S 2693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIT4�OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 2693
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICKf )N SUIMITI'AI,DAU
o � cW Two qA Oso 3lo/
4-CONTACT,
LICNO. w N/C CONTROL#
Fill'I'F.CUENGINEER: LIC NO: AD RP PHONE: J BUILDING PERMIT INFO
r Z� ❑ Consultant l°ccs Paid by Applicant(Initial) ELECT PLUMB ME 11
5� a /V is T
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT' FEE
1 hereby ti the I am licensed under positions of Chapter 9 4eommondmg JOB DESCRIPTION
Od'Z th Section 700G.f Division 3 fine Business anti fescions Gde,an mY license is - O RESIDENTIAL{a1100 wt PERMIT ISSUANCE
lqq- n full force unA ell« C-'1 L7J ❑SFDWL ITCHIiN R1iMODEL
6W 1Dam)aw CJ�sy lw'XCnnvacmr APPLIANCES-RISIDP.NTIAL
FZu1 ❑ADDITION ❑PLUMBING RE-PIPE
Njy ARCHITECTS DECLARATION �e$t ❑MULTI-0NIT ❑STRUCTURAL
p. PANELS MODIFICATION
Z p Z 1 undersmnd my plans shall he used os public records
OZ-1 UP TO 200 AMPS []INTERIOR ❑CHIMNEY R17PAIR
E-.N.,t:M License)Pndassiannl 201-JUMAMPS IMPROVEMENT 0SWIMMING POOLS
5 C C a I hereby uRnn that�amlexelmp tromFthe Contreloor's License law for the OVER Iqp AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
xLx 0 a V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTITER
W LLO yQ which requires a Permit to amamm,alley improve,demolish,or repair any structure — —M
J prinnn if,"ancer'.ka"fire,theappliefou for such permit m Flea signed statement SPECIAL CIRCUIT/MISC.
F, y that[air,licmisi
ensed Puntamthe mosonsof the Ceomcmr,license law(Chapter 9
y'
41x00 hrmommcing with Section700(1mf Division 3ofthe Basins,and Professions Code)or TEMP.METER OR POLE[NST COMMERCIAL:
6 E cy that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
1 KILL Section 7031.5 hyamy applicant fora amtit,ubjeencteripplicam to acivil penalty elPOWER DEVICES ❑TENANT ❑FOOD SERVICE
I! W m t om than Evc hundred dollars($501). IMPROVEMENT'
C Q ❑ I,as owner of the preprite or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
22 winolldmnthe work,audthcnrncture isnot imeadc m.flered fursale(Sec.7N4.Business ^ [D OTHER
el.�an and Professions Code:The Commuters Licence Law does not apply ,,un owner of Q OUTLETS-SWITCHES-FIXTURES V
pmpemy who builds or improves thereon,and who does such work himself on thmugl
his own employees,provided but such improvements are not intended or offered far NEW RESIDENTIAL ELECTR SQ PI'.
sale.If,however.the building or improvement is sold within one year of completion.the Q. AREA $/SQ.FP.
owner-builder will have the burden of proving that he did not build or improve for pus-
pnscof Out. (Yf
1,as owner of the Popery,ant exclusively contracting with licensed contractors toor
iX
constmm the project(Sea 7M4,Business and Profes,ions Cod,In.—umcmr's Li 7
ceric law does not apply in an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
whn comma for such projects with u commetons)licensed pursuant to the Controcmr's L
License Law. PERMIT'ISSUANCE 7
I ant exempt under Sce. ,H&PC limbi,re con
AI TER-DRAIN&VENT-WATER IEA) VALUATION
lour Date
WORKER'S COMPENSATION DECLARNHON BACK FLOW PROTECT.DEVICE /J '^ fed
Ihereby affirm under penalty of perjury one at the l showing declarations. (D Cl
I have and will maintain a Certificate nfComcentto self-inure for Workers Compeer- DRAINS-FLOOR,ROUE AREA.GOND. STORIES TYPE CONSTRUCTIOT
On,as provided for by Session 3700of the Labor Code,for the pe,marmacc of the
work if hath this permit is issued. FIXTURES-PER TRAP
and will mainmin Worker's Compensation Insurance.as required by Section
700ofthe Lader Cere.tmthe peformane ofthework fnwbrb thisperoit i,i,sucd. GAS-EA.SYS HIM-I INC.d OD'1'LETS OC GROUP l �APVZ.(
Cameerky',Co se. l�n'su� agamic vu 1Jy Noy��fy�Dl fp< GAS-EA.SYSTEM-OVER4 EA)
Gl
f[ CERTIFICA'T'E Off EXEMPTION FROM WORKriIiRS' IJ= GRL>A5FlINDUSTRI.WASTE INTERCEPTOR COMPP.NSATION INSURANCE BNLDING DIVES_IO_N_FE_ES__
('Ibis station need no the completed ifthe pemtit is for one hundred dollars($10B GREASETRAP
or lessg PLANCHECK PEE
Lcedifyrhat iamepefformnnce of the work far whichthis lamtit is issued,l shall SEWER-SANITARY-STORM EA.BIT 17..
