S 2776 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUu.' NC DIVISION APPLICATIONIPERNUT PLUMBING,-mecunNlCAL S.
ry Z
BUILDING PROJEC9'IDENTIFICATION l7 G
❑UILDING AIIIIRESS: - SANITARY NO. APPLICN'ION SUBMITTAL DATE
161ST Cavo .e or. -3
OWNER S NAME: PIfONE D CONTRA OR''SNA� LIC NO: NIC CONTROL#
Se jo!j�zlosk % ii
Vite
ARCHD'EC'VENGIN.ER: LIC NO: ADDRESS: EJ
3 yqLj LA n4fter 1-414e
CON'I'AC'1': PHONE r IBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL�UMMB MECH
El EJ /GI ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under pmvidons of chapter v hemiuttenting JOB DESCRIPTION
O=Z with Section 70(k'I of Division 3 oflhe Business and PrafessionsCode,and license is
I Y RESIDENTIAL,
Fes- fullfcreeandeRe PERMIT ISSUANCE
,vwa I". Lk ❑SFDWL ❑KITCHEN REMODEL
QUU I Ib Cl. s Lic.p APPLIANCES-RFSIDENTIAI, ❑ADDITION 0PLUMBING RE-PIPE
in4W Dae Commmnr.6r
ARCI{ITECTS DECfARATION [I MULTI-UNIT E)STRUCTURAL
Z 0yz I understand my plans shall b,used as public records PANELS MODIFICATION
O Z'-'-M UP TO 200 AMPS [:I INTERIOR ❑CHIMNEY REPAIR
F'; ll Lunn'.]Prouxsinnal 21)1-H)00AMPS IMPROVEMENT I]SWIMMING POOLS
ie Oat I ionRmmia'r DECLARATION Cart ION OVER 1000 AMPS ❑HATH REMODEUREPAIR ❑DEMOLITION
1 hereby.(lien that 11, exempt,nam the Cnaraxm's LiAny v Law far the
iqqx5 ,U followingreasna Permit
tion]onstr N,niter and improve.
Castle:Any city or county SIGNS ELECTRICAL El OTHER
u+3 0 ti'which requires n permit m construe[alter,improve,demolish,or repair any structure
F.ulO I poor to its issuance,also rectums the applicant far such permit in file a signed statement SPECIAL CIRCUITIMISC.
ho' Iba be is licensed pursuantN
to e provisions oflhc Committers License Law(Chapter 9
W�GO (ximucrcingwith Section 700( Division 3 ofthe Business and Pianissimos Code)or TEMP.METER OR POLE INS'T. R
6 4 e�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of EW ,DG/ADDITION ❑DEMOLITION
Summer 703 L5 by anyapplicam fare pe rentodjecndiecipplican 1.a civil penalty of POWER DEVICES
^m NT ❑FOODSERVICE
mmarc Nan live hundred dollam lSS1N)). IMP EMENT
F=G ❑1,as owner ofehe property,army employees with wages as their sole compensation, SWIMMING POOL ELECTRIC !yr-LI
FQ will Jn the work.and the strvmure i.not imm�JeJ nr nO'ercd for sale(Sec.]044,Nosiness OTHER _
L3 m uad Professions CNV:The Cmmraanr's License Law does not apply to an owner of DO ILETS-SWITCHES-IgX'I'URES
property who builds or Improves thereon,and who do V,such work himself or through
his own cntpinyceM pmvlded flm such impowunicnts amain intended ar offeard for NEW RESIIIHNTIAl.HLECI'R SQ FT
vale.If,haaaser,the building or impmveneent is,old wilhionneyenr ofcmmpletion,the SQ f.FLOOR AREA &SQ.FT.
owner-builder will have the burden ar proving that he dud not build or improve for Pm-
'wr of sole.).
❑ 1,to mane,of the property,an.exclusively canlrcenng with licensed cnmracm,to TOTAL:
mama the project(Sec.70 4.Business and Professions CNet)The Cootrsetars Li-
censelawdoesnotapplytoanownerof property who builds or improves thereon.and QTy, PLUMBING PERMIT FEE
who comeacts for such pmjects with a conventions)licensed pursuant to the Counselors
License Law. PERMIT ISSUANCE.
❑lam exempt under Sec. ,B&PCfimthisreasvo _
Owner nam ALTER-DRAIN&VENT-WATER DA) VALUA'IJON
•WORKER'S COMPENSAq'ION DECLARATION HACK FLOW PROTECT.DEVICE
ffi
1 hereby arm under penult,of perany one a1 ],a following declaration.,.
