S 2165 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFR'I'INO NUIL=C-ELECTRICAL PHSy`{IT No
BUILDING DIVISION APPLICATION/PERMIT TING PROJECTECHANIFIC PHS
2165
BUILDING I'ROJI?C'E'IUF.N'1'IFIC'ATIIIN
BUILDING ADDRESS: SANI'T'ARY NO, APPLICATION SUBMITIAI.DAdP..
I
OWNER'S NAME: PHONE CON FRAC'IURIS NAME LIC NO: /V-'S`'•
NIC CONTROL
IARCHITECDENG Ili R: LIC NO: ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECII
❑ �4 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPHRMIT FEE
1 hereby affirm That I am licensed under provisions of Chapter 9(cmnmenc{ng JOB DESCRIPTION
QW 0a wiliSectar awmnrDivixion3 onhe 6ixaacsand Ponessionscode,and ray livens,is RESIDENTIAL:
I 1- PIiItM IT'ISSl1ANCC
a LLy F„ mlullforce tau , I I.
❑SFDWL CHEN REMODEL
<-U I.iccnse Guxs l l.ie.q `C �` S gpPhigNCES-ItGSNENTIAL ❑ADDITION ❑PLUMBING RIid'll'E
F-Z W Datc CnntTnctnr
H5y ARCHITECFS DECLARATION ---_� PANELS ❑MULTI-UNIT El STRUCTURAL
mQ Imak,...nndmy ple.hec
anall bcedas pubhewa,nle MODIFICATION
OZI-C UP 10200 AMT'S ❑INTERIOR []CHIMNEY REPAIR
F 4!:W Licensed Profcaionw 20I-1000AMPS IMPROVI?MENT DSWIMMINGPOOIS
90
'4 OWNER BUILDER DECLARATION
J OVI2R 1000AMPS ❑BATH REM )ELTEPAIR El DEMOLITION
WQ I herd,,arum Ihm I am exempt man The Contrmmr'n Liwnec Luw,for the
G L U rcuewin, Section 0031.5.Bunmeas and prnfessions Code:An I D OWER .MA 2i e,rJ
X3 following ydyarwamy SIGNS ELGC'1'RICAL N I __11
W a h which its issuance,
a permit re uir requires
alar, for su demwkh,or mash any wmmum �1.�_�T N �+ 1 -�i�O
aa Pr, t t: '.0 n q The ( hPen iu flsigned.t statement SPECIAL CIRCl1R/MISC.
Y t
Than heiv liolawdp a u this i o llh Contracts),Uccn,Lal (Chapter9
0�C (tnnnene nbwih Senn,70E))of D,doma3tl Thu l4:ne; m
dlfos;os Code)o' IEMIR.MEI1?)tOIt POLE L:
INp COMMERCIAL
W a e C Thal he is exempt Therefrom and the basis for the uJl,,cd cscomaan.Any violniso of ❑N17 BLDG/ADDITION D DEMOLITION
a'
Section 7031.5 bdany applicant for a permit wbjects Theupplicanl to a civil penahy of POWER DEVICES
to []TENANT []FOODSERVICE
4�y w more Wan Eve hundred call...($500), IMPROVEMENT
6 D I,vx owncrnf the pnrpm y,nnny enlPloyccs witll wxgen un lhclr nnle nnnpensmion, SWIMMING POOLE-,'
LS.p wi 11 do the work,and the structure is not intended or til lewd for sale(See.](H4.Business ❑OTHER
6,3 m and Professions Code:TTe Contractor's License Law does not apply to an owner of CUT LETS-SWIT ES-F S
property who hinds or improves thereon,and who does such work himself or Through
his own employees,provided that such itnpmven,cats are not iawmlad w uttered for NI?W RESIDES
site.ILhowe,er.thehuilding orimprovenwat is sold satin enc yea dconcplAos,the SQ.FI'.FLOOR AREA $/.S'Q,FI'.
,cire,Imilde,will have the burden of proving Om,he did am build or improve furfair,
[] I,us nwrmr of the Sec.70y,mm excluxi veld mntrawmg with licensedcontractor,
atomre., t 1.
