B 0414 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU I LDING-ELECT'"CAU PERMIT No.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MELI.AsHCAl
DENT
BUILDING PROJECT I Ill"At HYN oL4%L+ 2 9 5 Q
B U DIN
i1L6 6 ADDRESS SANI�R)10. APPLICATIONSUBMIFTALI)NUE
?, DO -A�4!0,01111k"4 FkCe
OWNER S NAM�S PHONE: CONTRACTOR S NAME: LIC NO.
-OLO e NiCI' CONTROL#
GW(;HITEC7U/LlpGINEER: ADDRHSS�
F&-X (/,0C1Laz- cg"5- 0 :2� —
CONTACT. q HONE _N'� BUILDING PERMIT INFO
I. D Consultant Fees Paid by Applicant(Initial) BLIND ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ICU,
I hemb,liffintillon I ton Bertram ince,,noviviom;of Chapter 9 mommumer, QTY FLECFRIC PERMIT FEE
Qwz with Saloon 70(Xp at Division 3 ofific Iftiontaiamid m1fir,,ims Code,malm,fivemen, JOB DESCRIFTIQ>_�
�00 in full force and effect. PERMIT ISSUANCE
W vii — ,-<K,1TCHEN REMODEL
U�U License Class—[.it.#
W Dole—Contractor— APPLIANCES-RESIDENTIAL
CADDITION El LUMBINGI.E...
ARCHITECTS DECLARATION LJ MUIJ FUNIT 0 STRUC`FURAL
ZOIi I understand my plains shisall thannadvoi c IF PANELS
4—C UP TO 200 AMPS MODIFICATION
Ito kid Lialuxed Im,ficionewl INTERIOR 0 Cl IIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT 0 SWIMMING POLLS
.2 OVER 1000AMPS
< I hereby tuffiron that I am exempt front the Contractor's License Law for the RATH RE-NIOD171JRFPAIR 0 Hr�OLITION
U filholin,lesson.(Scrons,70315.B re.are Polaclion,Codd�Air,anoto,,mou, SIGNS ELL ER
�0 which vanilla,.permit 10'arearract..],a,mimosa,demolish. ,,.,.it any immune — _CTRICAL
Hot to its issuance.also mquims the applicant for such period to rile a argued structural
that he is ficenced mislaid it)the provisions of(he Contractor's License Law(Chapter 9 —
p SPECIAL CIRCUITIMUSC, Olt
ocurrionarrin,,B)h Section 70duptifDMomin 3ofthe Businessland tv fidsonow Care)or
0 FEMP.METER OR PULE.
ti�a. that he is exempt thamfirms,and the basis for the liflal exemptinn.Any violation of —— VY FO
Section 7031.5 by any applicant for it Permit subjects the applicant to a civil penalty of R DEVICES ]T'g1.1GMK11 ION 0 DEMOLITION
not n a thim Fla forthaddoll,al($50u), — POWE 0 TE El FOOD SERVICE
SWIMMING POOL ELECTRI IMPROVEMENT
X in will do the volark,lind the structure is a,),intended comffidisid far 1.11(Sar,70,14 Business — 4C�Cg Ociffilli
M.— and Professions Coile:The Contractor's License Law does not imply to 'a"it Lo OUTI.E[S-SWZFCHE,9-17,XkUR?,re,
property.1m buld,.1 fialoole,their..,and who does such work onesell or through —— -a
his own employees,provided that such improssumants am not intended or offered for NEW RESIDENTIAL ELECTR
role,If,however,the building or improvement is sold within lose year I pletem.the
owner madda,will have the burden III owim, Iran he did an,buildoohmi Far pill-
pon,of salr)�
0 1.sawan, I the Inciaml,a.c.,hialdy amotmadr,,iffs I nerved rvrftmrm�in To rAL: i6it�3 o
a nalrool I he pnfaal(Sar,7044.Bmince,add P...fic,does C.I The C ourda,Lt.
cause Law does ato apply it)an owner ofpm,cay who builds or improves therand,and QTY I j PLUMBING PERMIT FEE 7
who contracts for such pmjccts with a collonclofts)licensed proustrat to the Contrachar's
Liaers,Uw.
E]I aa�pcftrpl under Sec. PERMIT I ISSUANCE
IT&P C for this ressom
ALTER-DRAIN A,VENT-WXIER(FAT
a', Dole VALUATION
WORKER S COMPENSATION DECLARATION BACK FLOW Plaff HC K DEVICE
I hereby affirm under Penalty of partly one of the following decuriflons: — 2 5-,
1 have and will maintain a Cardficate ofCortand to calf-ireashe for Worker's Crashed. DRAINS-FLOOR,ROOR,AREA,COND.
