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CITY OF CUI'ER'1'INO RUILIIING-ELP,CI'RICAL
BUILDING C MVISION APPLICATIONA'F.RMIT PLUMBING- MECHANICAL.
BUILDING PROJECT IDKNTIFICATION
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PE ITNO 2150 ^I I
2 � 5 ,L
SANITARY NO.
AI'i'LICA110N S11BM1'I'I'AL DATE
BUILDING ADDRESS:
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OWNERS NAME Sm i;kb I'li NHI
CON"RALT[Ifs n :: / NO'
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N/C
❑
CONTR
ARCHITFC/ENGINEFR: LIC NO:
ADI tligS:
� L
CONTACT', PHONE:
❑ Consultant EMS Paid by Applicant (Initial)
- 1 UILDINC FERMI INFO
RI❑UG EIJ❑'�.Cf PI UMB MECCII
LI NSIiD CONTRACTOR'S DECLARATION
I hereby amrm that 1 am licensed under provisions or chapter 9 monnimac;ng
will Sectian 7EIXt of Division 3 of the Business and Prefc#sions Code, and my license is
in full force end ell
QTY ELECPRIC PI?RMIT FEL
_
JOB IJFiSCRII'PION
RESIDENTIAL
❑ShDWL El KITCHEN REMODEL.
1'F.RMI'f ISSUANCIi
APPLIANCES-RGSIDF.N'I'IAL
Lleense Class Lia#—
Dura Comrncpn
---�
❑ADUI'1'ION El PLUMBING kIi-PIPE
❑MULTI -UNIT ❑STRUcrURAL
CHIMNMODIFlGA'REPA
❑INTERIOR El CHIMNEY REPAIR
IMPROVI?ML'NT E] SWIMMING POOLS
ARCHITECTS TIEChnRA ION
I underslmW my plum ,hall he Load us public recalls
PANELS
UP 70200 AMPS
Liccmal Professional
2ol-IIX)BAMFS
OWNER -BUILDER DECLARATION
I hereby came, that 1 ant exampl from the Convenor's License Law far rhe
following mason. I Section ]031.5, Business unit Professions Coda Any city of toothy
❑ GI I'H RF.MODF.1/REPAIR Q DEMOLI'f10N
❑OTHER
OVEx IlKK) AMPS
SIGNS CLEC'I'RICA.
which mummies. permit In enmrmm, alter. improve, dion.1kh, or repair any nmerum
A.0 ZJ
pain, 1. Rs issuancu.aLa, requires t c.pidilind Roseau peril,, file named statement
mm be is reatwa panuam ,, me pinvLsb.... of the C,,mmemh hicea,e Law (Chadha 9
(commencing with Section 70(l Division Sof the Businesnand Professions Cale).
thal he i+exempt therefrom and the basis for the alleged exemption. Any violation of
SPECIAL Cl RCU I' 1'/MI SC.
w
'I'FJ R MEI OR POLE INS.
COMMERCIAL;
C1 NEW BLDG/ADDITION ❑ DEMOLITION
Section 70115 by any applicant lin a permit subjects dicapplicmmo o civil penalty of
not room than five hundred dollars (S500),
un owner oftM1c propcny, nr my anhployees with wages asthcirsnlcminp,nsnrinn,
will do the work. and the.sumcmre is nal emended or offered for sale (Sec.7fH4, Bovines,
and Professions Cade: Lee Contractors License Law docs not apply to an owner of
POWER DEVICES
❑TENANT ❑I'OOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL. ELECTRIC
OUTLETS -SWITCHES -FIXTURES
,,,,puny who baud, or int Pom, Btere rn, it I who does oven is k hi all ,,,sough
his own employee,, provided that such improvements are not intended or offered for
sp..If, hrweveq the huddling., intpmvement issuld widnhoneyearof w..amiliorim,
NEW RESIDENTIAL IiLEC1R SQ Fi'.
SQ.IT. FLOOR AREA
$/SQ.IT
waerbul Wer will have the burden of proving that he did not build or rations, lin pm-
pwc of sale.).
❑ 1, as owner of the propony, ant exclusively contrecting with licensed contractors to
TOTAL:
consumer the pail (See. 7044. Business and Professions Code:) "a Contmchds Li-
cinowLawJoesnotapplyin an owner of property who builds or improves lhereon.and
-
QTY. PLOMHING PERMIT FEE
who amtmeln Attach projcnn wills a crnmacmgs) licensed pursnanl to the Conmatohx
License law.
1]' lam exen"a under Sec. , B A, P C far do reason
I-FRMIT S N I1
Ownur Date
ALTIiR-DRAIN & ' - W 3R'EA'
VALUATION
WORKER'S COMPENSATION DECLAXA'HON
If ACK FLOW PROI'IiCT I . CI?
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self insure for W,,rkces Con.pea-
tear, as provided lit, by Suitt nn 9700 of"the labor Code, for the perfnmmnce of the
for which this permit is issued.
