30443 ANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
TY OF CUPFRTINO BUILDING-F.LF.CfRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMTITALDATE
fir Copfr-hry C0 91n-01
'NER'S N�E� L 0N.t: ANTRA qR'S NAME IC
NIC CONTROL p
iRCHHhuI7FNGINEER: LICNOr UR ❑
Can
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Q� ❑ ❑ R�
LICENSED CONTRACILSR:S DECLARATION QTY' ELECTRIC PERMIT FEE
1 nerehy affirm that 1 am haeed under provlsims of Eloper 9lcommrc
eiae JOB DESCRIPTION'
OaeZ with 70(0)of Divinon J crib,B.eiraxe ofeekmtaCWe,ark my littnw in
k 00 wn PERMIriSSUANCE RESIDENTIAL:
I„ fun roc etd cRe ❑SmWL ❑KITCHEN REMODEL
6 U Va �� Llan jq APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RFPIPE
Za Dam Cmn ser
ANCHI91iCTS DECLARATION PANELS MULTI-UNIT .0 STRUCIUkAL
Z 0 to z 1 unle"anal my plat shill he mad a,public ce-da - MODIFICATION
OZ—Q UP1020AMPS ❑INTERIOR El CHIMNEY REPAIR
P4I-"tr1 LianscJ Pmfcasionnl ]ill-IIxgIAMPS IMPROVINENT
O n1 OWNER-BUILDER DECLARATION OVER 100OAMPS (I BATH RINODELJREPAI( L)DEMOLITION
6 I hereby affirm shut 1 am exempt form the Contractor's Liao¢Fir,f«rbc
FG V fallowing moan.(Section 70313.Business end Protcitons Coca:Any city«county SIGNS ELECTRICAL ❑OTHP.R
Wa.
30� whichin iterm.a pantos to,cowmen cher,improva,demdis t «repay any swnum
O primoitsilwru ,alartyu've+troy iocicant for vach Contrarmit wren,La (swcmrnr SPECIAL CIRCUff/MISC.
f.vW1 N ma he is liansd prmuant to the provisi.m of the Cm.-swh License Low lCMgcrY
6'p0 (mmneacing with Sectio 7l00)of Divisida I0111 Buanec.and Porfcssion.Code)or TEMP.METER OR POLE INST. COMMERCIAL
a q o y rive he it,camp therefrom arW be,baso f«are alleged exempimt.Any violative of 0 NEW BLDGIADDMON ❑DEMOLITION
i� LL Sation 103 I3 by any tit icerufor a permit subject the applicent to a civil Imnaky of POWER DEVICES
F- oa more,than Eye huodred ddlm(5$BBk ❑TF7iANT ❑FOODSERVICE
=QFlI,novmerofdte faWenY,«my emplM'rea•imvaguud¢hmk cvrttpvmti«a SWIMMING POOL ELEEIn IMPROVEMENT
yF wEHbthewoh,and 0e wuctum umti«ertrd«offetM fm sok(Sec.1DW,Budrcas ❑OTHER
u]—� and Pmfeasiom Coca:The Cmtranof,Ga.law does cot apply to an m,or of OUTLETS-SWITCHES �
a 3—
pro.,who builds or inµnsn barcon,and wlao docs rich work himself m through
his own employee.,providd that s«h iminoemem,are not imendd«offered for NEW RESIDENTIAL EUEK OF
ole.If.boyo r,to Wilding or improvement is sold within me year ofrompletion,the SQ.FT.FLOOR AREA SISQ.Er.
