S 1546 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELEC1fRICAL Plitt I'M
BUILDING DIVISION APPLICATIONIPERMITPLUMPING..MECHANICAL 1546
BUILDING PROJECT IDEM UITCNPION
BUILDING ADDRESS; SANITARY NO. APPIACAI'ION SUBMITTAL DATE
22933 Y
OWNER'S NAMF3 I'HONF,: CONT/RLAC'TOR'S NAME: LIC NO.
n i E• C av i q� 2S2��f 31 ` i N u� NIC CONTROL#
ARCHITECI'li?NGINF.ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PIil2MIT INFO
❑ Crnsuhent Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm that 1 am licensed under provisions of chapter 9(cmntnencing _ _ JOB DESCRIPTION
C00 whir Section9000)nf Division Sof the looseness and Profeaalrnu Code,ti yIt, ni RESIDENTIAL:
{r1 O I'Iilt Ml f ISSDANCIi
C-N bfull farm nnA elect. 2 S ❑SPDWh ❑KITCHEN REMODEL
Q ryy_rD License asH ���o�� Lic.M APPLIANCES-RES11), HAL []ADDITION [I PLUMBING RE-PIPi
-Q6 Dale FY Cunllnclor
D lin ARCHITIiCTS DECLARA ION PANELS
❑MULTI-UNIT ❑STRULTURAL
~to Z 1 understand my plans shall be used as Public records h DIFICATION
OZ�q UP'1'O 200 AMPS ❑ HI
INTERIOR CMNEYREPAIR
Geensed l'mfc..ional 201-IWOAMPS IMPROVEMENT E]SWIMMING POOLS
OWNL'I-BUILDER DECLARATION OVER 000AMPS
El BATH REMOD9UREPAIR El DEMOLITION
U rmon1 hereby affirm that 1 am exanpl Iron the Contractor's License law Entire ❑OTHER
K 3 d following s .(Semmn 7031.5,Bm,irmoi and PnAessinn.v Code:Any city or county SIGNS PLECTRUM.
W R.� which requires a permit m crmlmm,aIle,,improve,demolish,or.,I, a,structure
F u'01 poor o itsissuance,also requires the applicant for such pemtinn file a uigned Statement SPECIAL CIRCUITMISC.
ythat he is licensed pursuant to the provisions of the Contractor's License Low(Chapter9
�CCCO (commencing wilb Section7001 Division 3 of he Brsem..ad Profession.,Code),), TIMI METER OR POLE INST. COMMERCIAL; ,
T Thal he ix exempt IM1crcfrom and the ho...far the alleged exumpdon.Any vnolmion of - ❑NIiW BLOGADDIT10N ❑DEMOLITION
t�ilE ra, Section 9031.5 by any applicant fora permit subject'Ibe upplkmt m o civil penallyof MOWER DEVICES ❑TBNAN'r ❑FOOD SERVICE
not more than live hundred dollars(850X).
h_Z> IMPROVEMENT
=Q ❑Lo rte aersdlhe property.car my employees wile wages etered rsaei(seta 0u .Bu mess SWIMMING POOL.ELECT RIC
f 11 Profession,,ande:The Cumknul,Licens Law
(See pl,to
Business ❑OTHEN
H
ed 3 and Pry,who
CNe:The eves then' License law dyes mol apply s if owner, li (1UfLErS-SWITCHES-FIXTURES
properly,who builds nnmproves thereon,and who Paas,such work himself or IhrrugM1
his own employees,providul that.such improvements um not intended or minced fm NEW RESIDENTIAL ELECTR S(�tvs -
sale.If,hwvcvur.the haddingor impmvnnem iasold with In wn
mmyutrnf . plednq dm SP PI'.FLOOR AREA %SV.lir.
own
er-builder will have the burden of proving that he did not build or improve in,par-
prim of sole.).
-11,a owner of the property.um exclusively contracting with licensed contractors to TOTAL
construct the pmjccr(Sec.7314,Business and Professions Cdc:)The Cnmmcfor'.Li-
nsc Lxwdoes not o
apply to an raw nor of property who build.or improvesY thereon,and QTPLUMBING PERMIT FF.F.
