S 4447APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPPRTINO BUILDING - F.LECTR
BUILDING DIVISION APPLICATION/PFRMIT PLUNIBING -MECHANICAL I S 4447
rnr, most:PR(111un- InFNTIFICATION
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OW •R'SNAKI E: f P ONE:
CONTRA OR' TNAME: 1 LIC NO.
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IBUILDING
PERMITINFO '
ryAT/s
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MEC?
� ❑
LICENSED CON Olt'S DEC ARATION
1 hereby affirm mm I am hrefm under promsmna or Chapter 9 (commencing
with Seetirn]00o)of Division3ofthcB iness and Rnfez,ions Codc. and lily licenw is
i ifullfarceand eRut.
I.ipensc Cla,s Lic. p
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QTY. ELECTRIC PERMIT" FCB
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JOB DFSCRIPTION
RESIDENTIAL:
❑SFDWL (]KITCHEN REMODEL
❑ADDITION C3 PLUMBING RH-PIPE.
CMULTI-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
C BATH REMODEUREPAIR ❑DEMOLITION
C OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
C IIT[CT'S DECLARAHON
un t o s I a aced rs public records
PANEI,S
UI"IO 2BI)AMPS w.
Cite, uJ P o ,stout
OWN' -BUILDER DECLARATION
1 hereby affirm ,hot m exempt from the Contractors License Law for the
following reason. (Satire ]031.5, Business and Pnrfessions Code: Any tory nr roomy
which requires a Bemtit w construct, altar, improve, demolish, or repair any structure
print m it,issuance.do,nepame,theapplicem branch perrainrfile a signed sell amen,
Mn he i s licensed par suaono the provisions of the Contractors License Law (Chapter 9
201-100AMP$
OVER IM)AMPS
SIGNS ELF.CI'RICAI.
SPECIAL CIRCUIT/X1ISC.
'I HMR METER OR POLE INS'❑
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
W 00
(an,nncncing with Seen....700(nia Divisinn3ol' the Business and Prrl'evd,m,1.Ir)or
shut he is exempt ,therefrom and the basis for the alleged exemptionAny violation of
XmN
FZaWW
W�G
Section 70315 by any applicant for a permit subjects the applicant m u civil penalty of
not more than five hundred dollars ($500).
Cl as owner of the propeny. or my employees with wages as their sole compensation,
do the is intended forsake 7044. Business
POWER DEVICES
�[!�. ANT FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
ourriuS—SWITCHES—FTXTURES
o
63$
will work, and the structure not irradiated (Sm.
and Professions Code: Me Contractile, Littnse I.uw does not apply m an owner of
property who builds or improves thereon, and who does such work himu•II nr tlnim
Ills own employee, provided that such improvement arc not intended or nflere0 for
sale. If, however, the building or improvernamis sold within one year rf complellnnJhe
NEW BESIDENT1At. ELECTR SQ IT.
SQ. FT. FLOOR AREA
$/SD FI'.
ovacu.milder will have the home. of pnrving that he did am baild m improve for pur-
pnu of soled.
❑Lasowner of the popmy am contracting with licensed contractors
construct the project (Sec. 70Business and professions CMTireCommcmri Li.
noapply oan
'
mho Law does fFrrtywhouiofi therm
QT- Y MBING PERMIT FEE
whocumbrousursuch Project, GmisIconrinlicensed pursue., 1. be Cnmuemes
PERMITilill
License Law.
I nm exempt under Sec. ,B&PCh"Ilds reason
Date
ALTFIi—uR VENH' —WATER [BA)
/ 61 VALUATIONOwner
O D
D
WORKER'S COMPENSATION DECLARATION
1 hereby nftirm nder penalty of per
ujury one of the following ded .'an.':
BACK PLOW PR( . DEVICE.
DRAINS — FLOOR.R E ,COND.
(have and will maintain aCenif¢me rf Conus mxelf-insure fur Workeee Compery
nation, as pmvidel for by Section 3700 of the Labor Code. for the perfmarmace of the
work for which this permit is issued.
