28877 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
• CITY OF CUPERTINO • BUILDING-ELECTRICAL. - PERMITNO n ''J
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL G 8 8 1
I BUILDING PROJECT'IDILNTIFICATION
DINGADDRESS SANITARY NO APPLICATION SUBMITTAL DATE
BUIL
22}4 n ALCY4LOF, . eD ��-�6�5
. OW R' NAME , PHONE: CON"FRAC'EOR'S NAM1tE; LIC NO
/1 �,C w ' - I� N/C CON]1tO1,N'ye—ow M
ARCHITECT/ENGINEER J LIC NO(./' ADDRESS .. ❑ `
CONTACT PHONE BUILDING PERMIT INFO
a ❑ CD nsultant Fees Paid by Applicant(initial) I BLDG ELFCf PLUMB MUCH
I. ❑ `� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'I'Y ELECTRIC PERMIT FEE
I Hereby afflm that 1 and the Business under provmmns of Chnplee nd ylicenn,, - - - JOB DESCRIPTION
W ap0 wi N Snhce ande et Devl\Inn3n1111cBminen+unJ Profnslom Cale,and my lice.+cn I L PURMITISSUANCE 'RESIDENTIAL:' M
•F+U m full
ense Cl...nd effect ' _ ❑SFDWL ❑KITCHEN RF,h10DBI.
E-UW) License le Can, APPLIANCES-RESIDENTIAL
F�W Dom Commr•^- ❑ADDITION ,C]PLUMBING RE-PIPE
I-De, ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 'OSTRUCTURAL
zCtRZ lundcnwnd my plam.allbemardieplbhcrecmds MODIFICATION
OZ� 1 UPTO20OANIPS
r=3t:nl Locased Professional ❑INTERIOR ❑CHIMNIEY REPAIR
a�d i3 OWNER-BUILDER DECLARATION 3111-I(1I111AMP5 Ih1PROV1EhfENT
ya C � I hereby affirm thin 1 and exempt Tom the Contractor's License Law for il- OVER 1 WUAMPS I ❑BATH REMODIEUREPAIR ❑DEMq TION v
Mu I ollnwmgreason.Soon.7031.5,Ilu+Inea+und Pmescion\Cnde:Any it,or county SIGNS ELECTRICAL' - 1 • ❑OTHER
Yl {L which m4mm%a permit en Cml+lruel,:Iller.Impnrve,JCllln t\I,nl rv`Ilall any dral um
Is to'nsissnanee,aBn requires the upplecaut for such permit In file a signed statement SPECIAL CIRCUD'IM1IISC
} thnthei sl¢enserImix .mallo,,ownums of the COmmcnlr'\Ltceme Law(Chap¢r9 _
20 (cmnmencing with Section7ognot Do,,,mn 3nfihe Bome+xand Profesamnc CWs)or TEMR MET OR POLE INST. COMMERCIAL
6 q C
chat he is exempt Neretrom and the basis for the alleged exemption Any violation of C1 NEW BLDGIADDITION ❑IlF.M01.ITI0N
nXl Is• Section 70315 by any applicant fore pennn subye<rc the applicant toecivd penalty of POWER DEVICES I �TENANI' ❑FOOD SERVICE
^z} n more than Eve hundred dollar,(SSW),
< Q I,uowner of Ne proPCny,nr my employees xnh wages ac their sole cnmlrcnwuon, SWIMMING POOL ELECTRIC IMPROVEMENT
WM wiliJmhe work,and the nmdure iwnl emended or offor.Jfof+ale(Sce 7044,BOSltic++ - -- C1 OTHER -
W eo and Professions Cnde.The Cmunamr's License Law does not apply man nwner of OUTLETS-SWITCHIES-FIXTURES
Pn,pery who builds or unprove+lhercnn,and who does such work Ourself or through,
his own employees;provided mat wch improvements are not in endod Or,offered he NIiN'RESIDENTIAL Ii1.liC'1'k I SQ IrI •a. '
sale It,however,the building ornlprovement is snM within oneyearnt completion SQ.PC FLOOR AREA $ISQ FT
per huilderwdl hmethehurdemof provmgthat hedol not build mimprove ferpur-
sole L-m nw.er of he Seem,. m exclusively contracting Ciro licensed nnuecmn n to 1 r I p A
core, the protect(Sec 744,Bmmess and Profession,,Ctldea The Contractors B @+
c
LI-
ceme".does not apply to anownerof pmpeny who hulldsor Improves thereon and QTY, PLUMBING PERMIT FEE OCT who contmcD for such prolecis with a commands)licensed pursuant The Contractor= • ��
E3ILaw: I PURSUE ISSUANCE 4 199
❑11 cxemp der Sea �} II A 11 C for this lieu... I'
,�V{��r AI:I IiR-OR.VN.@VLlN'1'-WATER IEAI "
we WO :R'S COM1IPENSATION DECI.ARA'110N Y I II r' Ut Uut-Ef1V11 V�%ION
e BACK FLOW PROTEOT.DEVICE
I ereby afR .der pemAty of pe,ury tine ofthe follawm,declarations
(have and will domain a Certificate of Coment to sell-msure for Worker\Compen-' DRAINS-FLOOR,ROOF,AREA.COND
satmn,us provided for by Section 3700 of the Labor Code,for the perfnmwnm ofill
STORIES TYPE,CONSTRUCTION
work for which Nis perms is issued I FIXTURES-PER TRAP '
1 have and will dlammm Worker+Compensation Insumncc,es regmred by Secunn I I'
IOW of the Labor Cade,for perfnrmmncc of the work for which Nispnm.isrswed IGAS-EA.SYSTEM-IINC.4DITLETS OCC.GROUP APN
My Worker's Compensation Imumnce carrier and Policy radar arc:
Clinic'. Policy No, I GAS-EA.SYS7 EM-0VER 4(EA)
CER I1FICATT:Op EXEMPTION FRONT WOR K HRS' ^y
COMPENSATION INSURANCE '• Gkl?ASFJINDUSTRL WASTE IN]'fiRCEPTOR 1 H1111.UINGDIVISIONiI!L'ti
('This section need not he completed it me Permit n fm One hundred dollars l$1W)' GREASETRAP -- -
or less.) PLANCHECK FEE '
Loy any person any manner sm stwork for subject is penniusnwed.ish°II SEWER-SANITARY•-S'IORM EA.2W FT.
