S 2559 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'fINO BUILDING-ELECTRICAL PERMI Y NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 2559
BUILDING PROJECT IDRYTIFICATION
BUILDING ADDRESS �r ♦ ��. SANITARY NO. APYLICAIION SJ(U{�RMrI'fAL4AIE
OW, :R:SN M': 1/-/"' 'HO P: C '1 L//•la}R$ A. 131 .IC I� Z
pX+� G (� NIC CONTROLM
Vi
C ACI: -/l PH NE: 7 W BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG BI.13cr PLUMB MECH
�Of1 ❑ ❑ ❑
LICENSED CONT'RACTOR'S DEChA ATION QTY. ELECTRIC PERMIT FEE
I herehy afltnn mal I an Ra..ed amfer pmar,,iom,,of Ch:lptc.9(commena'org JOB DESCRIPTION
Od'Z tit Section 9r]Ofgof Dlvicionlol'Ih.Businces vnJ Pnsl'msainPs mica rliccn,w is RESIDENTIAL'
u W. wr YL+HMI'I'ISSIJANCE
F-ly� in full force and e0e<u ❑$FDW'1. [3 KITCHEN RE.\10DI!I.
aUU License Cl"s Licn APPLIANCES-RESIDENTIAL ❑AUDIT]ON ❑PLUMBING RE-PIPE
v-Z w Data coa laemr
ARCHI'TECT'S DEC]A PION ❑MUCH--NII ❑STRUCrTURAL
f' z I understand my plans shall he used m public records YANIiIS MODIFICATION
ZOZ-0 UPT0200AMPS Z- - Z D ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed l'ndcssional 201-1000AMPS IMPROVEMENT 0SWIMMING POOIS
y WrY Z,I OWNER BUILDER UECLARA'I'ION OVER I(00AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
K G 1 hereby offmt that I am cror's exempt from the Cou nLicense Law for the
0.�(p6U fi11-ingmasoo.(Seel.n9031-5.Nosiness and Profe.,,.ion,Codd Anycfly mearumy SIGNS ELECTRICAL ❑OTHER
H 0 urF which reyulm,,1,permit to ealtetnlet,inter,impn,ve.a, but,car"Pon,any nobt Ire
'� � lid...1.it,i...ance,III so rcquiresthc applicam forsuch pernrin0 If le s.ignedviur'lenl SPEC Ad.CI RCI]I I'/M ISC.
thin he is licensed pursedu 1.he finis........(the Contract.,...Linen,eLaw(Chipters)
1+1 E+00 (commencing with Socdon 7000)of Us isi.n3of the Business and Food..ims C:xle)or TE MPL:
.M FITR OR POLE INS'r. COMMERCIAL
Ily o r1- That he is exempt Percl'rnm nnI the basis for Ibe idegc:l tsempf( Any,:Mutton of ❑NEW BLDG/ADDR ION ❑DEMOI.ITION
Wm Section"103 Li by anyapplicanl fist a pemtit objects lheap,lteam to a c lvil penally of POW]?R DEVICHS ❑'TENANT ❑FOOD SERVICE
t more than five hundred dollars 1$500).
IMPROVEMENT
�60 Lonowner of the m, Ira,t of myemployeeswith Pared asmei(S.794.ho Minn, SWIM M1IING P(RB.ELECTRIC
2 will dmthe,ions C d e:The Contra nor s License Law do for of apply to an holiness ❑OTHER
6'3 m and Pnd'cs+inm Code:The Contractors License Iso does not apply In an owner of OU'I'LIiTS-50011 CIII35-I'X''DRES
his own who bails.or improves thereon,and who docs sunt work himself of through
his own foster,
the provided ,i such improvements old.arc not Intended or offered for NEW RESIDENTIAL ELECTR SQ FII
wale.lf.however.the building nr irnpmvenmm lx-old within ono year nfwmfilaiun,the SQ 17.FLOOR AREA SISQ.IT.
own
er-huilde,will Inds,the human of pros ung no,he did not bvi Id or all I'or III,
pow of.sslc)
I,as owner of the property,am exclusively contracting with licenwd contrect les 1. TOIAI
metre Y the pmjcG(Sec.ID W,H-ines and Pn noiuns Cou,T w Coll nrnnr,I.i-
,cree Low dmeenot upPly loamownr,ofpmpeny who huilds.rimpnwes therc.n,and QTY. PLUMBING PERMIT FETE
whocontowts forsuch pmjectswith a mnlramor(s)Ileenwd pursuant.the C.m icaus
License law. PERM["r ISSUANCE.
