S 1548 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING PE81JII N
BI11LDING DIVISION APPLICATIONIII IIT I-LUNIBISG-MECHANICAL
V o 1548
BUILDING PROJECT IDEN'I'IFTGYCION
BUILDING ADDRESS: SANITARY NO. API'1.1CAI'ION SUBMI I'IAI.DAH'
222(D'}� � -22 Cl
OWNER'S WNI7: I'���((ONI+ p CON'1'HACTURS NAME L: LIC NO.
(J��O N SIC (� C�O1N,T�H/UI I.
ARCHITECTIENGINEF.R: LIC N(I: O ADDHF_S5: ❑ X I 1
CONTACT: 1 1 PHONE BUILDING PERMIT'INFO
/T - (', 1(y / ke Q O 0
El consultant Fees Pail by Applicant(Initial) IfX, [LIiCT PLUMB M111iClI
LICENSED CONTRACTOR DECLARATION OO-y ELECI'RICPERMIT' FEIi
1 nenenr mhnm mal 1 am HeenNdd under Provisions it cnapmr 9(mmmmemg JOB DESCRIPI'ION
GC7 wimscniona(XIBInff) n 3 ifare Business and Profess) mlgan yliclnw i. RESIDENTIAL
W O PERMIT ISSUANCE RESIDENTIAL
Fx W in full force uM vlfect. _ ��mjj ❑$PUWI. ❑KITCHEN REh1(lUlih
aUU LimmeC v` LiaM l-- APPLIANCIES-RESIDENTIAL ❑ADDI'ITON [I PLUMBING RF.-PIPE
F W
uh2 Ilt.nII EL
PANELS MODIFICATIONAHC 11'11DiCL ION ❑MUCI'1UNIT ❑SNRN.
1,5y1 uJervnyPlnsall e toodaxpM1lienecNZONz
OZ=� UP T02W AMPS ❑INTERIOR E]CHIMNEY REPAIR
C-F'W Lieensed Processional 201-H100AMPS IMPROVEMENT IMMI,NG POOLS
OWNER BUILDER DECLARATION
OCU I hereby affirm that 1 am exempt Into me Contracon,License Law for the OVER 1000AMP4 ❑BATH RIih101lF.URF;PA DIiA101,ITION
y W ❑OTHER
d following III f5minn 9B.3 L5,11us nc. nnJ Prnfcs ns CuJc:Any city n crummy SIGNS L'LICCCHICAI.
wbieh regal a"on,....nems...nher,ain.pm c,di moEan. ,ot,fan am amemrc O
f".amjOQ p,iunm is i.� mue.uBn.....us mcaPPllcum ho,such Pcnainn filcuogrwd,omcmcm SPIiCInL CIItCIII'I'IMISC.
�IyY� that he is licensed pursuant o the provisions of the Contractor'.License Law(Chapter 9 COMMERCIAL:
WCL�Q (surrounding all Sectinn701 Division 3 of the Business and Proessions Code)or TEMP.ME 1'I7H OR POLE 1 NST.
a a e C ba.he is exempt thetrrrom and me basis fico the alleged exemption.Any violation of El NEW BLIR'i/ADDITION ❑UEh10LITI0N
W^vi
Section?031.5 by any applicant for a permit subjects the applicant n a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not alone than live hundred dollars($50()). IMPROVEMENT
gsQ -1 1,as ownendmd molxry,ur,u,mp ,,r,with waged of their vnlcmmpeastolor SWIMMING POOL HLECOOC
2CF. will di the wod,nnA the oloCmre isnot intended to ol'irred hoode(Sec.91144,Business [I OTHER
YSm and Poll..Into Cn le:'The Contrite I'sLatala.e law d— ,it apply u+an owner it OUG.17'IS-SWI'ICUES-ITUT URES
pn,,,Iy who milds or innPr,ve,manus,and who docs ouch work lanow fart through
his own employee.,provided in.,such imp ownwas am not intended or offered for NEW RCSIDIi EAI,ELECTH SU ET.
sale.If.howevimaic heading.,impmoncm iswld wimiri— year of umpleaomae SQ.IT.FLOOR AREA $/SQ,FT.
onsuar-builder will have the burden of proving tom herald not Wild or improve for pm-
'e of plc). T(TPAL:
L ax owner or the po psmy,am exclusively contracting with IiceroW nmlmdit2 m
nssmct the project(Sec.IlW4,Business and Professions Coact)I be GmlrmCooN Li-
...Lawdoc uX llPpur IT an ownclot pinperty wbo b id, mph cN mason,and QTY. B G RMI FEE
whocrnnowl,In .1hpmjel with aennlmmnrtO licensed p....i nmL ha Contmmnr.
