S 2798 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECFRICAI, PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL Q n O
BUILDING PROJECT IDRN DF'ICA9'IUN J L o
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2
OW ER'SNAMB If1Nli: / CONTRAC'TOR'S NAME: LIC NO'. �'����
ego k Pr �S3'�j'Crl.D N/C CONI'ROLM
FIW All TFCC/IN NP I.IC NO: ADDRESS: El el�
CONTACT. ['[]ONE' BUILDING PERMIT INFO
� ❑ Consultant Fees Paid by Applicant(Initial) B�L,DGG ELLFCCT PLUMB MEECCHH
// IJ L{i� lLT CI
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under presidents of chapter 9(amnmencns JON DESCRIPTION
I, fuBooboo 7d eficeDrvi 3oflhc Runinenn Nnfevsio/y CpJe.gadya..Jicenm ix
Eco, in full and.R2m. Y ((7r/�J/- C6�'(O/ P[RMfC ISSUANCE IeTFDNrI El KITCHEN REMODEI.
�VZU Llcenxe Claae Lic.M - APPLIANCHS-RESIDENTIAL []ADDITION El PLUMBING RF,-PIPE
FdLL Doc CIS DB .ARATION El MULTI-UNIT ❑ST'RUCfURAL
z p y z 1 understand my plans shall be used as public records PANliLS MODIFICATION
OZ—p UPT0200AMPS [I INTERIOR El CHIMNEY REPAIR
Q4t:W Licensed Professional 20I-1000AMPS IMPROVEMENT )]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVCR IBM AMPS ❑BATH REMODIiVREPAIR QDEMOLITION
a'Q I herchy allino Ihut 1 am cscmpt from the Contractor's Llceaae Law Gm the
aO y V following reason.(Section 731.5,Ba,io...and Pnlfessio 1,Code:Any city or cmtnlYSIGNS ELIiCCRICAL El OTHER
LL which requires u permit to commach alter.Improve,demolish,.r repair any sw,ame
rLL0 print to its issuance,ulsumum..,he applicant Forman permimo tdc',ugmedsnmntem SPECIAL CI CUIT/MISC.
F,
o' that he is licensed pursuant to the provisions of the Contractor's License Law(Chaptera)
p0 (commencing with Section 7")ofDivision J ofthe Business and Profession,Gslc)or TBT
R POLL NST. R '
a e c that he is exempt dercfmm and the basis for the alleged cxemptioo Any violation of ❑NEW DITION [I DEMOLITION
r 4• Section 7031 5 by any applicant for a permit subjects the applicant to a civil penalty,of POWBR D ,
m TENANT ❑FOOD SIiRVICF,
not more than five hundred m dollars($5(X). IMPROVI3Ml?N'C
~, O ❑ I,as uwnenff the przopeny,or my enpinyces with wugce as mcir sole compensation, SWIMMING POOL ,SCIRIC
F will Bothe work,and thestruemre is not intended ureteral f.rsale(Ses.7)44,Business ❑OTHIR
1'3 and Professions Cady.The Contractor's License Law does not apply to an owner of OUCI.ITS-S TCH 19 CURES
prnpeny who.....Jx.r improves themon.and who does such work himself or Ibmugh
his own employes,provided that such improvements am not intended or oRerad lot NEW RL'SIDENTIA l.li-ITt SQ Fl�
ace,11,he,ver.Be building or improvement is old within.eyewofcompdetm Int SQ.FU FLOOR AREA £/SQ.FC.