not employ any persrm in any manner so as to Became subject o the Workers'Gompen, ENERGY FEE
z sat ion laws of Cathcart,Dare WATER I[EATER WNENVELECfR
z Applicant GRADING FEE
h NOTICE TO APPLICANT:IL after making this Cenifieste of Exemption,you xheuld WATER SYSTEMOD EATING
h t : become subject to the Workers Compensation provisions of de,Wlmmac
hr Cade,you s SOUS THE
forthwith comply with truth provi,ions or this permit shall be deemed revoked. WATER SERVICE
Ila Q
CONSTRUCT ION LENDING AGENCY NEW RISIDF.NTIAL PLMB. SQ.IT. PAIR
V0 Hamebyafftrm Otmthereisac...tmaimn lending agency for the Parforn:me,of Date Receipt#
U. — the work far which this Permit is toned(Sec.3097,Civ.C.) 'TOTAL.
O ULenders Name AI
Lender's Address
fy� I fearfy that I have read this application and state ohm the abase information is HUILD
cancer.I agree to comply with all city and county ordinances and watt laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby sutherve representatives of this city m.nmrupon the SETS
above-mentioned property lot inspection purposes. Pf?EMIT'ISSUANCE
(We)agree to save,indemnity and keep harmless the City of Cu,mm.again, J f:LIiCTRIC 'E r
Iiabilities,judgmems,costs and expenses which may in any way creme against said City ATTER OR ADD TO MECII. .:L_� PLUMB :PER Q
in nsequemx of the granting of this permit. e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL.I,,NON-POINT AIR HANDLING UNIT(To 10010 CFM)
MIfCIIANIL LPEIi 41
SOURCF 'IONy.
1�J�5/_Y•`^n-� l AIR HANDLING UNIT(OVER Iq(1W CPM) CONSTRUCTION TAX
Signamm I Applicant/Cnntrnclor Doc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the PI at or future boldingrecupant none or handl.haiardin,material HEATING UNIT('to 100 to,BI'U)
ac Jefated by the Cuvemino Municipal Cede.Chapter Q.12,and the Health and Safety
da,Swtinn 2553^_(m)'! HEATING UNI'I'(OVER IW,(Xp BTtI)
t ❑Yo B•}( VENTILATION PAN(SINGLERESID) PAID
Date Receipt
Will the ap,li...I or more,building occupant use eyflipmem or devices which HOILER-COMP(31IP OR 100,000 BTU)
it hmrerdous air fon andermea as defined by dee me
Bay Area Air Quality Managent TOTAL:
tuna? / BOILER-COMP(OVER 100,NXI BTU)
❑Yes el<
I have read the lineations materials equiremcmwnder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATI3 s
pointfnmiu Health&Safety Code,S«tions 255(15,25573 and 2553x.1 understand that if the NEW RESIDENTIAL MICH. SQ.IT. �/Pl A
nHe Safety Co have tenant oho itis my rand 2554.1 mppp tfta 'hat if the
of doe rcqu me whh usta a steno kxuanacnfa Canrl�pA:e( �,� �--T
Ownernramhoriaedagem -J Doe IAL'/ 0 ISSUED BY: Q
OFFICE
F
C�a
y v o .? r y -�- O Z.
C
9 5
y _• L`. N �� c y d N C J
Cer
c m _ m ❑
eD \
O
O
3
Cl)
.. o
IM
(co
_ e
401n —I 9�8 I-28— '
91n� 75- '-30—'-38—
'A 18212
r
C
G
C �J
ma 111
n
c O
u II
M o
(o a
0 3If
i. �J
R
G
J-
3
I
� l
fl
i
I I
� r
40� 12 - 85 -26- 1 18 12� 75 30
102 12
f
G.
C> O p
09�'