991000027 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �� ('DOJO
CITY OF CUPRRTINO BUILDING-ELECTRICAL VERB IT NO.
BUILDING DIVISION APPLICATIONAXERMIT PING IROJEINGC F:CIIANHEIC p
BUILDING 1'NOJELT IDNN"I'IF'1CATION T
SANITARY NO. APPLICATION SIIBMII'IAI.DAT
BUILDING ADDRESS:
0500 ( Co�►�T /D- -g
OWNERS NAME: PHONli: CO A ORIS NAME: ca fC NO: 1 NIC `CONTROLN
tili
CHITECI'l1iNGlNlipk: LIC NO: AD %N. Oe/ACRV2 61111 _S"� ❑ r Ca. Y�
lZ� )k 6_Z % ( 1`
CONTACT: M 't PHONE
BUILDING PERMIT INFO
$jL1gµ I,Ia FF
4MON-1-"7141 Consultant Fees Pales by Applicant(Initial) Itl.11(1 ELECT PLUMB MLCiI
L,IJ�LIXv, X ❑
JCIiNSHD CON"TRAC TOR:$DECLARATION QTY. ELECTRIC FERMIT FEIi TOR DESCRIPTION
1 hcrehy norm thin[;air Ilcrnsed under pmviainnc of Chapter 9("n nerncing
awz wimSccdon70a))of Division 3onhe Busine—ne Pmfesninns Gdc.amd mylllcnw i. RESIDENTIAL:
O PERMIT'ISSUANCIi
CUFEMODEL
fullforcc:m Fkcl. _' '�Z I ]I ❑SFDWL ❑PLUMKITCHEN RE-PHT
QUU Licence Cl Lk.p APPLIANCRS—kP_SIUIiM1Al. ❑ADDITION ❑PhUMdIRG kli-I'll'li
t.Zul Dae Commas°r ❑MUU1'L-UNIT ❑STRUCTURAL.
r,Qd ARCHITECTS DECLARATION PANELS MODIFICATION'
z C)h Z 1 understand my plans shall h used as public«cards
OZ�a - UP TO 2IX)AMPS ❑INTI!RIOk El CHIMNEY REPAIR
F Z,I +p Licensed Professional 20140IMAMPS IMPROVEMENT E]SWIMMING POOLS
CY�� OWNER-RUILDER DECLARATION OVER 10MAMR4 ❑BAl'H REMODEL/REPAIR El DEMOLITION
i C Q I hereby affir that I am exempt farm the Commences Liecme Law for the
�a U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL OI IILR
ma which requires o permit to couswet,also,improve,demolish,or repair any stmeture
F— J priors t issuance.alsorequiresm applicant for such tin flsignedstatement SPECIAL CIRCU IT/MISC
�E- that lie licensedlire t' theprovisions fth Collateral, L (Chaper9 COMMERCIAL,
M x Q MO (tam 6 'b S cW ](XNq fU' 'on 3 fah B .' ss; d V I uour,Code)or TEMP.METER OR POLE INST.
6L y o e bar he is cecmpl Ihamfinm and the basis fur the alleged exemption.Any vinlatinn of ❑NI!W BLDG/ADUI'IION ❑DF:MOLI'PION
m Section](q 1.5 by any applicant ban perp subject,the applicant ,,a civil penalty of POWER BE ICCti 42( IiNAN'I' ❑FOOD SERVICI!
not mon:man floe hundred dollar,(SNX0. PROV HMENI
=Q ❑1 Isle prop rY army employers 't b:Ell d purnf m, SWIMMING POOL HLLCI'RI ❑OIHER
Cie wllA al k 1'hc.l t ainfe dJ Il d(nsl (S ](hallussl
6'3m
and l I.:' :Cade:Th Coal' . 's License1 J rot apply to was of OUTLIIS-SWI TCHUS— '1'11 �YN-�l/ 1`W TNI
proryry who builds or improve,thereon,and who does such work himself or Innmgn
his awn employees,provided that such impnwemnns um not intended of o0cmd fill NEW RESIDENTIAL ELECI'R
,.[I.It.however,the handingor improvement is sold within one year afcrmpletinn.the SU�PI'.I FLOOR AREA 5/SV PI'.