,DRAINS- FLOOR. ROOF, AREA, CONE.
STORIES
'TYPE CONSTRUCT ION
FIXTURES - PER TRAP
Rhave and will maintain Writers Compeewtmn Insurance, as required by Section
,,,' the Labar Gale, for the put larea a of the work lpin wphTic�h pe,mil is issued
(IAS - EA. SYSTEM- I I NC. 4 OF I' LETS
DEC. GROUP
APN
�this
My War is Con hemafm l tum O.ker and Policy lAXdl/_�d4ili
Cnrricr: Policy Nu:
..
GAS- EA. SYSTEM -OVER 4(U)
GREASMNDUSfRI. WASTE! INTERCEMOR
I N PROM WORKERS'
CER FICHE OP COMPENSATION
COMPIiNSATION INSURANCIi
BUILDING DIVISION II ;ES
(This,vctionnood nod Wcnntpdemd ifthciennit is Garen, hundred dollars I$I tho
nr less.)
GREAS17TRAII
PLANCI IECK FEE
SEWER -SANITARY- S' I' ORM BA. 200 FII
ENERGY FEE
I ccnify met in plc performance of the work forwhich Wes permit is issued, I shall
not employ any pctann in any manner so as to become subject ,, hhe Warkard Canhperr
N'AIER IIIiATIiR WNENTIIJ.ECI'N
CRADING FEB
nation laws of California. Dare
Applicant
NOTICE TO APPLICANT: It, ,fear making this Certificate of Exemption, you should
become subject to me worker. Contpensanon provisions of me Jabot Code, you must
WATER SYST UNIONE.ATING
SOILS FEE
feubwirh comply with such pmvixiors n, lhi, permit ,hull he dernowd evoked.
WAT17R SERVICE
CONSTRUCTION LENDING AGENCY
I hcrebyvli nuhiumare is ucovtmnion lwhdingngcncy lin the pe,formerwas,
NEW ItE510 t SQ
PAID
Dela Rneipr#
TOTAL:
me work for whim mis permit is issued (See. 3097, civ, C.)
I.enlc', Naini
QTY. :Ctl AL IT ftf;�BE
Lenders AJJrexs
BUILDING F ,
I ccnify that I have read this application and store ohm the above information is
correct. I ugreelocnmply wilhall eigtmdmumyordimmcsnnJ sense laws relating to
building construction, and hereby amhonie representative% of this city to enter upon the
SEISMIC FEE
PERNEI I LANCE
ELECTRIC PEE
above-menlinncd poapmy for iaspcclion purposes.
(We) agree losove, Invention, and keep hatntaee the City of Cuputino.,,, n,,
PLUMBING FEE
Iiahilitit,,judgmems,mc—mclexpemesvehich may in any wnyaccruealshaysaid City
in consequence of he,
ALTER OR OM'
A111CHANICAI. PEE
Nate
APPLICANT ,,,U���{(({{{NDIiR ANDS AND WILL COMPLY WITH Al.l. NON -POINT
SOUI+aGS..@ 4710, S.
AIR HAND .LNG UNI'I'(TO IB00B CPDD
AIR HANDLING UNIT (OVER III,(IIX)CI'M)
CONSTRUCTION TAX
IAN
Signnwreu AppliamtAZARDO Dale
HAZARDOUS MAT'IiRIALS DISCLO9Undl
EXHAUST HDOD (W/UUC'q
HOUSING MITIGATION FEE
BEATING UNIT TIO IIM),lX)O BTII)
Will the applivam ,,datum building acmpam sorra nr handle hazaNnue mmenal
a, drained by the Cn ucefir Mona 1pal CnJe, Chaplc, 9.12, and the Ileallh and Safety
Coda, Sector 255321,1^
BEATING UNIT (OVER IKNXI BTU) -
VI?N'I'II.ATIONI'ANISINGI.Ii RFSID)
Ya No
PAID Data Receipt#
BOILER -COMP LIHP OR EX),M) BTU)
Will the applicant or future building occupant use equipment or devices which
emit haeallous air mnraminar s as defined by the Bey Area Air Quality Management
TO
BOILER -COMP (OVER(X)
i 100,0 BTU)
District'
❑Yes ❑No
CONDITI(INER
yuirenen pR
1 have real the havrJies materials rc rs under Chapter 695 of Bethe Cali-
frmia health R Safeq CnJe, Sections 255115, 25533 and 25534.1 unde,sumJ Nat if the
ISSUANCE IIXI E n
NEW RESIDEN'fl Al. MECH, SQ. FI'.
hu'Ildingdoes smiumally there fcnam,thst It is my respomihility lemaifydienceste t
M Ne requitenhems which matt be net Puerto issuance of a Cenificee of Occupancy.
ISSUEDBY:00/1rP
TOTAL:
Ownerorauthorieed agent Ilam
OFFICE