,stivarn,p..dal for by Scanlon 370"of tha Labor Coca to,the partmal a of the — STORIES YPE CON TION
walk for which this put is issued FIXTURES-PER r MAP
0 1 have and will maintain Worker's Compensation Insulation, as,requircal by'Section a— i 0,
37M of the Labor Code,for the perfiamarro,of the work for whi Ift this parriel IN issued, GAS-FA.SYS I Fill-I INC.4 0171 LETS 44-go—
My Worker a Compensation insurance carrier and Policy number am; -1t OCC.GROR IF AIN
Carrine': Policy Nw: GAS-ITA. 4(EA)
CERTIFICATE OF 13'XEMPTION FROM WORKERS'
COMB�� SATION INSURANCE GREASIANDUS I RL WASTE INTERCEPTOR
or (Hill Iran--thad ma be,morallened iffloapearlut is Form,handled dids.(SHXH — GREA�ETRAP BUILDINC IA is NN FEES
I crIfifY Hill in IF,111hommula ofthe avals far which his pannu(i,noumd,I still PLANCHECK FBI.
amrmPkm any jursom in a",alsou'll-w to Formula object to ffirWaket CtionNe- — SEWER-SANITARY-STURM CA 200FK
Z sation Law,ofCalifistrum Date WATER HEA7FER WNENTIELEC'UR vURGY FEE
2 Applicant GRADING FEE
w) NOTICEIDAPPLICANT BE after making this Cernficandid'Excreption.you should WATER SYSTEMI R�Tffsftl
become subject to The Wmkrev Cionspational provisions of he Ladar,Code,you last — SOILS ME
ftmftwifth comply with such provisimes this moned,luff im derroldnevoked.
�z WAT17R SERVICE
z CONSTRUCTION LENDING AGENCY NEWRESIDENNIALPLMIL SQ,17. PAID
U 0 1 hereby affirm that there is a construction lending agency forthe performance of [)are Ri#
r. the work f which Hit.......I is is,ord(Ser.3097.Ci,C.) —1
U laradr,Name TOTAL
Lerider,Addres, TOTALI 6.?.
I ceftif,it I I hoscomilffi, doinahm add ,am the, he Fo,a information is . BUILDINC.FEE
V) correct.I agree to comply with all city and county ordinances and state 1.wl ortating to Q
U Z building construction.and Inachyandionts,mpmwnmzives ofthiscity tocater alumna 1'y. MECHANICAL PERMIT SEISMIC ITH
itthereve-meamitured property f imparload portents.
(We).9me ,I Visit molarroul,and keep hornless(he C I PERM[F ISSUANC17
u,ot C.,wroon,mild ELECTRIC FEE
liabilific,judgmeria.coxis andexpersel whichrons,in any wayinanuagaindand City ALTER OR ADD TO MECIL
in consequence of the granting of this amount. PLUMBING FEE
APPLICANT UNDERSTANDS ANT)WILL COMPLY WIT]I ALL NON-POIN F
SOURCE REGULATIONS. AIR HANDLING UNITOO 10,00t CIFNI) MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONIAX
Signorina id'Applicall/Connormar Data EXHAUST HOOD(W/DIJCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITTEN]]ON FEE
Wiliflic.,dicad...future building card,mi,thron.,handle hicandom,nudenal HEATING UNIT G 0 100.00D RED)
Tas difined by the Co,taino Municipal CouL.Chapter 9.12.and(he[Icahn and Safety ——
Code.Seen..25532(a)? BEATING UNIT,(OVER 100.daid),ru)
0 Yes ON. I I PAR 0
lttti_ I I VETFU LXI[ON PAN(SING
Will am ft,fievial or(of...FaMon,oraft,dat me or airlines which an, Ra,c,,t It
our ha.,d..a at,contaminants a dtflimal byllic Bay A.Air Quality Management BUFFER-COME ETH R I 00.01(t)BTU)
a
0 Y"
I
Di...ne'? I OTA,:/_Ic-c'Ap
I "C"
0 We []No BOILER-COM
/OVER 100,000[11 LU
I have ad'he handookatil ormalial Isspinamens unde,Chapter 6M,ff the C I AIR CON/110I
I asom Hadth&Safilly Code,Sections 25505,25533 oil 25534 1 undernand Ill.,it the ANCE DI11V
I an ff I Y to ratify thicamormal
mildiii,dre, or comently have nerant.Ill.,it is my H,,annabil NEW !SIDENUALMECIL SQ.ItU
of c I I
.find ficalcof0actiparnacy
I ag 7'
o.....as ificatired ,.I TOTAI, :D
OFFICE
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