C 0415ICANTTO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU1LIti-EI.ECTRICA],
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING PRO CT IDENT'IF'ICATION
1LRAy 50415
SOOOI /��,•I•a
❑UILDINOG AI�ESS'. �� � �1 .-. ���4"k
0OWNER'S
SANI'FAkY NU.
APPLICATION SUIIMITTAI. UATI
PE�?: —
CONN/C
COM'ROL#
ARCHITECT/ENGINIIER: LIC NO:
ADD
(04❑
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG ELECT PLI1hUi MECH
❑ Consultant Fees Paid by Applicant (Initial)
❑ ❑ (�a( ❑
LICENSED CONTRACTOR'SDECLARATION
I hereby affirm mat 19'.. licensed under provisions of chapter 9 (cmmtnenddg
with S,pdko]IX0)af Division 3mram Imo.essand PonficOons Cmde,a rylmense is
i in formand Q� .�
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RFSIDENTIAI:
❑SFDWL El KITCHEN REMODF.I.
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
Jeense lash _(__.a<KA Lich#
CnntrrR'i3if�c�jyyy(((����iSLL�� ct
[I ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑STRUCFURAL
MODIFICATION
C1 INTERIOR E1 CHIMNEY REPAIR
IMPROVEMENT El SWIMMING POOLS
{ ARCIf M=S DECLARATION
I undemmed my plans shall W used es pthlic rar.rds
j Licensed Prrific. rad
PANELS'
UP TO 2W AMPS
201-INSAMPS
OWNI!R-BUILOHR DECLARATION
I hereby affirm that 1 am exempt from the Contrazlnis License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
whicM1 requires a permit m nmstmcr alter, improve, Jenmlixh, n repan any xwaure
pricer m its ksumm,.IsoregmmatW... heart forsuc on,a leasigne temeat
[I BATH REM ODEI/REPAIR DEMOUT11014
T`J�'��H�R cA
k0' ISL MEu t
OVER I(XIOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUMMISC.
a �ti
r
that he is licensed Fanwood to the pmvismnsofthc Cu 'ICM1upsr9
COMMERCIAL,
ooramencimgwlth Se''un9lXXpnf Dlvisimn3t eI nJ Profession Cmd0m
, that he is exempt from mJ the It 's (seethe leg exe son. Any violation of
'TEMP. MATER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section"031.51, ny applicam (Drape t,mbjecsthe pplica 1 ld a civil Penalty of
not more shun( ehunJrW drillar� (450X
o Lisdwn afthepropeny, lir in swish wages nstheir sole compensation,
will Jolhe rk,andthes wren tiro deJ oroBcreJf�r sole (SecJ044, Business
and Professi - Cale:' a Contme s License Law dues not apply to an owner of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES -FIXTURF_S
NEW RESIDENTIAL ELECTR SQ FF.
prnpeny, who hat - s ofthe n, and who Jres melt work himulf or through
his awn employees nrvlded that such improvements are not imended or named for
sale. IL however the mIdidgor impnwemem is sold within one yearofeampleti..a,the
SQ. Ff. FLOOR AREA
SJSQ.1'f.
conamlmilder will h e the handed of proving that he did not build or improve farpur-
posa aLmlaJ.
I, as owner of Ne progeny, am exclusively contracting with licensed enmrmmn to
TOTAL:
construct the project (Sm. 7044, Business and Professions Code:)The Cuntmnms LL -
cruse Low docs net apply nm an owner of propcdy who builds or improves therum,and
QTY. PLUMBING PERMIT FEE
whocoronets forsuch projects with acuntmemr(s)licensed pursuun tothe Contructots
License Law.
I and me npt under See. . B & P C for this mason
PERMIT ISSUANCE
Owner Dote
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
q —7
WORKERS COMPENSATION DECLARATION
BACK PLOW PROTECT'. DEVICE
1 hereby affirm under penalty of perjury one of the following declamlions:
'Dlhmr
STORIES
TYPECONSTRUCTION
mJ will mainmina Ccnificatcof Cnnscm fossil(-insurcfor Worker's Compcm-
smion, as onsided for by Section 3700 of the Labor Cade, for the performance of the
work far which this .it is issued.
DRAINS- FLOOR, ROOF. AREA, COND.
