S 1361 APPLICANT-TO FILL-IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
_ tw BUS]. PE IT NO.
'OF COPF.RTINO ' 13 61
'14UILDINCDIVISION APPI,ICATION/PIsRMI7• PING RODENG TIDENOFICMECHANICA,
ItU11.II1Nl;1'H(IJECI'IDF.NTIF'll'A'I'IUN
• BIJILDINt
��� /�/ SANITARYNO. jA.11.VLICAI[ON SIIBMI'F"LDATI?
OW PIIpQNe:�9 CONTE OHS NAME:
pG N — 2 (.Uv+N' �.C7I�a e3 1 Nlc CGNTRDLN
tCHIT LIC NO: Ms: ❑
WC p �10VN7•
C)N•�TFACCE PHONE: BUILDING PERMIT INFO
hj,— `ARIIIII 4kpli : ❑ Consultant Fees Paid by Applicant(initial) Bldf, ELECT PLUMB MECII
LICENSED CON'fRACI' DECLARATION QTY 1.LECTRIC PERMIT FEE
I heresy at LIC mal 1 am licensed ander o[Chupar 9(wmnamcing JOB DESCRIPTION
May mSeclintnmxgonlivininam3ofine Basinecs ant Pmrexaionacode,amen licenmle RESIDENTIAL, `
u10c) wt PERMIT ISSUANCE
F1— mfullforce and ell (� ?ORE ❑SFDWL LI(jTCHEN REMODEL
_5 alj
OUU L¢amsc CII Com APPLIANCI3-RfSIDENIIAL ❑ADDITION ////❑PLUMBINGRE-PIPE
N64 Date CnnlmCroriij
ARCHITECCS UECLARA ION ❑MUTA 1-UNIT C1 STRUCTURAL
F.,? PANELS MODIFICATION
,Z O I understand any plans shall M used m'public records
OZ-0 UI'T0210AMPS 0INTIiR10R E3 CHIMNEY REPAIR
Licensed Pool'essional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
CYC OWNER-BUILDER DECLARATION OVER IIIf10AMPS ❑RATH REMODELMEPAIR [I DEMOLITION
C
C< I herchy affirm that I am cannot from the Contmmnr'v Lennie Law for the
OyU following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
m 3 LL in which requires a permit to construct,alter,improve,demolish,or repair any stmcmre
prior to its issuance,also requires the applicant for such Permit to lile a signedsmtemmn SPECIAL CIRCUIT/MISC.
fa rn�
That he is licensed pursuant to the previsions of me Commences License law Chatter
W itCO (mtnmeneing with Smaino 70,xpof Division Sof m be B amens and Prof..ions Code)or 'IEP.MET OR POLE INST. [IElCOMMERCIAL
K M a y that he is exempt merefrm and The hands for the alleged exemption.Any violation of NEW BLDUADDGHON DEMOLITION
Wool Section 7031,5 by any applicant fora permit subjects the applicant to acivil penallynl POWER DEVICES %6kENANT ❑EGOS)SERVICE
t more than live hundred dollies($5W).
,c,'y Y MPROVFiA1ENT
x< 0 I,as owner of the pmpenY,or my employees win wages vsade(S sole compcmaion, SWIMMING INq .LE 'NIC
�[..,q will do Bre wars.and me 1s,Co a da to d Limit n Law do for I,,apply ]1144,I smer ss �OTHi?R
L 3= and any who
C«)c:ITe CnnUmctoes L n,]vi Law does urn apply i,if owner of OUTLELS-S WITC i - XTURIS
prupeny who M1yees,ld,car imded that
t such i,and veno doss such wnrk ded saturated
tu through -
salawn employees,provided Cham weh mentis old w are not intended ar nlffifcJ hto NIiW RISIDIiNTiAI.ELEC'' $Q FT.
cele.IL however,the building or improvement is sold within ane year of cmmplemioo,me SQ.FT.Iq,00R AREA $ISQ.FI'.
