S 1742 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PESIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. PES
L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. K) • 1 V �v SANITARY NO. APPLICATION SUBMITTAL DATE,
fli
OW G NA ,I �' - PHONE. _ (/ ACTA9111L A_ OR'S NAME: __-UC NO NIC G CONTROL It
ARCHITECT/FNGIryEF.R: /�/ LIC�N4w0-i'vl _( ADDRESS: ❑
CONTACT' JAZ
PHONE BUILDING PERMIT INFO
C , I {�,/ V 157-dYSY ❑ Consultant Fe Paid by Applicant(Initial) BLDG ELECT
ELE T PLUMB SUCH
❑ ❑ ❑
ICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby a Irm that 1 and littnsed ander provisona of Chapter 9(commencing JOB DESCRIPTION
with Section70(10)of Division 3(lithe Businessand Proressiens Cale,antro I PERMIT ISSUANCE
�FWO in full forecast cocoa. Yiccnse is RESIDENTIAL
�UZV License Class Lick IE1SFDWL ❑KITCHEN REMODEL
y<a Date Coallam, APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ',EIMULTI-UNIT ❑STRUCTURAL
ZZ so z 1 Understand my plans shall he ins d as pontic record. PANELS
MODIFICATION
O
UP T0200 AMPS
rC�.F'Q License)Pride ss,anW P15TEOVE 11 CHIMNEY REPAIR
.1 201-1,7X1AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
d 1 hereby affirm thin I and exempt from line Conmaenrrs License Law for the OVER 1000 AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
IYpaV Tullman
g wason(Section 7031.5.Bmmp,x and Pamocalim,Code Ia1 gGlo¢Gy�0¢¢ sy y.,county
SIGNS ELECTRICAL
❑O�THE�R
whim requiresR II h p demolish, repair any
pros its issuance.
I. q Ilie If hp II signed.tat mens SPECIAL CIRCUIT/MI$C.ba,he s licensed puruanto he pro iom ofNe GommLicense LawChapter 9
('
communing with Section)OI]()ofDiviaminJofthe Business and Professions Code)or TEMP.MER'ER OR POLE,NST. CQMMERCIAL,
4 6 C C that lopea exempt Terraria.and he basis for the alleged exemption.Any violation of
�( El NEW BLDG/ADDITION El DEMOLITION
1+1^r/Ki Semon]703 1.5 by any hoodelicanlrs(S50rmil subjeusthe vppllcam to.civil penahy of POWER DEVICES
h,i y nn,more than live hundred dollars($5171), ❑TENANT El FOOD SERVICE
Sp Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the walk,and the nmdureis not intended OroBered for sola(Sec.7044.Business ❑OTHER
3 m and Professions Code: Be Contractor's License Law does not nEdy to an owner of OUTLETS-SWITCHES-ITE
S
property who builds or improves thereon,and who does such work himself or through
life own employees,provided that each improvement are not intended or offered for I NEW RESIDENTIAL ELECT SQ P-L
sale.If,however,the building or improvement is sold within one year ofecmpleion the SQ.FT.FLOOR AREA $/SQ.FT.
er-builder will have the hUNen of proving that he did not build or improve for put-
false Ol'sa1e.),
❑1,as owner or the property,am exclusively contracting with licensed contractors to A 01
const
ruct ,(Sec]044.prosiness and Pmfeti<iens Code)The Qnwuors Ll-
ccoseapply to an owner of property wan nnimsmintprnvestherion,and QTY PLUMBING PERMIT E
1-menwren❑ Ie B&P C for this reason PPRMITISSUANCE
IT' Owne ALTER-DRAIN&VENT-WM ER(CA) VALUATION
WORKER'S COMP NSATION DECLARATION BACK FLOW PROTECT.DEVICE O J
I hereby affirm under pe It, perjury one at he following declarations 3('J 0
ElIM1aveanJwillmainparaCe el"Consenttnself-insumfor Workers Coinen- DRAINS-FLOOR,ROOF,AREA,COND.