License law. PERMIT ISSUANCE
❑1 our exempt under Sm. .B kI'Cfnr this o
ALTEk-DHAINk VENO' VALUATION
)xDam
� `''�
W(1RKER'S COM PINSAI'[ON DECLARATION RACK FLOW PROTECT'.DEVICE / o
!IT not of larjury int i(meIiJlowmg Jmlaradim: 1
ncmhy ntl
Q l havdand will a(;Ion a Ccni0mac11fConscnt msulLlastm Sur Workers Corpsen- DRAINS-FLOOR.RIIOF,AREA,COND' STORIES 'I'YI'E CONS IRUCII UN
amon,':p 'Idris hrSector,1]01)uld Lb Cot fol I 'c(If'lie
work f which lli pia Ied. FIXTURES I'I:R'I'RAP
❑1 has,and willnuatum.Workers Courperecition Insurance, required by Section
Am) fuse Latin C bt f dre performenriveofthwork for fish hispe t isi:: til. GAS EA SYN I Ch1-I INC.4 OUT-HTS OCCGROUP MIN
My Workers Compensation Insurance tamer and Policy number am:
Cartier: Pal icy NeI GAS-EA.SYSTEM-OVER 4 BA) fN1
CI?R'I'IIICATI?(lF li%IiMVI'ION FROM WORKERS' OHBASI%INDUS'1'HI.WASI'131N'TIiHCHPI OR r
COMPENSAIION INSURANCE. f if LL 11 IAVISIONIEES
Tlu,,chtlrn nccJnm be colnplcmd i I the Pcmnit is fill 11.11 hundreddil lura is 100) GREASE IRA['
I,less.) 1'LANCIIIECK FIV,
I ccnify that in the performance al me work for which this permit is swed.l shall SEWER-SANITARY-STORM EA.NX)17..
.in employ any vennn in any nvnner so as to become sobjrcl it)the Workers'Compcn- ENERGY FEE
Z su tun laws of Culifnmia.Date WATER HEATER WNIR T/F.LBCI'R GRACING Flit'
ZO Applicant
NOTICHTO APPLICANT:IL arta ranking Ilii.Cenilicate of Exemption,you should WATER SYSTEM/IItEATING soil's 1:131:
become olrul ,,the Workers C1n+pins; in Proof... of Inc Lamar Code,YLot mus'
W Q fin Is or comply withrov
uucn plsiom Ur thus(Mnuil.hall be dcuned red.vokeWATEk SERVICE
n' CONSTRUCT[ON LENDING AGENCY' NEW RESIDSNTIAI,PLMB. SQ.ET PAID
I hereby mw
alHmuhauhem isaroctin.lendingugenfon
cy fnr the pernand ceCam p
VU. the work for which this Permit is issued(Sec iIN).Civ.CJ c 'COT r
O U1<nder's Name 'TOTAL:
Lender'.AJdmss
I ccnify Ihm I have read this appfiwadon and am that Inc above inrommtioo is BUILDING ITiE, 00
p' g IY. MECHANICAL PERMIT hlili
UZbuilding agmx to with and seamyromisecesandalinelawsuranin"he Q" SEISMIC heli 0
U Z 'maiming mngroedinn,and nerenr aminmi,c repredmadveanrmi.dtymdmdrapom me
abtn'c-mentioned propsny for inspection purEswes. PERMIT ISSUANCE ELECTRIC FEE
Oss, egret h—vc indemnify and keep harmless the City of Cupcnino against pp p
liabilitic>judgmcnts,coasanJeapcmcN which may any way theme against Nail City ALTER OR ADD TO MUCH. PLUIWII tl Et) M �JD
connequcnce dlIt grdming of this pdmnil.
AI'1'LICAN'1' CIikS'IANUS ANU WII COMPLY WITII AL1,NON-POINT AIR HANDLING UNIT LTO IB.IXX)CFM) MECHANICAL I'IEI. _
S ;HI:C I.AI'll)NS.�� �♦�ElCt.
AIR IIANULIN(:UNI'I'(OVIEH III,I1fX1 CIsM) it 1' �t t
SolIrIffopplirunVComracmr Dec EXHAUST IIOUD(WIDUCI) HOUSING MITIGATION FEIi
HAZARDOUS MAITRIN S DISCLOSURE
Will the applicant or future building mcary'nt store or handle hard material HEATING UNI 100 IfM).gX)B'1Il) ,IIY Ut" UUI
as defined by the Cupenina Municipal Code.Chapter 9.12,and the HeAh and Safety HEATING UNI"1'(OVER IW.(XXI RIIH
Code.Scaloi 25532110'!
❑Yes [I No VENTILATION FAN(SINOLE RESID) PAID
Ihnd Reociptp
Will me upPloant nr funum holding m'cupant use eynlpnant est Jcvicrx which pO11,EH-COME'131IP OR IINI,IXNI H'IlJ)
)nit havarlou,air unmilitmnt,as defined by the Bay Area Air Quality Manogement 'BYfAI
L
t^. BOILER-COMP(OVER 1 WJXX)pill)
❑YIN —1 No
)have read the)narallous mamrinls requimmrn¢unokr Chapter h45 of the Cali AIR CONDI'I IONIER ISSUANCE IJA'I'EE
Health k S:ddy Coale,Suctions 255115,25533 and 255311 tmdenenW that if the NEW RFSIDI!N'1'IN,MECII. SQ,FT.gdiarmnl rurnnnly navea mn11m1,drnil is my rt.govithity toniinyme mmpalureyuineourswfictinst M:nlmprio(T ononennfn Cenificnm of(MupanrY.rmaumirirsd agent Date TOTAL: ISSUED BY: v • 70
OFFICE