S 2996 APPLICANTTO FILL IN INFORMATION WITHIN RED.LINES-USE BALL.POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
-BUILDING PROJECT IDENI'WICATION
BUILDING ADDRESS! SANITARY NO. APPLICATION SAUBMITTAL DATE
WNER'S NAA1 D ON C'ONfj{9jT1'OR'S NA E: LIC NO: 3 V-9
SU t 4I Md 40$'/ e.B NIC CONTROL,
Ill' OLNGINEER: LIC O: ADD IIIA 'r El
IrHO-N�)l d
932-1
COry "
' PERMIT INFO"
(`4W/ ❑ Corlultant Fees Paid by Applicant(Initial)I BLDG ELECT PLUMB MECH
6 -o r� ❑k - C3- . [�
LICENSEI CON']RACTOR S DECLARAMON QTY. 'Ls.LGCTRIG PERMIT' FEE' 1
I hereby odrra that 1 licensed d p r CI I l 9ng .,, JOB DESCRIPTION
�Cz wire sect on lolw)ofD :on3nnnLBaa wProfes:int.coca and„y ice e _ 2 RESIDENTIAL:
ill
n fufirm ande0'ml PERMITISSUANCE3y S
W^ - E;?fFDWL ❑KI'I'CHF':N RCMODEI.
h�UFUU I,icmue Clash Lic.N
Qa APPLIANCES-RESIDENTIAL 11 ADDITION El PLUMBING RE-PIPF.
Datc Cemranor
ARCHITECTS DECLARATION ❑MUCfI-UNIT El STRUCTURAL
'Da, PANELS
OZ4- lundcmmnd my plans shall he uaulmpuMic rccnM. CHIMNMODIFEY
CA'f10N
OZ�Q' UP TO 2W AMPS C1 INTERIOR ❑CHIMNI?Y RI?PAIR
W Torcasio]Profess...al 401-I000AMPS IMPROVEMENT ]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER IBIXIAMPS Fl BATH REMODEUREPAIR [I DEMOLITION
1 %6 I hereby affirm that I am esempt from the Contractor's License Low for the
O y U following eco a(Sedan 9031.5,Bualness vnd Post..inns Code:Any city or county SIGNS Pl.IiCTRICAL [:1 OTHER
G a G m which require,a permit to construct,clear,improve,denmlish,or repair now structure _
C' p,wa In its is.unnm,aLro termite,thcaffih,am inrmchptnon,, a asignedsumemem SPECIAL CIRCUITIMISC.
.11 that he is llcen.ulpur.uanlmhatprnmsionsnf1m,Commenn's License Law(Clo,ne,9
(commencing with Section 700pof Di cop 3 of dm Businsean
el Pmfessions Code)., TIME MBfER OR POLE INS'I'. COMMERCIAL:
(c
that he is esampt tberefronn add the basis for the alleged wanname Any violation of Q NEW BLDG/ADDITION ❑DEMOLITION
W Section 90315 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEV
ICES a]^m ❑TENANT ❑FOOD SERVICE
urn more Nan Evt hundred dollars y empl
F Z S^ IMPROVEMENT
pd ❑I,ns nwnend'Ne pmpeny,or my ennpinyms wide wa......cir solemmpcmmion, SWIMMING POOL P.LFATRIC
CdCA ae will do the work.and the switched,is not intended or offered re, ole(Sca9M4,Ru,fneas COLLIERgm vnd Professions Code:The Commcter's License Law does not apply to an owner of OU'I'I.f:'I'S-SWITCHES-FIXTIIRF.S
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such innprovomems an,not Intended or offered for NEW RFSIDENTIAI.ELECTR �S 1
sale.If,however,the building or improvement is sold within oneye:uefwmpletion, its SQ.FC FLOOR AREA $1SQ,Ff..
er-h rilder will have the burden of proving that he did not build or improve for par-
pu e of sale,. 4��5�-
❑ I,as owner none nropear,am c.aaaialy wttanetlng conn us«.1 wmmenn m Z L:
construct tproject(S 7044,Business andProfessions Code:)Bid Cone-mtursL - 1. 4
I- dense Law doesr applyl r of p p ty w hit ba'Ids or Iupnwes mereo,,and QTY. PLUMBING PERMIT FEE
It contracts fr such projectsxth a contractor(s)I'eenmJ pursuant to the Contractor s
1,cense I.aw. PERMIT ISSUA
❑I am exompt under Sec. ,B&P C for this reason
AUTER-DRAIN TER(FA) VALUATION
e Data
WORKER S COMPENSATION DECLARATION RACK FLOW OTECT 1 O
Iheretiy nffrm under penalty nrperjury natal the following declarntinns: _
I have and will mainutin a Certificate of Consent to self-insure for Worker's Gmn,vau- DRAINS-FLOOR,ROOF,AREA,C STORIES TYPE CONSTRUCTION
mdnn,as provided for by Section 3000 of the Labor Codc,for the petlarmonce mine
work for which this p rion is a,mal. FIXTURES-PER TRAP
❑ I have emd will maintain Workers Compcmation In.wevna,as required by Scene.