owner-hankler will have the burden of proving that he did nal build or improve for poo,
[j1oc town. TOTAL: ��/
1, f ale.). of the pmpcnY•am exelusirely rontacting with licensed cnmacusrs m o��fff"'
mnstract the project(Sec.1(W,Business and Professions Code:)The Cantmnors Li- D
rears,law roes nm apply man owner of Fopeny who builds or improves he... ad QTY PLUMBING PERMIT FEE
who contracts for such projects with a comraclods)licensed pursuant,,he Cotnraaols
License law. PERMIT ISSUANCE OCT 199
I am exempt under See .B&P C for this reason
ALTER—DRAIN S,V NT—WATER(EA) VALUATION
caner, Date P�01oo0
K'ORKIik'S COMPENSATION DECLARATION BACK FLOW IBOTIiC I'.DEVICH T)
T hereby dfna under penely of perjury one of'be fullowing drelumtione IIJJ
I have and will montaina Cenidw'cof Comm�un,clM1lnsum lir W..ke"Crmpen- DRAINS—FLOOR.ROOF,AREA,COND' SN'Boli5—..� �IYPBCHN99 echo
cation,us Pmvlded Ira by Section 3700 of the Lubar Code,for the lµd'orcr nce of the
work for which']oil permit is issued FIXTURES—PER I RAI'
LAhave and will maintain Worker's Compensation Insurance.as required by Section
!IA)of the Lthm Calc.far the perfrmanncc ofthe walk for which this Penni'is iswed. GAS—Ii ,SYSIIM-I INCA OUTLETS OCC.GROUP / p AI�'�
My Waders CT nsmi Insurance carrier and Policy nm rye ( /W� V
Came p910 IIMc+• Policy Na: (—F(0 GAS—F.A.SYS'I'Ehf-UVIiRJ(LA) O
CERTIIICATE F EXEMPTION FROM WORKERS' GREASMNDUSTRI,WAS 11:INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need nosh asmpleted Base Permit is but hundred dollars(SIM) 11EA1l:T1AP
PLANCHr:CK Flili
or
less.)
Iccnify that in'in anyPerformance ofthe becrarwhichthin'he Wokt is s.,C.I shallmKB- SEWER-SANITARY-S'T'ORM EA.20D FT. I!NIIRGY tLE
nen employ any pcwm in any manner so as to hmme mbjen In'he K'urken'Compen-
0 O Applicant
Lo sof C.1i omit.Dam WATER HEATER W/VENTR!I.ECTR GRADING PER
sn but ICE DO AP%.ICAW:If,,free making anis Cenilicsro of Excmptiun.You should WATER SYSTEMIURI!A'I'ING ;IIAID
Plitt
a ; bornane subject m the Worker's Compensation provisions of the Labor Code,you most
limhw'nh,amply with such Pmvxaona ar'his permit shall he deemed revoked. WATER SERVICE
PL Q CONSTRUCTION LENDING AGENCY NEW RLSIDI!NPIAL PI.MB. SQ.ET.Z) z arc Korei,,
I hcruny nl'fnn thnuhcre iso con,tmmion Icnding ogcncy liarthepurinranamceof{ULO the work for which mi,peri'is issued(Sec.309],C'tv.C) 1'AL:
C) U Lender,Normo 'TOTALLenders Addr,s ING FEE
I calory That 1 have read this applilaim.and state that the above ialnmation rct mca.I traccu'crmPly wI'll all dry and county ordinances and state laws relining ts' QTY MECHANICAL PERMIT FEE IC Igili
U building cannion.and hemby ouNorice representatives of this city to enter upon the
abmr.mentioned properly far inspection pu0'rses. PERMIT ISSUANCE IiLIiCI RIC III
(We)agree to rove.indemnify and keep historical the City of Cupenina again t
liabilities.judgments.costs and expenses which may in any way weenie agaim,said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS A )WILL COMPLY WITH At.[.NON.POINT AIR HANDLING UNIT DO 10.000 CFM) MECHANICAL ELF,
SOURCE RI ULA ONS.
ALR HANDLING UNIT(OVER FB.000 CFM) CONSTRUCrION'L'AX
Signature f pp scnnVCnn actor Dune EXHAUST HOOD ONEMUC) []DOSING MITIGAHON FEE
HAZARDOUS MATE. t S DISCLOSURE
WI he applicant or auttrebuildiogrc.upant,nne0ahnndle .nlous material HEATING ONI'T(fO Ballad)IITU)
as eflued by the Culterino Municipal Code Chapter o c Health and Safety HEATING UNIT(OVER W JXX)BTU)
Cuda.Seroma 255)2(,1! PAID
❑Yue 1¢No VEM'11.A'IION FAN(SINGLE RESID) Uute Rccciptp
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(.1111-OR IIsour .BTU) ,
nit harnnlous air commercials as defined by the Bay Arca Air Quality Management TOTAL. 0 1.
)isvim] BOILER—COMP(OVER 100,000 111 Ye 7CI No
//� AIR CONDI'1'IONIiR ISSUANCE DATE
I have dEh read the Cud,.S s mamd'uls requiremana under Chapter 6:15 of the Cali- .T�
hsmia gdoe &telae CDM.Sato s 255 d i 2553)and 25SJa.I uMtify m ohm if the NEW RPSIDCNI'IAL MliCll, SQ.ET.
otmengdrc neo takhrus t ',met itismy resofaCifil rot notifymeaha
of the rtyuir tones hich mus Priormicmorce nfa Cenilic teof(4ca� ---^�—�
Uwnero au nwJ agent Da'e� TOTAL: 1SSU17D BY:
OFFICE