S 2789APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'1'dtTINO
BUD,D'NCDIVISIO,N APPLICATION/PERMIT
i
BUILDING. - ELECTRICAL
PLUMBING -.MECHANICAL
BUILDING PROJECT IUEIVII IFICA'I'[(IN
PEiRMIINO,
C 7 Q Q
A / u .J
BADDRESS:
�EUILDING
0' I' Liii r�
SANITARYNG.
APPLICA'TIONSUBMITI'AI,DAlh
NTTJS.SNAME: N�1/VE--
Cf N`RiO�R'S NAM
NIC
❑
CON] ROL#
<CHITECII GINEER: LIC NO: ADDRESS: j
(CITiDJ Vitt 1�
CONTACT: PHONE:
BUILDING PERMIT INFO
BI.DG HLECI' PLUMB MHCH
❑ Consultant Fees Paid by Applicant(initial)
24.3 -0cyll
P` E5— E�- e'
LICENSED CONTRACTOR'S DECLARATION
I hewhy a1Rmt den 1 am Nomad node, prnvilinn, of chapter 9 tcomrancins
with Seetion](XXI) of Division 3ofiha Ru,incsl nd Profa,ion, Gak,end my license i,YPRIME'
in lull fora nnA dlivt. Q
Clp.c. V Lic.X
Dwe 4�� GntIna
QTY ELECTRIC PERMIT
ISSUANCE
AI'I'LIANCES-RIiSIDIiNTIAI. '
FEE
IO
JOB DESCRIPTION
RESIDENTIAL'
W
❑SPDWL FYfICI{RN REMODELhiccmc
❑ADDIT[ON ❑ PLUMBING 107 PHIL
STRUC[
❑M111.T1-UNIT ❑MODIF[ AIIA
CHhJS CA'REP
[I INTERIOR ❑CHIMNIiY REPAIR
IMPROVEMENT C1SWIMMING POOLS
DECL
ARCIIII he tnSDECLARATH)N PANELS
1 unJersmnJ my plans shall M: uAJ us public remNs
UPT02(XIAMI'S
Licensed Professional 201-1000AMPS
OWNER -BUILDER UF,CLARAI'ION
1 hereby union that I an, exempt from the Contractor's License Law t'or the
Iullo.mki rcl, n (Salinn70315. lhoine,and Profession, Code Any city err county
OVER ❑XXIAMPS
C'TCAL
SIGNS 171.I!RI
❑ BATH REMODIi1lRFIIAIR ❑DEMGLI"TION
❑(YTIIER
which requires a Ixrmit b construct, alter, improve, denmli,b. or repair snv ,wmure
prior a R,i„uanm,dA requires the applicant rnrwch permit m lilt a,igneJumemm,a
that he is licensed passu..... the provision, of the Coal mcmr', I.wan,e Law (Chapter, )
(axsmcncing with Senion]000)ofDwi,iuo 3oDhe Umincrzand Profc,siom CIAO nr
m
that he is exempt 1hemGom and the breis for the alleged exemption. Any vialmion of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
SPECIAL CIRCUITIMLSC.
'rEb1P. b1ITHR OR POLE INS' 1.
at,
POWER DEVICES
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑T17NANT ❑FOODSERVICE
n mom than five hundred dollars (55(X1).
�l,a,ownrroflbeprapengormy mnpluycc,with wages t„Chair tele cutup ......
will An the work unJ lhc,wemrc isnot intob&db,,:BemJ bosde(See ]On. Bu,inem
and Po f,,,ion, Codd The ComvcloA License Irw docs not apply m an owner nl
property who build, uT improve, thereon, and who R,,,,.ch work blmAlf or through
his own employees, provided chat such improvenants am not intended or offered for
sale, If, however. the building or improvement is sold within oneyaarofcomplction, the
SWIMM INC, TOOL 131,ECIltIC
`
1 Ott I'LL 1 S -SWITCHES- FIX 'IURF:
NEW RESIDENTIAL ELPC!R SQ IT.
Q D
IMPROVEMENT—, -�-
❑O111HR. 1
: • 7-�
i I 1
SQ F-P!FL RARF.A�
{j1
9f1(CSQ Ic11
JsJ7.J1 u
wer-hadder will have the burden of tem he did nm build or iso far
u n { & pmvc oar-
,
pose
1, a,owns(of the See 7 , um cxdn,ivnd comrdcting with Ikon,] cnntrm'tnII m
mssmn the pn jet (Sec. ]fano Booms, and property here n. Li-
who ds or u pro Cs thereon.
nsclawdteor sOmb apply loan ith aCt l'pmpeny whored fa%munurvhe Cmdms.and
wM,commcc,fimuch pmjccu withanvnmcrosiq Licensed pusuum techs Comnnnl',
QTY. PLUMBING PERMIT
Ttc:
FEE
1' {�
L�_._._...
tt Lax'.