SPORT )
04
TYPE CONSTRUCTION
FIXTURES — PER TRtlassw
1 have and will maintain Workers Compensation Insumuce, as required by Section
37Nlofthe LaborCrdu, for the performuneeofthe wnrk for which this lrcrialil is lsened.
GAS — IIA. SYSTEM -I INC. UTL' S
OCC. GROUP
APN
My Workers Compensation Insurance carrier and Policy number am.
Cartier: Policy No,
Q
��ffq'
311D—V
GAS — EA. SYSTEM- FR I EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need nm bepompleted if the permit isfrnrne hundrtd Jolles($100)
rf less)
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GREASEJIND ' I ERCF.P 0
BUILDING DIVISION FEES
GRI3A5 '
PLANCHF.CK FEE
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I certify that in the performnnceofthe work for which this permit is issued, l shall
not employ any Frisian in any manner, so near lsmi u,,nbjmIto,he Worker, Comped-
xutinn Lows of Cul'dnmia. Dam -
Applicant
SE :R—S
All:k urn
Y — STORM
rn', rc
I:NHRGY FEE z O
-
GRADING PEE
NOTICE TO APPLICANT, IL aper making this CeniOcme of Exemption, you should
hecnme subject to the Wohces Compensation provisions of the laobor Cale, you must
comply with such previsions or this Tenant shall he revoked
forthwith deemed
CONSTRUCTION LENDlNGnGENCY
Iherehy anion that thercisaans,mctien lending agency frolic performance of
the work for which thislwrn,i,l, issued(Sm. 3097, Civ, C.)
WATER SYST REA'fING
WAERSERVI E
SOILS FEE
PAID
Date Receipt
NEW BESIDE SQ. FT.
O
Lenders Name
TOTAL:
Address
WLenders
11
oF. V)
U Z
TOTAL:
BUIG FEF,
1 certify that 1 have read this application and state that he above infmmution is
correct.) agree.comply with all city and county ordinances and state laws relining to
huildingeomtroulon, and hereby authodm representatives ofthis city incineration the
- -, -
QTMECHANICAL PERMIT IF HE
Y„
SEIS IC FEE
above-mentioned property for inspection purposes,
(We) agree m save, indemnify and keep hafmless the City of Cupfinn started
PERMIT ISSUANCE .J J it
EL F O
nlll'ERORADDTOMECIL
Iiabililles,judgments, costs and expenses which may in anyway vecrue against said Cuy
in an,srquence of the gntn,ing of Ihie Pamir.
PLUMBING FEE
AIR HANDLING UNl'I'(IO 10,WOCFM)
MECHANICAL FEE
APPLIC T UtS AND WILL COMPLY WITH LL N )N -POINT
SOUR IO
AIR HANDLING UNIT Io,(NXI CFM)
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CONSTRUCTION TAX
Applic
.,ge ur f UC`1,� or Date
HA'LN )GUS MATERIALS DISCLOSU
EXHAUST FOOD OVIDUCT)
HOUSING MITIGATION Fl3G
[IRA] ]NO UNIT (TO 1pB,EfA]BTU)
Will Ne appli<on rfuture building ssccuprm sem or handle hmunhms material
as defined by the Cupanifo Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 255321a1'I s
❑ Yes %A.
Will the opplic mt nr furore building occupant use equipment or devices which
emit hazardous air contnmieanes as defined by the Bay Area Air Quality Management
IIEA'I'INC. UNIT (OVER IWAY) BTU)
PAID
Date Receiptp
VGNTIIA'fION PAN SINGLE Ill
BOILER— COMP QHP OR 100,0810 BTU)
DlnncB
❑Yes <No
BOILER — COMP (OVER Ifak00(1 BTU)
AIR CONDITIONE0.
1 have read the omeardn a nateria], acuiremm�t under Chapter fi 9ff5ttof the Cali-
fi�mta lin &, t 'mons 255115, 2.5531 and 25534. 1 ndersl: A Ibis if the
builds c mnvm,ohm it is my rcrpnuibilny ul Lha mcupnnt
��.� % p ll m> y
umel rinno issuance ol'u'n g �anc.
ISSUANCE DATE
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NEW ItIiSIDENTIAI. MfiCll. SQ. FI'.
r OFFICE