who comroch,lar such projects with n erntmcmr(s)licensed pursnam m the Commands
License Law vERMI'r ISSUANCE
❑I am ustran under Sec. .B&P C far Ibis renwn
Owner Dale AMHR-DRAW&VI?NI'-WATER(EA) , ! VALUATION
WORKER'S COMPENSATION DECLARATION HACK PLOW PRCH`FC ..DEVICE y- -8
1 hereby ofitm under penalty of perjury one of the following dmlar amsm 1 O
I❑ I have and will maintain a Certifiers of Consent to set 6 annum for Worker's Coupon DRAINS-FLOOR,ROOK.AREA,CONDS'I(ORIES TYPE CONS'I'RUC'I'ION
action,as provldcd for by Suer an 3700 of the Labor Code,Ior thn performmmc rf the
work for which this permit i.Issued. FIX,URES-PERT RAI'
❑I have and will maintain Worker's Compensation Insurance,ax revalued by Section
ldWoflhe Lalau Code,for be perfommnerf the work for which this)emit is issued. GAS-EA.SYSTEM.]INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance cannot and Policy ntanher are:
Codec Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF ItXEMPr10N FROM WORKERS'
COMPENSA'I'I ON INSURA NCI: OREAS MNDUSTR I.WASTE PTERCCPTOR s ,. I1I11401NG DIV SIGN PEES,`, ,.
(Dissect inmJ nal be nnnplclul if ihepnmilNDunne hondooldollnfs SI00) (IIt ItASI?TRAP
carless.) PLANCHECK Ilii?
I certify that in the perfrinnancerl lM1e surd for which this it isi ue .hall SEWER-SANITARY-S FORM F.A.20X1 F1'.
nmemdur,toyperuminanymunnef , stn fhe rate subjca the n lis'( rope ENERGY igili
0 Z sation Laws Ilifomia.Dale WATIiR HEATER WNIiNT/ELF:CfR GRADING FEE
Z O Applicata N
NOILCE'DO APPLICANT.If,after making Nifis
is Cor csof Exemptirn,you should WAI'I7R SYSTEmn REAHNG SOILS hili
hedrme subject u,the Worker'.C...npcnsation provision.of the Jahn,Code,yr.must
forthwith comply with such pmvislornnr thispeamit shall be deanned revoked. WA'H?RSERVICE
D Q
CONSTRUCTION LENDING AGENCY NEW RISII,I`
DENTIALMR. SQ.FC PAID
U O Date Receipt X
I hereby hthi that there is s construction 3mt
lending agency fnrthe perfoanee of
the work[rir which lhis permit is issued(See..30099,Civ.C.)
o (~ Lender's Name TOTAL:
LU Lmtdu'IAMrcax 'TIYI'A1.:
1 ready gree thus l hove rasa Ibisty and
county informers
form that the shove insm nis BUILDING PEI?
rZ buirecn l onstr to comply with all city and comfy ninive ees and sats laws miring upthe QTY. MECHANICAL PERMIT FGIi
C,.) z alsovengcrtioned irmand hercbyection prposes. moves of this cirytocnmr upmlhc SEISMIC PEI?
above-mentioned for inspection keephs. PERMIT ISSUANCE
(We)agree m save,indemnify and keep formless the City of Cupeninn against ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way acme agsinsl said City ACI'ER OR ADD TO MECIL
in on
sequence of the gdamm,of this permit. PLUMBING FEE
APPLCAN'I'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Apt HANDLING UNIT fFO 10.0(X1 CPM)
SOURCE,REGULATIONS. MGCHANICAIJTE
AIR HANDLING UNIT(OVER 10,000CITq CONSTRUCTION TAX
Signature of Applicam/Contmmor Dec EXHAUST HOOD(W/DUCn HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will t he tmpllcamnr future hmIdingumupanlsem or handle haeordou.nmtemil H HATING UNIT(TO 100.00 BTU)
a,defined by the Ctmen?nn Municipal Code,Charlie,9,12,and the Hen11h and Safely
Code,Section 25532(a)^. JJ F117A'I'ING UNIT OVER 100,000 BT U)
[:I Ye, I Isu PAID -
// VENI'ILAfION FAN(SINGLE RESIDI• pate RcmiptX Will the applicam lir future building occupant use equipment or device.,which
emit hrdtoloun sir cotnaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(THP OR I011()(id BTU)
DisnicO 'TOTAL
O Yu 11 BOILER-COMP(OVER 100.000 BTU)
I have mad!thea do seal els requirement under Chapter fi95 of the Cali- AIR CONDI'I IONER ISSUANCE DATE
hand'
H Safe Cn mein 5505.25533 anti 25534.I milersfand that if the NEW RESIDENTIAL MECH. SQ,FT.
linin c mdy ease n,that it is my resrymsibility m notify the iterationZ2 �t y
rf0 regmoo eau hich st be aorta issroneenfa Certificate o�f O,
Owner nr Lori dJ+ogee Data TOTAL: ISSUED BY: v P —^�
OFFICE