❑ I havcand will nlnintainu Cenifcme nl C..nscnnnsclf-Insure for Workers Compcn- DRAINS-FLOOR.ROOF,AREA.CONU. STORIES q'YI'Ii CONSTRUCTION
motion,ox pruviJcJ far by Section PINI ml the Luhnr Code,for tlm perfaenanee arms O
work far which this permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Wmki Compensation Insurance,as required by Section
37001the Luise CNV,for the pel ,m
if once of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLET'S OCC.GROUP APN
My Werke Co nsar Inwmn currier and Pulley nn�m}}tb��a��rGAS-EA.SYSTEM OVER4(IiAI
Cartiee Policy No.J
CERTIFI ATEOF SATION10NWtA, O K R GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(Thi.xxtttion nem not be cmmpleteJ tithe permit is fmronc hundred dollen 1511Xq CREASE TRAP
or IcssJ Pf.ANCHECK FEE
[cenifylhat in the performancenfthe work lin which Nis permit is isned[,hall SHWER-SANITARY-STORM EA.2B)FT.
gat mnpiny any person in any manner m as Ice become subject m the Warkms'Campton ENERGY FEE
� z mail.."Laws of California.Data WATER HEATER WNEN'DELEent
Applic:me GRADING FEE
w-t NOTICE TO APPLICANT:If,after making this Cerlillcale of Exemplar, h I 1
y g ,, sou WATGRSYSTEMlfRF.ATLNG
hec..ntu xuhjea to the Workers Compensaion pmvlsioos of 0m Labor Code,you mull SOILS FEE
� Q fnnhwith emarly with such isaa,monsor this permit shall la,Jeemad revoked. WATER SERVICE V
7z CONSTRUCTION LENDING AGENCYNGW RESIDENT[AL PLMB. SQ,FT, PAID
U0 I hereby affirm that them is a construction lending agency for the performance of Date Receipt
F the work for which this permit is issued(Sec.3097,Civ.CJ
0U Landers Name TOTAL:
IanJerx Address T -
1 certify that 1 have matins applicmion and sale that the above information is BUILDING FE
Zt concel,I agree to comply with all city and county eminences and state laws relalimg to QTY MECHANICAL PERMIT FEE
(,) building cormarcim,andhereby amhnriw represcamovesoftbis city los"mropon the SEISMIC F..
alxweamcnlioned properly for inspersion purposes.
Oise)agree to save,indemnify unit keep harmless the City of Caperton against PERMIT ISSUANCE EI.IiCI RIC -E
liabilities,judgments,costs and expenses which nay In any way terms,against said City ACTERORADDTOMECH. 0
npmscqucnce of In 'arcing or F,a,L PLUMBING ,F,
API'LICAN DF STAND'. WILL COMPLY WITH ALL NON-110IN'Y AIR HANDLING UNIT(TO B.WOCFM)
SOUR L ON. MIiC1LAN ICA FEE
G AIR HANDLING UNIT(OVER 10,01I CFM) CONSTRUC`DGkf TAX
Sliesmillea.plil ..t(Ccalkleactiar Dae EXHAUST HOOD(W/DUCT)
HAZARDOUS! ALS DISCLOSURE HOUSING MITIGATION FEE
Willtheapplicant or fumrch tildin Vitalism store or handle hvamous material BEATING UNIT(TO 100,NX)Bq'UI
as dcfn sl by the Cupertino Mu cipal Code,Chapter 9.12,and the Health end Safety
Came.Section 2553200 HEATING UNIT(OVER I(X),(XX)H n
I]Ya, No 1- PAID) 1
VENTILATION PAN(SINGLE RES -
p� Will the applicant or future building occupant use eyuipmeml or device,which N 'Dae Receipt p
mnit imeablous air emasamnanl,mde0nnl by the Huy Arca Air Quality Monagemeal BOILER-COMP(311POR IN),00N1 ) n n of
Daniel? / I T(YI'AL.
❑Ycr B•j4 BOILER-COMP(OVHR IINI,IXNI H' I�IF'1\ w
AIR CONDITIONER
[have he umous materials myuiremcnls under Chapter has of the Cnli ISSUANCE ATE
fomis Hwlt fee 'Ne,Sections E5,25533 and 25534.1 understrnd that if the NEW RESIDENTIAL MECH. B. .FT �S 2—
a
building cu nay havast hat it ismyre�sL'onsibilirymnotify the cecurynt /S
ft nt is
set -�y Cenifc w of ccup,
O m m rN agent Dam TOTAL: ISSUED BY: �-
OFFICE