owner will have me burden of proving that he did act build..improve for pur-
a",ofnule.) Z13 5rrJ 373V � ✓
❑ 1,an owner ni'the p..pan,,not enclsively comruedny wort licensed commcmns m TOTA y2'/
conswet the project(Sea 70R 1.Business and Pmfessio¢s Codc:)The Contract r,Li
cause,law does not apply to an owner of property who builds or improves memos.and QTY. PLUMBING PERMIT FEE
who convects for such projects with a commands)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑I am naernm under Sec ,If&P C for this tutor
er
ALI'CR-DRAIN&VENT-WA'I'IR(EA) VALUATION
w WORKER'S COMI'hNSAGON DECLARDate AI BACK PLOW PROTECT'.DEVICE
I hereby affirm under Penalty of Perjury one of the following declaration:
❑ Ihme andwillmaimninaCenihcam of Consenuo ulLinsure for Workers Compcn- DRAINS-FLOOR,ROOF.ARBA,CONED. STORIES '1'YPIiCONSTRUCTION
ration,as provide)for by Section 3701 of the labor Code,far the performnc
ae of the
work for which this .is is issued FIXTURFS-PER TRAP Al
[:]1 have and will maintain Worker's Componcution Insurance,as required by Section YYl 'V
3700 of the Tabu Code,for the perfonnanccof the work lin which this permit is issued, GAS- 5 C.4 OU'l LETS OCC.GItRO���UP APN
Cy Workcrrnypeafi.Alncc curricr:md Policy ,blit . QU. GAS YSTE --' 4(EA) /J J 8 /y.,
/dr IKC.. Polmy No.: L I`
CI:RTII IC O OF SATI N INN FROM WORKERS'
COMPENSATION INSURANCE GRI DUSTRL N'AS .INTE C.PfOR
(This swoon need not becompleted ifaw permit kfor one hundred dollme lS 100) BUILDING DIVISION Il3FS
or less.) GR I:TRAI;Pa 11 , EE PLANCH 'till S O
Iwnify ohm in the perfnrmunce nl'Ihewotkraishichthoperm il,i....L I,ball - vers T
Pany par ymannw no un 1 S' I?R-SANITARY-S'fORM IiA.20�FI' �V
not arms, xnn in uo no beeomeauh'wno,hu Wnrkecd Cnmory I
N 7R V
zZ sell..Lawsof C.1Borniu.Data A IEATER WNINUBI.ECI'R
O Applicant
N NOTICE TO APPLICANT:IL after making this Cenifcnte of Fearapsom.ycash ould WATHR SYS
a ; becmna subject m the Worker,Compenwdnm provisions of the labor GMs,you mea
W forthwith comply with such provisions or this Permit shall be carried revoked. WATER SCRVICE
CONSere isa orUouc NDINdingaeCY NF:W ItIiSIDF.NTIAL PLMB. SQ.PI'. PA
U work
by whuff1nn woruIisacof(Site3097,Cing agency for the perfonnune:all Urate Receipt
Hthe work for which this permit is Issue)(Sec.J09],Civ.G7
QLenders Name
U /� T 1
Lenders Address v TOTA
F0. I cattily that 1 have read this application and stem that the above intonations,is ROIL NGVE a
V) correct.I agree to comply with all city and county ordinances andsmte laws renting a' QTY. MECHANICAL PERMIT FEE
v U boldingunnwctimn.and hereby umhmire mmesenm,ivcs of this city memeraptm the -SRi E v
above-mentioned prepeny for n,,x,,tlon pury.sos.
(we)u,ma m ante,Indcomify nn.l keep harmless the City of Cape Lino ngminxt PP.RMIT ISSUANCE. HLH IC PTL'
liabilities,judgmems.Outland enpsame,which may in me against said City ALTER OR ADD TO MECH. /
in i'I.0 RING FEE
nseque cul,he gSTA IAl.WIL f
APPLI ANT UNI'ITR A 'AND WILL COX LY ITN ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MI: ANICAL FliF.
S
OR CNEGIII\TI
AIR HANDLING UNIT(OVI:R 10.000 COAL
CONSTRUCTION TAX
I7WHI
cant/Cmura.tnr Doc EXHAUST HOOD(W/DUCT) HOUSING MITIG6CI NPEE 8't/
IIA7.ARDOUS MATER ALS DI LOSURE
the applicant orfuom buildingecopom store or handle hazuNous material HEATING UNIT(TO 1110.000 BTU)
ythe C.pcnino Municipal Gale.Chapter 9.12,and the Health and Safwy
n 25532BU / HEATING UNIT(OVER 100.000 BTU)
, k-tr/� PAIDVENTIhATION PAN(SINGLI3 RLSID)the npplicum or foam bIldiog.......I use cgodpnamt or deviwn whichBOII ER-COMP(3HP OR IIIf1,OfX1 BTU)us aircontuminants us Jditad by me Nay Alien Air Quality Munugctnrnt TOTAIBOILER-COMP(OVER 1(01.(XXIRTU)s
I have maul the hazard.... aorials AIR CONDITIONER
rtquimme - Chap,er695 ofine Cali ISS CE DATE
fools Health&Safety C e colons 2,5505,255]3 25534, undemm�J mm if the NIiW RESIUF.NTIAL MICII. SQ.I9'.
'dlmgdo. u¢ eato..nkthm it is mY resp,.. uccuptmt
of ha 'ten ,ich ma nn prinnnisvuancc ofm C' ilio fOoeu
er or.m.ized agent /Date P TOT L. ar� ISSUED BY.
OFFICE