S 2615 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CHANICAL
CITY OF CUPIdRTINO BUILDING-ELECTFUGAL TERM IT NO.
' IUILDING DIVISION APPLICATION/PERMIT TPROG-MNIDWOFIIC
" BUILDING 1'ROJN:CI'IDENpiF'IC.QI'ION
m ILDINO ADDRESS: SANITARY Not, APPI.ICA'I'ION SUBMI TIAL DAI'13
1152,1 _SUU s �q9
,ll
VNIiR:SN h1E: PHONE, C(l 1'RACI'OB'S NAhiG LIC NIP. ~
NIC CONI U,p
'11'1'ECPHNOINEHR: LIC NI ADIYRESS: A —,�• ❑
HO YG 1YJ�/3` _SNI ,
CONTACT, r�n(oN r. _ � '•'BUILDING PERMIT INFO
Dt £i /J� CY '1 ❑ Consultant Fees Paid by Applicant(Inilia) HLDG ELECT PLUMB SHE
❑ ❑ ❑
I ICI NSFD CONTRACTOR S DI CI ARAPIO.N
QTY - LLEC'1 RIC-1 IiRJI1T FCL;
Ih nyaffmM1tI d under - of Chapter 9(conme g 1 ]06 DESCRIPTION
U .Lm. r. ,aunt xF nn.a.h awn tyfea tau. RESIDENTIAL:
Qa7 coons f �Bnnl rd .
Dl0 PI HMII ISSUANCE'
lul ; Itl SL'� E¢ p 6 ❑SFDWL ❑KITCHIiN kIihlODPI.
6�N¢U Ualc Commit c APPLIANCES RESIDENTI Al, []ADDITION ❑PLUMBINGRF.PIPE
A 'l HTEC1':S DI LARA1'ION ❑MUl:FI UNIT ❑STRUCTURAL
'Dor)
Z 1 understand m shall The used as Public records PANELS MODIFICATION
ZOrn� 5'p w.,w
OX—, ❑P'1lI2W AMPS ❑INTI?RIOR ❑CHIMNEY REPAIR
Licensed Pnncvsiannl 2111-1000AMPS IMPIiOVEMENT DSWIMMING POOLS
OWNER-BUILDER OI:CI,ARA'I'ION OVER HHOAMPS ❑BATH REiMOUEIIREPAIR ❑DEiMOCITION
C d I heaeby uIfrnl Inns I ern esen,a from The Cnnhucaor'e Iitnnse Law for the
U following Scaioa 90315.Business and l'ndcsslnns Code:An , I 11 On IEC
'�( g reason.( ir city m county SIGNS ELECT
0.1 Coy
which requims a Permit to construct,alter,improve,denmlish.or repair any<uumure
f❑p'lo art ,in ......isolitce,Nan,c"niru l he appliaam to ouch pmnliuo li le a ignwl alalenlcnt S III C I RCUL'1'/MISCK if. ^ � �
yWy'a, that he I, pthrohnt to lncpmvinionsofd¢Coal e.....s License Le.(Chapter 9 L,
W�09 (amunrncing with Section IlXXDof DivisimO oflhe Business and Professions Cade,or TEMP.MET ER OR POLE INST COMMERCIAL'
the he is can Ta u,"o rum and the hasis for the alleged exuatpllan.Any viniuunn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W.my Sermon]031.5 by any applicant lhr u Penni,subjects the npplicanl nr a civil,wnah,ofPOWER DEVICES ❑TENANT ❑FOOD SERVICE
not more
than five hundred dollars(5500).
IMPROVEMENT -
6 _,,own pn...co,ornty employees with wage'as that, aD compenduion, SWIMMING POOL IELEC'fNIC
0 n
� O willdo The wnrk.and i1a,mmemre u not imendcd ser offeredlin sale lScc.9(s4d,Blniness ❑OTHER
f�I m and Portioions Coll:'Ihe Contractor's License Law docs not apply m an—act of GUILEfS-SWITCIIPS-ItlX'IVRILS
property who huilds ar improvu,hercon,and who does such work himself or through
his own employees,provided Lha.such Intpmvemams me not manded or offered lar NEW RLSIUENTIAh Ii1,EC!'It SQ FI'.
sale.If,howevct.the building I,
he issnld within one yearofcoopladannhc SQ.FI'J'LOOR AREA $ItiQ,F1'.
want-hmlder will have the harden of proving That he did not hadd or improve for pur-
poe nLsale.).
contractors of the property um exclusively contracting with licensed contractnto Tfl'1'AL:
ELT t la,1rI t(Sce.70PLIhismessand PollicSsIOT14 Code:)File Commences Li.
carvel-Oddlevivolapplyinanownerol'poryrty n h Id.orinproves Thereonand •QTY.', s PLUMBINGPERMIT
who tnaCls for sunh molects w'macantracmr[s)licensed pumm�nolhe Cnmmmors
License Low, PERMIT ISSUANCE I ,�
❑I ame%tmpT anderSm ,11&PC],a This mason
AL]ER-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO Y I'ECT.DIiVICP.
