S3338 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'fINO BGaGING-ELECTRICM, PE nT NO.
BUILDING DIVISION APPLICATIONIPERMIT PING P OJEL7IDEN-1 MECHANICAL 3.338
BUILDING I'll(1JF;CT IDE\1'IPICATIUN
BUILDINOADDRESS: / SANITARY NO, APPLICATION SUBMITTAL DA'IE
67 � (�.e- Jam, OB GERE MASONRY /
OWN R' NAM1I& P ON@. CONTRACTOR'S NAM1f E:PBE�CA 95000LIC NO: N CONTROL#
ARCHITECTAINGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/' ❑ Consultant Fees Paid by Applicant(Initial) D Ii1.ECT PLUMB MECH
J ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I berm.,affirm mw I am licensed ander provisionsof chanter v(commenting JOB DESCRIPTION
e'�p who soectin] rnr;vi 3ofwc Baamezn vrofctaions c"1 an .,license is RESIDENTIAL":
4: e--�S1 - PERMIT ISSUANCE
CW F- in full force a can (�' C! ❑SFDR'L El KITCHEN REMODEL
QVLimnte CLCss Li
Vch APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RF,-PIPE
NZW Dam Cu
r�Q1 ARCIiI ITE . I IF El MULTIUNIT ❑STRUCTURAL
~�Z dors and .,grunt shall be used use public rernrds /// D"' IANELS p90DIFICAHON
ZOZ�C UPTO 2WAMPS [I INTERIOR ✓��/C,IN EY REPAIR
I—r3 F'W Licensed Professional 261-1000AMPS IMPROVEMENT SWIMMING POOLS
5Y OWNER-BUILDER DECLARATION OVER 1000AMPS 0 BATH REMODEUREPAIR 0DEMOLITION
1 hereoy union thin 1 am excnopt Iron the Counter Littn.ve Law for'he
O L V following reamm.(Section 7031,5,Business and Penfestlmw Cade Any city a coun'Y SIGNS ELECIAICAI. [I OTHER
'3 LL y wnilimynire,u pemril hr eardorm,alts,-illrp tile.dernolith,or ei,aw,amy,lot
Q primmits issumice.alkoys theappreartf sachptmdtl file a.gree smsnem SPECIAL CIRCUS 17MISC.
'hath licensed pum tt Thep 'ismn. Ilh Contractor's L Iaw(Chapter 9
WCOMMERCIAL,
fai11�G0 (commercial,wish Secunn](YM0rlDivision3ofthe Business and Profe..ions Cade)" DEMP.METER OR POLIS INST.
g. 5 thin he is exempt and the buts for the ailenal eeemptinn.Any violation of 0 KEW BLDG/AUDITION ❑DEb101.IT10N
XmLL
Section 7031.5 byany applicant for a permoOubjec's(he applicant oo civil Penalty of POWER DEVICES
W fin o'more man five hundred dollars(SSW). ElTENANTFOOD SERVICE
SSD 1,a.owner or ole r IMPROVEMENT
property, isms re,ndexwhhwagesaaalc(sale anntpeovine, SWIMMING POOL El 4. will dome e,joa,andthetle Coal l.nOlinlrndtl o I..w dos nulc(Scc.,Fla,Owner
towner OU TESTS SWI'fCIILS-I�IX'NRES
W a Old l f Code: Coal I rte I 1 docs ' 1 PIY I of
4'3� pial,ry h b 'Id. or p "th on, nJ 'h I sxuch kl' Il nr Wmugh
his ply pr J d that such in p n m:are n 'intended offered for NEW REM TN AL
11 LEC
SQ
sale.IL however,Cc building or improvement is sold within one yew of vompletinn.Ihc SQ.FT.FLOOR ARRA S/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for pur-
prscn(salaJ.