nasion, SI'OkIES "TYPE CONSTRUCTION
as provided for by Section 3900of the Labor Code.for IM1c perfommnee of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 at he Labor Code to,the performance of the .,it for which Ihis Permit is issued. GAS-EA.SYS TF.M-I INC,4 OUTLETS OCG GROUP APN
My Worker's Compensation Insurance carver and Vol icy number arc:
Carrier: Policy No.: GAS-EA.SYSTFM-OVER4(EA)
CERTIFICATE OF F.XEMMON FROM WORKERS'
COMPENSATION INSURANCE GRFASFIINDUSTRL WASTE INTERCEPTOR
(I his.senine head nut be completed if the permit is picture hundred duller,IS I(N) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
Loy any that inthe any mannrof lam as
for subject
hthin Tacrthe Wokis en' dl,hall SEWER-SANITARY-STORM EA.200 PT.
not employ any Pelson in any manner sin as to become subject to the Workers'Cnmpen- ENERGY FEE
O Z saloon Laws of California.Date WATER HEATER WNENT/ELECTR -
z 0 Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making 0i,Cenlfieate of Exemption,you should WATER SYSTEM/I'RFAT]NO
ai become subject to the Work,,,Compensation provisions of the Labnr Code you must SOILS FEE
{>a forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
a Q
U
CONSTRUCTION LENDING AGENCY Z NEW RESIDEN IALPLMB SQ.EL PAID
I hereby
o,wil affirm that ised(Seconstruction0 landing agency for the performance of PDale kcceip,k
W�
the work forwhich this permit is issued(Sec,309],Civ.C.) V
Q (~ Lenders Name TOTAL: '
V Lender,Address TOTAL'.
Er-a I certify that 1 have read this application and state IM1c,the above information is LDP 'F
.. Z correct l agree to comply with all city and coamy ordinances and state low,rcle0ng to QTY, MECHANICAL PERMIT FEE
U � building construction,and hereby authorize representatives of this city to enrerup�n the ARMIC 5U
above-hour tied property for inspect ion purposa,,
We)agree In save,Indemnify and keep hassles, he Co,of Crisham.again., PERMITISSUANCE TyLj3Cl'RlEkhk3
1'r :tide, jui,orms.emolndexpemeswhel, ny in wry way zcemeagain.asaid Cil, -
encenfthegramingoft ' permit. ALTER OR ADO TO MECH.
Sa PLUMBING FEE
APPLANI'UNDERSTA DS D WI-, OMPLY WITH ALL NPN-POINT AIR HANDLING UNIT('1010,000 CFM)
SOIJRCEkEC MECHANICAL FEB
6 AIR HANDLING UNIT(OVER Qflusp CFM) CONSTRUCTION TAX
ature of App)ieunVCon Top r ate EXHAUST HOOD OCTUCT HOUSING MITIGATION PEE
HA AR US MATERIALS DISCLOSURE.
Will the right nl am huildingoccupion mre nr handle hazardous material HEATING UNIT(1-0 100,000 BTU)
as defined by the Cupenin,Municipal Code Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 HEATING ON]r(OVER 100.070 BTU)
❑Ye.v E3 No
VENTILATION FAN(SINGLE RESID) PAID Date Receiptk
Will the applicant or future building occupant use equipment or de vices which BOILER-COMP JHPOR IIXI,1100 BTU
call,haz.Nous air contaminant as defined by the Bay Aron Air Quality Management ( >
Beat BOILER-COMP(OVER 10of"BI U) TOTAL: '77
.,�
Y
No
Lha ad the hazardous themrial s0uiremenIl inter Chap,erfi95of,he Cali- AIR CONDITIONER ISSUANCE DATE
is Hca &Safety ode,S lions ,1.5,25. 25534.1 understand That if the NEW RESIDENTIAL.MECH. SQ.IT
IT it
rcu Ily sena, ,Nal it 1. :ponsihilily tOnotil' Ne nccupunl
tribe en, is ich ,home, do m' re Of a Cenill 0 c f fF
con oauthorized agent 1/ ale TOTAL: ISSUED BYw����r Vim'
OFFICE