rose reaLa trees notTpply in an Businessand
rty wh buildnto s
ori'I'hovesthereon, n - -
nselawWKsnwapplyloasowner withaommendywhobedpurrimpmrvhetommeand QTY. PIAMBING PGRMIT FEC
who emtrecu for such projects with v wmmcun(a)licensed pursuvm to Wa Commaor:v
License Law. PERMIT ISSUANCE
❑ lam exetupl under Sea .11 k P C furl his mason
Owner nate ALTER-DRAIN K VEN'1-WATER(HA) VALUATION
WORKER'S lir
COMPENSATION DECLARATION BACK PLOW 1'ROTF.Cf.DEVICE
1 hereby umt
ifinndcpemllty of perjurynuc of the litllnwing dedannins: ^—
❑Ihave nnJ will mainwin vCenitimveo[Co,sssnno sdf-insure far Worker's Cnmpen- DRAINS-FLOOR.ROORAIt NA, 'ONU' STIORIE$
'CON S'I'RI1CfION
scion,a provided for by Section J9gl of We labor Cale,for the peRomsence of the
work for which this permit is issued, IT X1ORES-PER TRAP
1 have and will maintain Work,r's Cnmpensadnn Insnrancre,as required by Section - -
39(N)uf The Labor Codes.li,,the pedunnan¢el the work for which this permit is lssuul. GAS-EA.SYS'INM-1 INC.4 OUTLI OCG GROUP APN
t My Wor -Co nsotimNrssurencccamerand Policyyy����jj.v,�Fcg,,
Cy Wmj;� E 1. Mrd Policy Nn:y�•y titinl� GAS-EA.SYSTEM-OVER4(EA) I n. Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE GREASE/1NDUSTRI.WASTH INI E i GR
BUILDING DIVISION FRES _
(Thlswction need nw Ce n,mpleeJ ifthc lwrmt,is forourbidooddoller,($100) GRHASHTRAP
or less.) A 'I .K blit.
Toy my
pa,mmaOr,o Wewnrkfnew floc rise Wr,,,' rima. SEWER-SANITARY-S'IORME g)1-7.I enpluy any porsms in wry manner nn as m hecnnm wbjeel vI the Workers'Cnrnpen. E?NIi ' HI3
Oz smiom lawso(California hate WATERHHA'IIRW/VEN'I'IELEC'R GRADIN FEE o Applicant GR
NOTICE TO APPLICANT If,after making this Certidcte of Exemption,you should WATER SYS1'RK4TREAi'ING
become x w,oa m the Wmkda Gnnpen,al o provisions of the Labor Core,you mum
Fy Ii,nhwith comply wish sudsprovisimnnnr this pct Intl shall he dccmel revoked WATER SERVICE I
a �
CONSTRUCTION LENDING
ngAGENCY
agency
NIiW RFSIDENTIAL PI,MB. SQ.FII PAID
s7 z - Data Receipt a
1hereby affirm Wauhem ixsed(Sitconstruction( hmd'tug agency for the pntln,munee of
V D Ihcwmk for which dos pennh is issued(Sec 31dl9,Civ,Cd
LA I" Lender's Nairne TOI'A h:
V Lenders Address TOTAL:
r 0.W: 1 moil,Wvt I hove read thin apPlicasinn and cam that the above inlummtion is BUILDING FER
� w correct.I;,,a-Iscmnpldwill,all aityuitcOnly nr linama.uwd atwe h,wa mlmingtm QTY. MECHANICAL PERMIT FFE.
G ,Z hnlldingc,nnaa,lion,and hemhynuthurim reprcecnlnliveanf This citymemoir upon the SEISMIC FNP?
above-mentioned propcny fia impretion pmposro' PERMIT ISSUANCE ' .�.
(We)agree 1.save,indemnify and keep harmless the City of Cupwtino against ELECTRIC FEE
liabilities,jmlgmenO.Ors'and expenses which slay in any wayaccme against said City ALTER OR ADD TO MECII.
Ise amsequewc m the granting of this permit. PLUMBING D?8
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO do,(N)OCPM) O a
MECHANICAL FEESOURCE REGULATIONS. p
AIR HANDLING UNIT(OVER I0,030 CFM) CONSTRUCT ION TAX
Signature of Applicant/Contacmr Date EXHAUS'P II001)(W/DMC1') HOUSING MITIGATION FET?
HAZARDOUS MATHRIAI 4 DISCLOSURE
Willda,applicvm or future building occupumamremr handle worm.smmerial BEATING UNIT(TO I00.0g10 BTU)
as deo nol by the Cupartl no Munlcipnl Code,Chupnr 9.12,and We Hedth and Sufwy
Code,Section 25532(a)'I BEAT INC,UNI(OVER 1011,1x)01 OIL)
[]Yes )4-N. PID ) l�K 7C
/
I
Dale Receipt
Will the applicant or future building occupant use equipment or devises which
coil hueaNnus air unmm�tnanls vx ddlocd by the Nay Atte Air Quality Manuguncnt BOILER-COMP(3HP OR IfHl,pAN111T11)
TOTAL:
Disvin?
]Ycs BOILER-COME(OVER 100.000 BTU)
G✓dn
``]]�� AIR CONDIT TONER
have Safer haode,Sc umv,255al, 5,25533 an under Chapter6.950the Cull- ISSUANCE DATE
diem Health ffi Orme lyhaea tenant,
25585,25533end255Jity to natmm�d Thattithe NEW RESIDEN'T'IAL M13CH. SQ.PI'.
hml gJmernw cunendy havea¢nant.shat it is my responsibility mnwify the Tncupam
'it
\
I 4utren�qu,whichonus,M tact prionotsxnanca of a §ticaae�ln mf OccTTpar
Ilk
\�'cj / 1
Owner .th 'Yffem Uwe TOTA L: ISSUI3UNY:✓�e-
OFFICE