o cr-huilder will have the burden of proving That he did not build or improve lin par
prove, as
mastic.). A I D
I,as owner of the titularly,an exclusively contracting with Iiromed enmracmn to AL: //pIIa,,s,,
construct the project(Sec.7144,Business and Proclaims Code:)The Contractor's Li- �/1 N�
c nsc law encs not apply Uo tm owner of pmpeny who huilJs or inmpmves thereon,and QTY. PLUMBING PERMIT FEF: �n'1hF 1 Q
who contracts for such projects with a curbactions)licensed puruuanuo the Comrucmes L rG //{J/��I-�`gp
License low. PERM]t ISSISANCF. co Uh '•V(�
❑ Iumexetnptundcr Si ,11,0 P C for this rcavnn U
ALTER-DRAIN IS,VENT-WATER(EA) tIIlION
.�T Owner Uume ��
WORKERS COMPENSATION DECLARATION
PACK FLOW PROTECT.DEVICE
I hereby affirm under Clary of perjury one of Uhf following declrtars,Co:
\ hese and will for
i Section Scam of the TwIff Code.for the sprommsce often DRAINS-FLOOR.HOUR GOND. STORIES TYPL CONSTRUCTION
1 norma,as provided for by Section 3]W of me lobo GNe,for me peAnmmnee of the
i wrnkfmr which mhiv Is,nniU is issued. FIX FURIES-PIT.R'fRAF'
have and will mm�(•� Workers Compensation Insurance,as required by Section
]]IM m(Ihc l: t �1f�y,� the perfnnnance of me wnrk Ltwhich thisyf-�{I QS-,,IIA SVSTIiM-I INCA OUT LUIS UCC GROUP APN
Worker' Tarion Insurance currier and Pn' i u�
Career Policy No_ -G SYSTEM OVBR4(EA)
'vkl IPICA'I'1i OF EXEMI4'ION FROM WORKERS' GREASPIINUUSTRL WASTE IMI'ERCEPI'Ok
COMPENSATION INSURANCE BUILDING DIVLSION FTFS
(Th'usoad Intl nm hiccon leteal fineperIi,is for one latdeaddolhciffio)(ry GRPASETRAP
or less.) PLANCIiIiCK IgiB
I certify that in mho performance ofine work lit winch this par miUisiswcA,lsholl SEWER-SANI'T'ARY-ST(1RM EA.200 Ff.
nnl employ any person in onq+L uC M1ytP FnJhe Workers'C'nmMn. ENERGY CLE
anion Lawn of CnlifnWATER IIEATEk WN1iNT/Ii1.liCIR
z Q Applicant GRADING FEE '
NUI ICE TOAPI'LICA . ,eller making tis Ccr ificaw of Exemption, ,in should WATER SVSTIiMOREATING SOILS iggi
h bermes subject m the Worker's Compensmiun provisions of me Labor Code,yon mann
{aIJ funhwith comply with such provisions or this permit shall Mdeenmed revoked. WATER SERVICE
O
z
CONS'I'RUCTION LENDING AGENCY NEW RISIUF.N'TIAL I'Lh1H. SQ.Irl'. PAID
U Date ccipmN
Iherebyores mhanhe.I.. (Seationlending agency Smile prof onnvnce of
V ff
the work fm which Uhiv permit is issurdcA 15cc.3097,Civ.C.)
u" LenJees Name TOTAL:
LUSd Lender's Address TOTAL: it I
yIcerailythat 1 have read this application and nam thm the aMve infonnaimn is BUILDING FEP
I Cr
E4 correct l agree In comply withal)city and county oninvnces and scale luwxrchningnc QTY. MECHANICAI,PERMIT FEF.
V z building construction,andhereby authorize represemmives of min city to ewer upon ma SF?ISMICP
ahnve-mentioned Property car inspection purposes. PERMIT'ISSUANCE
(We)agree m.save,indemnify unit keep harmless the City of cmanlno against ELCCCR 'PEE
liabilities,judgments,costs and expenses which may in anyway were against said City ALTER OR ADDTO MIiCH.
in asequence of rhe granting of thin permit PLUMBING FF.
APPLICANT UNDERSTANDS AND WI ,COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO ROCKI CFM(
SOURCE.REGULAT MECHANIC CLE
WI AIR HANDLINGONI'f(OVER 10,000CPM) CONSTRU IONTA%
Signature III ApplicartAlwWachorl `vale 17XI IAIIS'IHOOD IW/IIUC'Iq HOUSING ITIOATION FEE
HAIARDO S MATERIALS DISCLOSURE.
Will theapplicamnr future buildingrtecupan nmeorhandle hmanlousmmarial HEAPING IINIP(TO 100,0K)BTU)
as defined by me Catechist Municipal Code,Chapter 9.12,and the Health and Safety
Craft.Section M532m)'! I HEATING UNI'T OVER 100,000 BTU)
O Yes •\o VF.NTILAI'[ON I-AN(SINGLE RESSIn PAID
Will the applicant or fumu a huislus occupant Use equipment or devices which me Reccipm ro
nit momdous is contaminant as delinedh the Ha Area Air Quality Management BOILER-COME CUP OR 100,000 BTU)
Y Y Y g TO'CAI.:
OinOicB r\ / BOILER-COM 11(OVER 100,00011'TU)
❑Yes ITt7(m`
AIR CONDPTONER
I have read Ube hasadons materials mryirentmts under Chaptu 6,95 of robe Cali- IS CE DATE
(omit Health&Safety Code,Sections 2!1505,25533 and 25534.1 undeme al Uhot if the NEW RESIDENTIAL MSCI I. SQ.EL
building mss not currently haven heroin,thin it is my respn....ugly to nomlfy rhe se<apunl
of the requirements which most be met prior m issuance of a Centime,of Occupancy.
Owner or authorirW agent Date TOTAL: ISSUED BY:
OFFICE
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CUPERTINA M 95014 '