PERMIT ISSUANCE
s J `-'
0 I am exmnpt under Sea . B ffi P C for this reason
/ VALUATION
'� O r_3
r\L'1'F.R- DRAW & VENT - WIVE IiR (EA)
Data
1.11
WORKL 'S CQMPiiNSnl'IDN DEChAItAI'Il1ION BACK (:LOW I'R(YI"EC'T. DEVICE
1 hereby nllirm under pewlty o1 Inrjuryone of Ibe lidlowing dcclaodion,o
(](have and will nuenlain a Cenificale of Conttnt m,clGimvm for Wakcr',Co..I,.-
for by Section 3]1X1 of the Inbor Gds, less the perfonnance .(the
cation, a, pha, h his
k for which this permit is isauad.
t��/.J[� have and will mainnin Waders Compcncnion Inmrance, as required by Section
39(X1of chc latnu CnJe for the perfonnnnce nr the work fur which this .it is issued,
My Wmk,'a Cn I anent: n,umnce curnals, lPolicy : nt cr
Larrier: i+nA l'olisY N"c��� ViV�Oow'
CERTIFICATE 0V,XI',MI'1'ION FROM WORKERS'
COMPENSA'I ION INSURANCE
DRAINS- FLOOR, ROOF, AREA. COND.
FI%TURES -YF:R TRAP
GAS- EA. SYSTEM-( IN C.JOUTLITS
GAS-IiA. SYSTIiM-OVERJIIiM
GREASI%INDUS']'RL WAS' 117 IN'rERCEYTOR
0
STORIp'
TYPE CONS'IRUI7HON
O GROUP
A-.P3N�
��
BUILDING DIVISION IBES _
Illlisxilion need not Mcotnpleted irthe pcmtit is foronc hunched dollars(Mg)
or 4w 7
I cenifythm nthe pedonnance of Outwork forwhich Nki,cnal is isuN. I shall
t eploy ary FI in any msubject manner so a, to become suhjeco the Worker,' Conifer.
nom
GRF.ASE'rRAP
SEWER - SANITARY - STORM lin. 2008
PLANCHECK FRE
ENERGY FEE
GRADING FEE
cation Lawaof Cald innia. Date WA ER IIHAI'ER WIVEN'T/lil.E(]i'H
Applicant
j NOTICE TO APPLICANT: Ef: abc, nmking this Canificam of [aamption, you ,hoot,]
' become Abject u: the Worime, C ..... i nmtion provisions of the Lullor Codc you must
• foMwith comply with such previsions or this pcmtit shall he Jecmed mvokW.
WATER SYSTEM/BEATING
W'A'TER SERVICE
SOLI ti FILL,
CONSTRUCTION LENDING AGENCY
NEW RILSIDI!NTL\L PLMB. SGO FIL
PAID Dat Nviceipt M
I hereby affirm that hem is a con.nnation lending agency for the perfmmanre of
TOTAL
the work fta which this permit is i ,ued (Sec 3(N7, Civ. C.)
Lmnd,,, Nanm
bender's Aldo:,,
<I I EL
BUILDING HE
1 eenny that 1 have read dui, apph,dion and canIbm che Ir i e information is
] crrect.I agree to camnply with all city and county onircuri— and .state laws mlating o+
building construction, and hereby authorim repm%enmtivcs of this city to enter upon the
above-mentioned propcny for lmpection proposes.
(We) agree, pave, in temnlfy and keep hamiles the City of Cupenino ageci.,
IiabilltioJuJgum�to�,m,tuandexpcn,ewhieh tnayin'anyway accrueagainst s::idCity
QTY. MECHANICAL PERMIT
PERMIT ISSUANCEI,i)
ALIERORADDTOMECH.
FEE
SEISMIC FE
Ei.r=RK ",E Q
PLUMBING N-7 O
in umsegneneu 0 tl:e grunting 0 An"Fac
APPLICANT' UNDERSTANDS AND WELI. 1PLY WI'1'If ALL NON.POINT
AER HANDLING UNIT IID BL(XX) CFM)
MECHANICAL ':E
SOUP,('E R,�s,._ T
IU ERIC_ %O "j(�t��
3Dam
AIR HANDLING UNIT (OVER 10.1X10CIM)
CON's IR Cr10N TAX
Siloan,,of ApB%camVC.rd avrr
I EXHAUST IV)OD(WIDUCT)
HOUSING MITIGATION FEE
IIAZ RDOUS fATERIALS DISCLOSURE
Will lhant,licuntnr lunate hnildingoanpam mor a or mantle hvuNrnc,mabnal
HCRrING GN1'I(FID I(a)last I1' ID
u, dviinN by tltu Cupertino Man lc opal Code. Chapter 1.12 tool the Health ttnd Salm,
Code. Stolon 25532(a)'I
(:J YO, TprVo
HEAPING UNIT' (OVER I IRI,(XX11f I U)
VENI'ILA'I ION FAN(SIN 31.:Eg�l
PAID
Data Receipt x
Will the applicant or future tuilding oevalad use equipment or device, which
hara dousair contaminants a, dchned by the Buy ArcaAir Quality Management
I101Lr:R-COMP (3HP OR ❑)roil
BOILIiR-COMP(OVER IIX1❑
Yos 7(Ij1E
have red the hvallous niaterial,rt I, under Chater 695 of the Cali-
n4nnia Ilcalth & tiufdy Code.Sections25505,25511 and 255W.I unJemmm11ha1 it the
AI R CON In I'IONER
Nf:W RISIDIiNT1AL hfECH,SQ. FIIJ
ISSUANCE DATES25533
building dons ten currently hartamount. shat n is my mrym,ibilicy as unify the macupam
l/ l
ofth� menu whie�Znanprioriui,ua ofaCeniI r � n
dr
ISSIJI!iI BY:
Uwncr ur:uttboritc gee Dmu Tf3
11 OFFICE
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