3IIq smile Labor Coda wrthe performanda of the work far which this permit is issued, GAS-HA,SYSTEM-IINC,4GOT, OCCGROUP APE
My Worker' Com =pxatiun Insumne ca d Policy number arc:
Carrcr: Policy Na.:� GAS-BA.SVSTHM-OVI3R 4(f3A) -
ER IFI TE E LE�4PTION FRO RCF,..
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR } ,R ICD G r IYIS_ION FEES I
fThi....ionneednnt he,mr,amed ifhae permit I,fur one hundred dollars($109) GREASE TRAP
or les-) PLANCHECK FEFA
I evilly thin in the performaneenphe work forwhich(his penniei.issued,Ichall SE"HE-SANITARY-S ORM EA.200 FT.
not employ any person In any moaner so as to hecomestebjeei m the Workers'Camper- _ ENERGY IT d
let inn Laws of California,Date WATIELF.
ER HEATER WNENTCTR LS
it
zp Applicum GRADING F
Z r~Ni NOTICE TO APPLICANT IC after making this Ceaifirrw of Exemplion,you should WATER SYSTEMITREATING
a7 became subject In he Worknea Compensation provisions of the Labor Code,ysu mual SOILS FEE
LkL feahwitb comply withsuch provisinesonhis perntitshall be dcemairevoked. WATER SERVICE
Q
CONSTRUCTION LENDING
embe,AGENCY NEW RESIIIENPIAL PLMB. SQ.PT. PAID
l herchy a[f rat havthacrc isumnatrus0mn lending agency In,the ptdnnmmnm of Date Rewipl8
IA P the work for which this permit is issued(Sea 3041,civ.C.)
0 Lenders Noted L /
CTS Lender's Add... 'AL:
6t I certify thin I h read thisapplication d I t J nit h f bun's BUILDJN S ��
Fy Vl tamest 1
Uagree m comply lit ll lY J Y di d la rm m QTTY MECHANICAL PERM-
IT FEE
Z n
abovo-memluned property airritation purpe
PERMIT ISSUANCE
(WI)agree to save,'mdunnify and keep biomass the Cil,of Canino against I FE
incoisequenc e(ifthe costs and of this permit.
envy in any conyturret agninat said Guy ALTER OR AUDIO SUCH. 2-
In consequence of the granting of lhir permit PI'
APPLICANT UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) MEC FEE /S
St�LIliL4' ULATIONS. 2
///��� AIR'HANDLING UNIT(OVER I 1000 CFM) C "fR ON TAX
Si" mot Applicant/ nntrvemr e EXHAUST IIOOU(WIUUC'q HWSI MITIGATION FLrH
HAZARDOUS MATERIALS DISCIASURP.
Will Ne applicant future building omupmm.vow or handle hvmMous mate nl I]P.AT[NO UNIT(TO 100,000 BTU)
as defined by hat Captain.Municipal Code,Chapter 9.12,and the Health and Safely
Cada Section 25532op1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn PAID
VENTILATION PAN(SINGLE RES ID) Dale Rmei #tM '
Will the app contaminants
building by upant tire Bay Area
Air Qualitparrat in y
Management
ant BOILER-COME OHP OR 100,000 BI U)
mit haeanloua air wnanminnms its dellncd by the Bay Arca Alr Quality Mvnagemenl
Disaicl7 BOILER-COMP(OVER 100,000 BTU))
[:j Ya, No
I batrend Neh J t 1 a Chapter tAIR CONDITIONER hat Cnh- - �UANCB DATE
!onto Health
&Sdey Code,Sector,' 2555 05255 a ,q
39 J255J61 1 wdAt iflhe NRW RHS IPEN I'IALMECH. SQ.Ff
huilJ ngdnes nm currcnlyM1 t etltty 'p :Nllyl If)Ih cupum
-Nerc memswh' t a,lberdid,a fm .ant 'f of car, y.
OvO or author' cat Dat ISSUED BY:111'r I �-`►
OFFICE