1-1 I tan exempt under Soc. ,B&PC for this reason
Owner ])ata. ALTHR-DRAIN&VENT-WATER(13A) VALUATION
WOR KERS COMPENS ATION DECLA RATION BACK[:LOW PROTECT DEVICE
IImrchyit finn under Ill of Iwpury enc of me bull.,i ng Jcdonniu I,
❑ I havemod will maintain aCenilicru,dCorwral.sel6inare for Worker'sCanins- DRAINS-FLOOR.ROOF,AREA,COND. STORIES 'TYPE CONSTRUCT ION
cation,as provided for by Section 3200of the Istmr Code.for the perfommnce of the
work for which this permit is issued. FIXTURES-PERI RAP
I have and will malnmin Workers Compantxation Inxunrnre,as required by Scenda
1910 of the Lahr Cute,for the
suranc mamc,ofthewlic for whiehfiu which lrel_V� GAS-I?A.SYS'I'13M-I INC40UTLIrI'S (1Cd GROl1P AI'N
My ar; Insurance cartierand Policy..
earner: /'�I Ie- Policy No.: ,�Ik GAS-EA.SYS'IT:M-0VBRJ(EA)
CEKI IICATE Dh EXEMPT ION PRO aco
COMPENSATION INSURA lJ GREASI]INDUS'I'RIl WAS'IF INTERCEPTOR -
BUILDINGDIVISIONFEES _
(Minsection waluentecompletedifthepeunt isfbormbundmd Jollm,($1o0) GREASE MAP
or less.) -K IEE
Imnd,daftiolhaperf.nnunceof lit,work for which this permit is ixsunl,lxholl SEWER-SANITARY_SrndtM E Fr.
nut employs, in anymm�nersoas m become aubjoel[.,he Workers'Coullie, I!NE C '1!13
z cation Lawsof Californm Dae WATER HGTH WIVENIELECf I,
O O
Applicant GRA I REE
q NO'fIC17TO APPLICAN'1:Ifrdlcr mold,mix Ccoibcmeof llxension. no xhumd WAI 17.11 SYS'1'13Mf1'RHAfINO
a , bc ,mewhjecl I.the Wnrkee'e Compensation provisinnx of the Ichor Code,you must )II
m
GLI r. forthwith comply with such pravisrnns or this permit shall M deemed revoked WA1177R SERVICE
aQ
C'ONS're iso I ION cnsimc LENDING AGENCY NEW ItGSIDP.N'I'IAL PhMR. SQ.PT, PAID
V Iherehyamnn that mere lsoeonsweJnnlenCagency forth,perronnunce of ole Receifit#
Ilse work for which Thi.permit is is, (Sec.1(19).Co.iv.CJ "Y
OF' Leader,,Name TOTAL:
Lit Leodor'x AJdre,,s TOTAL:
1certify that I hove rent Ibis application ad none Iha the alio,,Inform.......is IIUILDI 11 '
taA correct.l agree to comply with all it,and county national and state laws telling n, QI'Y, MECHANICAL PERMIT ITE
V Z building conswnion,and hereby authorize representatives of this city to enter upon the SEISMIC IT.
shovumenroned pmpaly for inxpcetion imf.'scs.
(Wc).gree lu,,:uve indemnify and Acep hvnnlcas the City of Cupenlnn agvimt Yf?RMI']'ISSUANCE 131.HCTRIC TH
liabilities,judgments,costs and expenses which may in anyway accrue against said City gLT13N OR AD1)'IO MECH.
in ..sequence of the granting of this permit. PLUMBIN( E
AI'PLIC N UNDFItS 'ANDS A WILL OMPLY WITH ALL NO -PO AIR HANDLING UNIT(TO H000I1CIM1
SOURC RECi 1 S. MECHANICAI EB
AIR I HANDLING UNIT(OVER 10.00 CPM) CONSTRUCTION TAX
Yignaurno Applicant/Contmnor I to RXIIAUSTHOOD(W/MUCf) ]HOUSING MITIGATION FEE
IIAZ RDOUSMAT13RIALSDISCI-OSURE
Will theapplicam or(ream building:ccupam smreermadle afurchimbaerial HEAI'INGUNI'T('IO 100,00011TU)
as defined by the Ctinamno Municipal Cole,Chapter Q.12,and the Ifealth and Safety
Code,S,Ob;2553200/ HEATING UNI I(OVER 100,000 131 U)
El W, fy1JJ N. VON'ITLATION FAN(SINGLE RESID) PAID -
Da¢ Receipt x
Will the applicant or future building occupant use equipment or devices which
anal hvr.raxlnux it c..naminams uu cfimd by the Buy Arco Air Quality Managmnem TOILER-COMP(3HP OR 100,000 RT U)
IQI' L:
Dism°1 BOILER-COMP(OVER I(SL00f)RTU)
❑Yc>
ILove mad(he hmuN.us materials rcqulr,mentx under Chtgner 6.95 of rhe Odi- AIR CONDITIONER ISSUANCE 11ATE
I..tate Ilenllh&xd ,cm
,Se iota 255()5,25533 and 25534.1 und,rstanJ hall if h, NIiW RESIDENTIAL MECIL SQ,PC
buildin kr�ns ten t titisnrymspowfludiya nndfy a t
of the n orto",I ace oI Certitleaty�If (// Y
G ale TOTAL; ISSUED RV:
OFFICE