M,URES - PER TRAP
Ej 1 have and will maintain Worker's Compensation Imsumnce, as required by Section
371X1 of the Laboyi-yCode.
Nr�rrtNfoo�rmance of the work//fruryyrpyw���hiyy�_c//h`at��hy}n/i//s�pemtit ms issue9.
GAS - HA. SYS TEM -1 INC 4 OUTLETS
OCC GROUT'
APN
��forte
My Wst (• LII) P l cy No YLLbI+�� �
Comer
GAS - HA. SYSTEM -OVER 4 (EA)
GREASE%INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF BXEiM IFROM WORKERS'
COMPENSATIONINENSURANCE
BUILDING DIVISION FEES
(Urkwipind need not mcomplcmd if the perosis is form. hundred dollars ($10A
or less)
ORCost; TRAP
PLANCHECK PEE
SEWER -SANITARY -STORM EA.200FT.
IiNERGY TLE
I manly that in the perfommdceafthe worItfor which this permit is issued, l shall
not employ any person in any mannersna/tnbua ` to the Workers' Comped-
'f
WATER HEATER WNEN IELEC IR O 4 V
GRADING Mi
r cation Laws! lifemle. Da [O
N
Applicant '��Sc T 1- r �1U•
iNOi'ICE TO APPLICANT: If, after making this Ccnificam of Eaemption, yen should
became subject to the Workers Compensation previsions of the Lobar Cale, you must
fonovith comply with such Provisions or this permit shall W deemed revoked.
WATER SYSTEMOREATING
SOUS FEE
WATER SERVICE
' CONSTRUCTION LENDING AGENCY
imit1 hereby affirm that them is a construction lending agency far the performance of
the work for which this peris issued (Sec. 91)19, Clv. C.)
lender's Name
PAID
Doe Receipt H
NEW RESIDENTIAL PUSH. SQ, ET.
TOTAL:
TAIAI.. y6 Q
Address
Lender's
BUILDING FEE
I curtly that 1 have rad this application and state that the above information is
corer. l agree to comply with all city and county ordinances and state laws slating to
building consnmmion. and hereby auNuris apmwoni ives of this city meant upon the
QTY, MECHANICAL PERMIT FEF.
SEISMIC FEE
PERMI'TISSUANC[
ALTERORADDTOMVCH.Q
ELECTRIC FEE
above-mentioned propeny for inspection purposes.
e, indemnify and keep hatless the City of Copenido against
(We) agree massive. m
Iiahil'uies,judgmend costs and expenses which may in anyway mews against said City
in nmsegdcncen gramimg of this pcmtiI
APPLICANT D13 )SAN 11.1. ONIPLY WITH ALL NON -POINT
I'I1IMBING hili
AIR HANDLING UNIT (TO Indo®CFM)
MECIIANICAI. FEE
S UI ,UL NS
AIR HANDLING UNI1 (OVER IO.OW CFM)
CONSTRUCTION TAX
a 9
Si mreof Applicadt/Com Datc
HAZARDOUS MATERIALS DISCLOSURE
EXIIAIJST HOOD (W/DUCT)
I IOUSINGMI'I'IGATIONFE
HEATING UNIT (TO 100,000 BJTB
_
Will the applicant or future Wilding ocaupanutnre orhandle hazardous material
;is defined by the Cupertian Municipal Code, Chapter 9 12, and the Heath and Safety
Code, Section 2553200?
❑Yes ,t�,' NO
Will the applicant or future Wilding occupant use equipment or devices which
emit bravadoes air conmmidams ns defined by the Bay Arca Air Quality Management
HEATING ON[ F (OVER 100,000 BTU)
l
Ile Re �iptRe N
VENTILATION FAN (SINGLE RESID)
BOILER-COMP (JHP OR IIXI,tN10 B'N)
N O T
OOILER- COMP (OVER 100.000 BTUI
r
Donict?
E] Ye, tpiso
AIR CONDITIONER
ISSUANCE DATE
I have reads elwcoma smaterials requirements ander Chapter 6.95 of the Car-
NEW RESIDENTIAL MECH. SQ. IT.
lthyC ectun2 0, SSJ3 2531.1 undemard that ifthe
fomia�Kluv
buildiurn' y .a scram, that' ism mull tultaify theacpamofthems sr' bet da Cenif am of Opelax
S -)
TCTIAL:
Own reuthnriu agent Date
OFFICE