not employ any Califon m any manner m as to become subject m the Workers'Compem
.out
,0 laws of California Dat• I ENERGY FEE
Applicant - I WATER HEATER WNIiNT/ELIiCfR I GRADING FEE In,Workers C Z b1Ohwith mplyown such a nikulis permit shall helm m dl i lyov must, WAI E RESIDENTIAL PLhNC I SQ IT - •PAIRSoil's I'lil!.
t NNNNNN������aaaa
U C) .I herebyuffira Nat there«. till eyhotheperforrnanceor Date
ReceiptN
the work for which rsM 7 s Sec J
LTS F" Lender's Name TOTAL:
WLender's Address I TOTAL, 1
Ly 1 candy th TI read Nic too and score dim the inaw mfonoabon is I BUILDING FBI;
ts7 coned Iogrcemdof nh all eit d county oNmancec.nd Ham lox+relaang to QTY, MECHANICAL PER MIT PEE
U bmldN,cmm�edP ,an in,,wtho ,u,mTcsenmuva of Nid Oa,,Iaa,Ofhpmn the ISEISM111C FFR
above-mention agree 7cny tnr in no,t,nn]kee,h PERMIT LSSUANCE
1 Wel agree nl save,nWemnety and keep hurenles\the Cuy ul Cupeninn upaenst a I F.hI?C'I'RIC Igili
hnhJnmc,judgments,costsundexpen+eswhechmaymnnywey uttmmegaenq said Cit ALTER OR ADD TONIE64 -
mnnt¢quencemft gmmengnt this permit. PLUMBING IrEE ^
APPLICANT UN' ERSTANUS ANU ILL COMPLY ITH ALL NON-POINT AIR HANDLING UNITOO Rosin CUM)
SOURCE REG ATIONS 1 MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CUM I I rONSTRUCDONTAX
ignelurc ApleanUC actor Date EXHAUST HOLD(W/DUCE) - - HOUSING MITIGATION FF.
RDOHSAIATERIALS DISCLOS URI? -- — - -- -
WillNe upphcam Or fommhadman,occupant orm or handle awaenous mammal HEATING UNIT(TO I nJlg1O BTU)
• + e Caperton)Municipal Cole.Chapter 9 12,and the Health and Safety -
is defined by th
Code.Sect
7yes 55?21.1' '" IIIiAI'ING UNIT(OVER IUgouO It'[UI
❑Yes No I I I a I '
VIiNTILATION FAN ISINOI.Ii RISIDI PAID
Will the applicant Or future building occupant use t or devices which _ Date f Receipt e
Pp e e eque, BOILER-COMP DHP OR I Offra BTU)
emitict? US err contatNnanH as defined by the Pay Aresmar Quality Management I I TOTAL
DrcmdP BOILER-CONIP(OVIik IN),00013TED I
• I have lead Nc hazardous nm¢rmis mqulrements undo Chapter 1,95 of Ne Code- I
AIR CONDLTIONER ISSUANCE DATE
fnrnia g'does&Safety Cale,Sections,dw 255 33 ,25534 1 unJmlanJ that d the, NEW ItF.SiUENTh\I.M[CH. SQ PI'.
huddmy does cumermly Code.Sections 2 that.umyrcspm.55341lnderoanneat if the • ''
Vitt Ne reyuereinenw wheehmna Mond fenmrm essuamm�fuCe.ehu¢of Occupancy. • n ', . ,
owner or authorized agent Date TOTAL. I$$QED BY.
-- OFFICE — — —