ovrcr-builder will have flW Wi M proving that he did act Wild or improve for Jam,
poseofe2leJ. 1 P
I,a.anter M the pmpeny,am exdusivcly emteacting wild licrosal comrectun o' T� 41 1 D
nstm.r aaa project(Sec.]IW,B.domi,amt Pruresoi ,Cmk:)Tbc Com actor',I.i. ` JU
Al
aWmttt ne law doer wv apply Ivan mwrcr of pnryvtywM built«improves thmon,anal QTY. PLUMBING PERMIT 5 E/�
wcuformch pnrjwra whh 2<nnwcux(p licenv.Ipmacuks
wnl to the Comm
Uccne law. PERMIT ISSUANCE �pI`
❑ I am cxarya under Sea. - ,B&PCfnno,rennin lr '�r -
♦ fI
ALTER-DIUIN&V[NT-WATFA(FA) VALUATIONTII'O
nor Date
WORKER'S COMPENSATION DECLARATION [JACK FLAW PROLEUM DEVICE G J�
1 Wrathy affirm mutter pentlty of perjury one of to fMl.n mg JaaaraBona,
I Wvearal will maintain Ccniftcwe of Canmmtos,lf-imine for Wmkera C.mpem DRAINS-FLOOR RODE,AREA,GOND. ST Its TYPE CONSTRUCTION
swion,u ro,idd for by SxEion 377 of the Labor Cade,for the parfi.,of Enc
For which thin permit u hasued. FIXTURES-PER TRAP
I heve W will mammon Workers Com,arromm Insurance.requiml by Seounn
J ofthl.abi Code,for tW paf«manz4the won for whicta this peord id,avad. GAS-PA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My W r m sant wmrcc c.rtie Poli Polity/' +�ry� / �N GAS-EA.SYSTENI OVER 4 IPA)
Canic�PdN ROMW119k
CERT KATE F COMPENSATION
INSURANCE OREASF/IYDU.STRL u'ASTE INTERCEPTOR
(Otis section rand naW compkrd if the, nom u For now,bacchanal do11as IS 100) - BUILDING DIVISION FEES
«IcvJ GREASETRAP PLtNCNCCK HE
1.story that in rhe perfomurc,of the ivvrk for w uch Enda permit is ia.anl,l dull
mot employ any potions in any mat w as to hacnne wbjca to the W«kcrs'Connived, SEWER-SANRARY-STONM PA.100 FT. ENERGY FEE
zwimt Lsvr rf WATER HIiATpt WNFXT/ELECTR
z 2 Applicant GRADING HE
J,, NOTICE'TO APPLI.ANT:If,alar nuking this Cenifcne f F emi am.you shod WATER SYS'TEM!"HATING
F head.s.biecd to the W'orkes Compcnwion mviono,of tltc Libor Code,you must SOILS IL?
Wrmhwith comply with such provisions or this permit shall W deemed revol:d: WAI1:K SERVICE
oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLNIB. SQ.irl PAID
V 0 l hereby affirm thdrhere in a comametion lording agemry for the Niformanaor Duro Receipt
{✓w I-t
the work for ani thio pomtit is issued(Sm.NyO.Civ.C,)
p U Icmkd Nate TOTAL:
WLed,es Addre.. TOTAL:I,entry that I hove tonal this upplicatim and state that the alcove imft.Iim is BUILDING FEE
Vj coml.l agta to comply with all city aW comity ordinances and mate lawx relating to QTY. MECHANICAL PERMIT FEE
V buildingcomuuction oral that airborne represenraivn of thi,city w,mitruryn the SEISMIC FEE
.hove-mentiomd pmp;ny or impaction pugases. 1 PERMIT ISSUANCE
(We)ague m cove,imlemnify and kip hamle.tie City of Cupermar agvifm ELECTRIC FEE
Iialithria.judgmens.costs endexpemes whkh may in any wayaameag.imE sad City ALTER OR ADDTOMF.CH.
n rnmtyuemz of tha graming of this permit. PLUMBING ITE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. `
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
' Sigwureor Applicau/Comrurm Dam EKIIAUSTHOOD(WMUCD
HOUSING MI11GA110N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dcappliaw«ran=buildin,oced,m mare or haNk hasoolms materiel HEATING UNIT fTO[M."BTU)
u defutd by the Catar iro Municipal Cod,Chapur 9.12 and the Fenian and Safety
,16Lode,Scrim2553312)'! HEATING UNIT(OVER BIG."BTU)
❑Yn ❑Nn VENTILATION FAN I SWGLE RESID) PAIDJ39..Q�
Will thea Due Ree<ipN
pplortu«furore Wilding occupant sex egwpmrnE it device which BOILER-COMP CUP OR 100,100 BTU)
emir huardws air<ontvninanto as defrck by the Bay Area Au QtWity Management TOTAL:
IbHnatY BOILER-COMP(OVER 100,000 BTU)
❑Yc ❑Nn
1 have read tW bwaNtas mm,mlk CTaprer AIR CONDMONEIR
mryimmeme dollar itd tom CWi- ISSUANCE DA
[omia Health&S.fdy Calc,Sc rinns 25ha511 is my veal 25574.1 um6rsund Lha urine NEW RPSIDENT'IAL MECH. SQ.FT. ^a
Wilding Jiman«s,derflyat mere aomit,maro ismy.of.0 rtifocodifythe
ldric,m 11
ortltr myDimn,ent.,vesico ntu.a W na:t pd«o i>suana mr.eeniraa of rxNµ,«y.
Owrcr or aurhonad agent Date TOTAL: ISSUEDBYS7,g e-
OFFICE