0 I,as owner Of the progeny,ton Oulmirvel,conwmiog with liecoved Common x m )1
don utmetthe project(Sec.7614,Business and Prale..io-CMe:1'Ihe Cunlmemrs u-
whml,awdoe,not rgtply loan.,net ofpnrge 1,who builds onmpre"10iereoo,and QTY PLUMBING PERMIT 'Erj
who Centuries for Inch pr Jests with uainvanor(rc)Ilecnstd puvxunnnn Ce Contractor x
License Law. PERMIT ISSUANCE,
1 am exempt under Sec. ,B K P C for Ihi.reason
ALTER-DRAW k VENT-WATER(EA) VALUATION
Owner Ua¢ `'
Wm aKERnder
COMPENSATION DECLARATION BACK ETON'PR(TI'I[LT.DEVICE / 9I
a have
and will
nmunder peoahy of rerofCon of Itieine of e followinginsurc for declaratWo6wr's Ca - / l�
Ihavc andwediIitimy eCion 37nc Of tale LauoCottr tire
Workersccof the
DRAINS-FLOOR,lt001:AREA,GOND. $TOR ±S TYPE CONS'I'RUCTION
sa'iun as for,hlhi fur by Senior 3]W Of the Lahnr Cude,foil Ire gerfnmamca of the
r which This Penni'is issued. ITS X9'UN[IN-I'fiR'I'RAP
'
o nJ will m oulano Worker's Co' nsaIinn Insurance,ac reyupppicecreel by Section
3]W urns bar add,fadrepeor h:afore work f�r�wnicn { rmyn GAS-EA SYJI'IibL11NC]OUThF.TS OCC GROUT' MIN
MyTb y'r1ra101J,'OreYMIeLCy n/ _y/J
GAS-EA.SYSTEM-OVER i(FA)
CERTIFICATE EXEMPTION FROM WORKERS GREASEIINDUSI kh WAS'I'F.INTERCGFD>R
COMPENSATION INSURANCE BII I LUING DIVISION FEES
(Thissectiannecdnol hewrnrplmwl it lncgemia.,to,one mJoildolk...NBXB GREASE TRAP _
or Iv,.) 1'LAKCI{ISCK PlilE
I Certify shat in the eftom ee afine work for which Inspector is issued,I shall IVGR-SANTI'ARY-tilOkp EA.2W
not employProton m
any pron in anv manner as to become subject to the Workers SE
Compcn- J "ERGY FEE
O Z soon.Laxer o(Cithfamia.[)arc WATER HEATER W/VBN'AL IS 'RAGING FEF,
z 2 Applicant I / QF-r, r
In NOTICE TO APPLICANT:If,Clooking aking In,Cenica
6m of Exemption,you should WATER SYSTEM?RGA 0`l9' ILS FEE
F1� become subjecuo the Wak,`,Cempensalion position,Of the Luka Code,you mus'
LYa [y forthwith comply with xuch provisions Or this permit shall toe detailed revoked. WATER SERVICE
Z" CONSTRUCTION LENDING AGENCY NEW RESIDEN'I'IAL I'll SQ.FL 'AID'
UQ I bench,infirm that mare is a eononction lending agency for the perturmaatc of Date RereiplN
D. — the work for which this permit is issued(Sec.3097.Ci,C.) TOTAL:
O V Leith Nano
Is J .AJd 'TOTAL:
W 1nfy that lh it on,appl f d: ImuM1 M information BUILDING FEF,
�r 0. City g QT MECHANICAL PERMI'P FrE
UZan .1'l, ircnrply 11 Ilut.... li county 1 e "a 1 Tarin a Q' SEISMIC I CC
UZ naaemg ronstmttio��,amlhertnrawrari.<rehn�,a:ntaantt or m'an'y i'en.,apan me
ahcwe-mentioned pmpeny for m,,ection gugswv, PIFRMIT ISSUANCE (ELECTRIC FEE
(Wp ngrc indemnify and keep Station,the City Of Cordovan against
hahiluesJudgmenl.costs and expenses which may in any wayaccree against said Coy ALTER OR ADD TO MECH. PLUMBING FEL'
in consequence of the standing of Cis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO to.000 CFM) MECHANICAL FRIT
SOURCE REGULA'T'IONS.
AIR HANDLING UNIT(OVER 10.000 CITU CONSTRUCTION TAX
Slgnawre it Afflict SIC an'inm" D'am EXHAUST HOOF(WIFUC17 I SOUSING MIS I IGAI SON ITE
HAZARDOUS MATERIALS DISCLOSURE
WAlme aRtAicum or home handingactipral,amor handle hara,dou material HEATING UNIT('10100,000 BTU)
as defnW by the Cu,wilarmyouliliNt.Code.Chapter 9.12,and the I Ical'h and Safety
Crile,Section 255)2(al"! HATING UNI"1'(OVER'(SI IDLE R BTU)
0\ ' VFMILATION FAN(9KGLL'RESIDI PAID Umc Rcceipa
Will 'gPli ' huilJ ng xcugunt use eq g r ,device 'hien I;OILER-CONI'GIII'OR Blo od011'TU)
�e IE, anI Ira rm u a a0.ad Shy me Bov Are A Quality Maagnrenr 'D Alli:
D atrcB BOILER-COMP(OVER 100.006 BTU)
E]Yes
I have oval the does ma tole"apocmcn,order Chager695mfrhe Cali- AIR CONDITIONER ISSUANCE DATE
fomia Safety Code.Se on.a 55115,25533 and 255J4.1 undenlanJ ma'if'he NEW RESIDENTIAL MECH. tiQ.FT. 11 / /7
nal Rdt is 'M1a cetera .ryrnanrinr������000000tttttt lily cupm
ofm A I ranoiasuano(alCBrit� pyan
O nr"ondwri..logon �� lalC 'I'O'1'ALo ISSUED BY:
OFFICE