S1485 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PE IIT NO.
BUILDING DIVISION APPLICATION/PERMIT rINGPROT-MRCBANHCN. 1485
BUIIAINC 1'RI)JF:CT WENT'IFICA'1'[ON
BUILDING ADDRESS SAN]I'ARY NO. APPLICATION SUBMITTAL DATE
OWNER'$N•\h�'I E' Rl/1Ie//� k//�� X'v PHONL. CONTRACTORS NAGE% lt, �x /N) NO NIC
/U`.'i'[� '"lAJ RAC ' N/C CONTROL#
ARCHITECT'/ENGINEER: LIC NO: ADDRESS: ❑
r bra 5-Oe 174, wb.
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH
LICENSED CONTRACTOR S DF(1AR\Z ION =IC PERMIT PEE �L{cl
QTY. ELLCTRI
1F n, n Ibn r d l p : lChaplet-n, II '' g JOB DESCRIPTION
poo whose f 9010) m il
�ECTSDECLARAIION
Bas td Pmfawkt uar:mtty lrro'c es RESIDENTIAL:
Fpp til III cUe c PERMIT ISSUANCI:
�Q O VP ❑SFDWI,IT1 pCHFPLUMBING
RE PIPE CCU~ hiecns,I / Lic.p '=
Q h I
U --�I �`i} APPLIANCES-RF.SIDEN'1'IAI. ❑ADDITION PLUMBING RF,.PIPE
o, me tF Contactor
m A PANELS ❑MULTI-UNIT []STRUCTURAL
pyZ 1.demam my plans shall he used as public records MODIFICATION
OZ�C UP TO'-(XIAMPS ❑INTERIOR ❑CHININEY REPAIR
•f.K)t:W Licensed Professional 201-1000AMPS IMPROVEMENT 0 SwISI,SIING POOLS
x ail OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEI/RF,PAIR [I DEMOLITION
x W,Q I hereby affirm that 1 am exempt from the Contractors License Law for the
yKj 3 F following reawn.(Section]031.5.Haziness and Pmfesaiom Cvsk:Any city or county SIGN'S ELECTRICAL ❑OTHER
4pH whch yu - pe tt t ct Ice P J of.h rrM tr
ysuctum
E'- 4 prior' italsorey h.thefo such permit' I signed tatetem PECNL CIRCUIT/...SC.
'hat he is licensed pursua the p of the Contractor's License Law(Chapter9
^�0 (commencing with Scant 9010)of Division 3 of'he Buvinc%s and l I sons Codc)(a TEMP.METER OR POLE INST. COMMERCIAL:
d d e C 'hu'he is exempt therefrom and the basis rar the alleged e,crmainn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X•"l'- section 7031.5 ny any upplinun for apermit s.bjOcaths applicant tutu nvilpcnalty of POWER DEVICES ❑TENAN'T ❑FOOD SERVICE
W not Fount bear rive hundred dolllm(S50),
ownernr the pro"ay,ur ray employees with wage.an their-roto clntprowenn, SWIMM INC,POOL ELECTO IC IMPROVE; 19
p-
villdothe vaskq111 ....... Hint Id Freedlb .'I (S 7044.Bt:' r,
n ❑OTIIER
G3ce and Irotrcdo:Code. I he Contrartur aL : Law duce I I
t ,t at nsviurof OUTLETS_SW 11 CI I FS FIX'I If If Ii,S
prop 'y who h 11:ar inproves'h d who does such workl t R'ordonsight
his t t q y providOd that orth' p t are "t d d offell or NEW RESIDENTIAL EUT!'It SQ 14.
solo 11'1 '1 ht IJ ng lnpmvem ' Id `Otto y f I I'i 09 the .1 .FLUOR AREA` $/SQ.FT.
budder will have the harden of proving Not he did not build or
r mpnne for paM^D
Ft.et1 , R g SNF
I] I f thep pen, I .I, t o g with licensed ' 1 .to 'TOTAL: p p
cunt til p ) t(S 7D B : dP f-.' C d:)Th C t t li ftlX M11NV
Li-
cerise Law does not apply' f property who builif,or mpruvo:thereon,and QTY PLUMBIN iRMIT FEE - �.J "jr .