I hereby affirm under penalty of perjury one of the following declarations: Q O
I have and wdI maimmn a Certilicnteaf Conanlmsdl-sower"far Werke-Cmin"n- DRAINS-FLOOR,ROOF.AREA,COND. TORICS TYPE CONS'MUCI'ION
,anion,as provided fur by Secllno 3100 of he[,.hot Coda,forme performance ol'the
work for which this parrin is issued / FIXTURE-PER'MAP
❑ I hove and will maintain W..ov"Compensation L'onarce,as re,ored by Section
3700(It the Latter Code,for the performance of The work far which Thin Enron,is issued. GAS-LA.SYS] I INC,4 OUT 1.1 i I'S UCC,GROUT' /4P.,)-ZoogMIN
My rida kio, omperosaiom Intron c'ani �yI I Policy n m •r \S-EA SYSTLM-0 (G) (�
CERT FICNITE OF EXEMPTION FROM WORKI?RS'
COMPENSATION INSURANCE GREASFIINUIJSTRI. fl INTI: GyF I�
Itf11L_DIFO DIVISION FRES___
(thin acdinn need oat rte ntmplmedifthe parols,is lar one honored dollars f811q) GIIEASE TRAP
or lens.) PLANCIII!CK IEE
Ieemy that in the p ofmmancel the work for which this permit isiucued.Ishall SANITARY- ORM • . WFC J
not cmin m tecomesuh'cct v,the Workers'Camera SEWCR-. ENERGY FEL
p y:aur Iten<aIt m any nta,mer.,t.a, 1 1
4
sation laws al California Dun WA'117R HLArFR WIVE '1'/LLGCI'It GRADING FE
0 Appheanl
s-t FN-t NOTICE TO APPLICANT:If,alio nmking this Certificate of Leemplian,you should WATER SYSTEMIT RE 1 y
a become subject to the Workers Cnngan,clim provisions of the Lunor Code,you nerd SOILS FEE
G.I fonhwithaniply with such provisions or this Permit shall the deenmJ revoked. WATER SERVICE
Q
that here is. 1f1N LENDING AGENCY NIiW RESIUIiN'fIAh I'LMIi. SQ.PI', PAID
] z thereby offimnhal there iso ronewaion lending agenry fnnhe performance of Dale Ill p
UO It,work for wMcn this panni,is issued(Sol.3091,Cie C.)
(••, Land—Num,
O U Lenders Adders PU,
} Q. _
I<etffy moll' lh' 'pp I and side IM1,th a information BUILDING FBI:
.F'. Van cornu l ,gmcnu,nply 11hry
all lily tyJ L-II If dl Q,I1'.'� sMLC1IANICAI;PF.RMI IF.B.
UZ building ronslmnton and hereby authon+n reptescmaf v.zof this nit,meOil,upnnhe SEISMIC FF.L J
abovomemioned pro,.,all Inspectionpuryvses. pERMI'f ISSUANCE
)agree In,ase,indemnify and keep harmless the Ciiyof Cnpcafinoaguinnl ELECT"AFF i
•liabilities,judgntents.costs and expenses which may in any way alcove against mid City ALI ER OR ADD TO MECII. O
in n,eaCcnncof(he nomin,of this pcnan. PLUh BI •Pili k
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NEIN-POINT AIR HANDLING UNITFIO ICOW C1'M)
SOURCE.REC LATIONS. - ME' 1'AI.FEE
AIR HANDLING UNIT(OVER HLXX)CENT) C. TR 11ION TAX
;DioncC
, e of ApplicanUCommctor Ila, ' EXIIAUS'I'HOOD(W/DUC'1) 1 USI G MI'1 IGATION FEL
I IAZARDOUS MATERIALS DISCLOSURE:
WIIIInc appl'manisr hater.building nmapan,,tum or ho n hmmdoan nnncrial 111?ATINC.UNI'I'(1'O 100,000 BTU)
efined try the Culwninu Municipal Code.Chapmr 9.12,and the Health send Safe,,
I.,Section 25532(a)l HHA'PENG UNIT(OVER 100.071 BTU)
Yes
VIENTILAI'[ON PAN 151NOhE RESID) PAID Ilan RccciplA
Will the applicant or future building occupant use equipment or devices which
s hmerdom air,onlantimm,sas dr,rS?by The Bay Area Air Quali,y Mnnagnnent ROLLER-COME(31113 OR 100,01X113"f U)
I
L3 Yea (;.No
POILER-COMP Hq.Oq)❑Til)
E III roaffie havardoun maot requircmene under Clutha,6,1)5 of the Coli- AIR CONDITIONER ISSUANCE DATE 9
forma Health&Sufny Code,Sections 25505,25533 and 255341 a aK dnd that if The NEW RESIDENTIAL MECII. SQ,EL
huil�ol,in,�g,A,.rr(as not nuarcnTly nu na�h mal syymy reap'n...Ind, la amI'ly Mentz pial
of///T! tsw ichor v., mcipdorwSiaeuanee or.Cendicate Ik up:
z --Y'
�dner rmtlhovcd agent - - - le 'I'lYI'AL: ISSUld)BY',
OFFICE