF,PI'OR
COMPENSATION INSURANCE ILDING ION FEES
(Thisseclimtnced Rol be camplGudd thcpermil h lirtunc lmnJrcdd,11 011X) CRIiASB T'kAl' By /
or less.) P Clil' FEC DIVISIp
I cenity that in thepMorm:mre of the work for which this pemdt is ismed,lshall SEWER-SANITARY-STORM EA.21X1 FF.
not cmpley any gerst in any manner so as m become subject to the Wurkcri Conflict, E ,I PRE 19
O ,'T. amine I.ewsofClao.nla.Dmc WAI'17I2 HEA'I'FRWIVENI IELECTR AUINO FEE
Z 0 Apphirst
y NOTICE TO APPEACANT.If,ager making this Cenificem of Exemption,you should WATER SYSTEMCREATING
F become subject to the Worker',Compensation provisions of Labor Core,you mut I SOILS ITE
Wti forthwithwmply with such provisioner this pemailshall he JttmN revoked WATER SERVICE?
Q
CONS'1'NULTION LENDING AGENCY NIiW NISIDIiMI'IAL PLM B. SQ.FT. PAID
U Z Uale Receipt X
V hereby which
rthemmiti is.ConSo,.30lendingagency for the ryr0lrmance of
nor work Na which Chic permit is issued(Sec.30'17.Civ.CJ
GT+ Lender's Nmnu , I[ Af'
V I.cndcr',Address 'TOTAL:
Grp - - - BUILDING i)?E
1 certify that i have with
thirty and court y ordinances state the the above ws relmion is
VZ1 mildingagree mio,and with all city and coumysofhid sura laader.pngm QTY MECHANICAL PERMIT .FEC
U ,2, building construction,and hereby authorize representatives of this city to cmeruq,n the - SEISMIC PIi Q Q
nhavo-mentionW pmpedy Go ho,ection 111111,1,11. PERMIT ISSUANCE VION
(We)egrcem save,Indcnmi fy and keep harmless IIIc City of CuPcrtico agvinsl LI, sliabilities,judgments,costs and expenses which may in any way acemeagainst said City ALTER OR ADD TO NIECE I. _J yy�in ren:scome ofthe granting of this Nrook.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITCIO l0,(NIBCFM)$OURL_'h RFGULATI(lN l4bi//I`(��..Q SlAlit IlAND1.IN0 UNIT(OVI?R I0,0(NICPbU XSign' ofApplicunUCnlnmuor Da EXHAUST HOOD(WMUCI') N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Brum building(acupam stare or handle haourduus order al HEALING UNIT'Cl 0100,)(X1 It DO)
as dc0ned by the Cupcdion Municipal Code,Chapter 9.12,and the Health and Safety
Cock,Section 255321x)? ' •\e HEATING UNIT(OVER 100,0D0 BTU)
❑Yw VI?NTILATION PAN(S I NGLE BESIDE PAID Date ReceiplX
Will the apPllcant or l'unhar building occupant use eyit'ami l in devices which
- i1 havardom an contaminants as definul by the Bay Area Air Quality Management BOLI ER-COME'(3HP OR 1[NE,IHN)BTU)
01
DistrictT .:
C]Yes n BOILER-COMP(OVER 100,000 RTU)
1 hire read the hacmdo s namerials rcyuircntemc older Clugrer 6.95 of the Cull- Alit CONDITIONER S
Enron.Health&Safuy Cade.Sections 25505,25533 and 25534.I understand Nat if the NI?W RESIDENTIAL MECfL SQ.FI. /
building does nnl cmmndy have v mnam,that it is my rexrymsihility m nmifylhe occugam
oro requireme la high rypsl hero ormissunace oluCeniOwtf ccupa c.
O o cmc .Il d agrm a _ T ISSUED BY:
OFFICE