who conflicts for such pugecµwith a contaaogs)licensed pumuannothr Comnelols G11 a Uri
License Lax% PERMIT ISSUANCE
0 1 am exempt under Sec. .B&P C for Nis reason
ALTER-DRAINVENT-WATER iAt VALUATION
Owner Dam
-� WORKER:S COMPENSATION DECLARATION BACK FLOW PR(YI'&ECf.UEVICIi
1hereby o irif under Penalty ofperjury one ofthe following declarations: LV
I haveand will mmnum C,uifi,.taufCmtscd toself-insure for Worker's Camper- DRAINS-FLOOR,ROOF.AREA,COND. STORIA. TYPE CONSTRUCTION
.wino,as provided for by Section 3710 of the lather Code.far the perforneeme of he
wmk fnr which This#anon in i"and, FIX"CURES-PER'1'RAP
I have and will inainorm Worker's Compntenon Inzuraneo,ax reynned by Section
37XIol m[.,incl'Cndc,fnrlLe performuncenC'no work for which thlx penny is iausl CAS-EA.SYS'TI!M-I INC.AOIII'LI!TS OCC.GROUP ANN
�ufIr�1"a un b' rand Policy tt
CurriaaN �try� ' t �✓c rlePand No.: 7 Y3. 69-R GAS-EA.SYS'TL'M�)VEIt40!A)
- C ATII OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE. CREASEINDIIS'TRI.WAS'I'li IN'I'PROTECTOR BUILDING UIVISIO_N_FEES
ClLie sec uoun,od notbc,lai Unit,perfi
i'is r an,hundred dollars(s l W) GREASETRAp
ar lass) PLANCHECK 19iii
Icenify that intoe MifurmrouccOthe work for which his Permit is issued,Isball SEWER-SANITARY-STORM EA.200 Fr
not employ any person in any manner loss to become subject m Ne W keri CmnPer- ENERGY IT,
O Z moan Laws of California.Date WATER HEATER WNENTl1!1-ECIR GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:1f,e0er cooking this Cenificme of Hxcrr on,you should WATER SYSTEM?REV'ING
F^ '� become mb'ect m the worker's Cnmpenia tion f the TaMtr Cost,you must SOILS PE'
prnvntumo
{017 forthwith comply with such pmviziom ur Nis pe.i,,h.11 be deemed revoked. WATER SERVICE
7 Z CONSTRUCTION LENDING AGENCY N8µ'RESIDENTIAL PLAtB. SV,FT. PAID
UQ 1herenyaftinn'hat nhemisaconztivadon lending agree,tonne lxof..no cc of Dv¢ Receipt#
Fthe work for which this permit is issued(Sec 3097,Civ.C.)
WiA�RDOUSMATCRIAUSDISCLOSURE
'.NameTO"IAL:
e ddres. _ :arty that I have rad this application and state that Neabnvu Ii lormatu.n ixgUI1,UING Il. eomemnelywi wlAnyondcoan'yordinanax:tndetatnlawxrelatIngm QTY. MECHANICAL PERMIT FEEing atlaction,and rchy ra�onze mpresenta6vuot'hlX cut m amar upon the 3P.ISMIC pI!I.nm t mud#tope Gtr inspection purpuvea- PERMlTISSUANCH 11LEC'IRICli( gore an a im eauu1,rnd keep hamdess Ne Coyel Celwnlno ogain.aieX. ens'smd,,,Nu...whichm. any way uacn¢ngaind said City ALTER OR ADD TO MECIIPLUMBIN( EI3
in sulu t 1t the granting of'his permit.ICAN ' )ERSIANDS AND WILL COMPLY WITH AI NON-P NT AIR HANDLING UNI'1'0010..XI CFM) MECHANICALIt.-
CERI:" IONS. AIR HANDLING UNI'I'(OVER gk(XX)CPM) CONS'IRUCION TAX
wm of App'e t/Commemr Dane EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
fAZ RDOUSMATCRIAUSDISCLOSURE
Will to .,dean'or future building recupanumre On handle harallous unlined HEATING UNIT(TO 100.00 BTU)
as defined by the Cutat Munieipa)CM,Chapter 9.12,and the Health and Safety
Cttdc.Section 25532(oln. - HEATING UNI T(OVER 100,0#[11 Of
Utes ❑NoVENTILATION IAN(SINGLE RESID) PAID Date Reccip'#
Will the applicant or future building orcepaut use equipment or devices which
e gO1LER-COMP 1311P OR 1(XI,IXXI ITTU)
mmi
it haxnrdous air comanants as defined hy'he any Arca Air Quality Management TOTAL:
Dixaicfl BOILER-COMP(OVER 1pOloof HIU)
CYe, Fl No
I lium rend Nc hmznlouv materials re 's under Cho Nr 6,95 of lha Ca I i- A IR CONDI'1'IONER ISSUANCE DATE
m P
minors
heed Iicae,neS:ano,Coda 5e ocia 25505,25.533
ru,and3[ly.F onallulanomm�d'hm II ant NEW RESIDENTIN.MliCll. SQ.PC
oLlsee dtan nrn ,which have a trnin p Nati'is royale Ofn Cifity to sally Ne ant
nl'tlm rtqui tonna wniHtnnz'Minet prior mmmcnfu Ccnificnm ollkcapancY.
Owner or anno ri'eed agent Dam T(yI'AL: ISSUED BY:
OFFICE