S 1767 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P[dtlT NO w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.6LVA
IECHANIC I. `V
BUILDING PROJF.LT IDENI'IF'ICATION
BUILDING ADDRESS: SANITARY NO. AI PLICAHON SUBMITTAL DATf
2 3 o GotuMgus Ad-02rJui C ';A
OWNE 'S NNgAME: p/ 1� `PHO - CONTRAMOR:S NAME. LIC NO:
1-1aQ) ler A36A0 �a1�s+�-1 N/C C�IONTRGI.»
-• A .HI'TE IENCaINFER LIC NO: ADDRESS: ❑
CONTACT: �a//YJYI PHONE
/ BUILDING PERMITINFO
�(,.{r�5/7 �/b� ❑ Consultant Fces Paid by Applicant(Initial) HLIx ELECT PLUMB MECH
LICENSED I t CONTRACTORS
under DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby arfmm mm I am licensed ander pnrviemna ar Chapter 9 mohmmeneing .LOB DESCRIPTION
��OZ wird Scetinn'1011Oprf❑ivision3afthe Business unit Pmfensinns Cale,and my license is PERMITISSUANCE
RESIDENTIAL'
�1F in full farce unit etlecn. ❑SFDWL ❑KITCHEN REMODEL
gzV License Chan Cont APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
y a cl nee cmnoadmr
F5y ARCIIITECFS DECLARATION PANELS ❑MUCfI-UNIT' ❑STRUCTURAL.
ZOyK Iundcomnd rayplans,hal beusedus public mesial., MODIFICATION
OZ4� UP TO 200 AMPS FERIOR [:1 CHIMNEY REPAIR
�Haq Licensed Pmfexainnol 2HI-I(Np AMPS IMPROVCMBN'f SWIMMING POOLS
�0 < OWNER-BULLOERm CLAknI(ONtracto OVER 1000 AMPS ❑BATH REM�Ir1FJ,(I EPA�IR DE
t1a1�� 1 hereby alliin that 1 tan exempt from the Contractor's license Law for the -;--Frr�-,
ppaass5 O y V following reason.(Section 7031.5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL []OTHER
u+3 W y which reymiren a permit to onotmn,nlmn improve,demolish,or repair any anted.
o) prior in Issuance,also requires the applicant for such pemhiuo file a signed statement SPECIAL CIRCUIT/MISC.
��}D than be is licensed punuatn m the provisions of the Convedorss License L e.(Chapter 9
y�j lY�C (commencing with Section TFXO of Division]of the Business and Professions Cod0or TEMP.MUMIR OR POLH INST. COMMERCIAL:
0.y o c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
kcI Section by any applicant for a permit subject,the officanfm»civil penalty of POWER DEVICES (DTENANT ❑PWD SERVICE
=Qnot more than live hundred dollars(8500). PROVIiM ENT
Ql,as owner afnhe pmpeny,ormycmpinyeeswinh wage,nsthcirmlc conpens:viun, SWIMMING POOL ELECTRIC OTHER
p� will do the work,and the noucure is not intended ar offered for sale(See.?044.Business /a
61`� and Professions Crde:The Contractor's License Law fres hot apply man owner of OUTLETS-SWITCIIES-I IX'fURCS
0.a^ property who builds,,,Improve thereon,and whodes,such work himselfcr through
his own enhployces,provided that such improvements am not intended or offered for NEW RR D IAL.ELECIR SQ ET.
sale.If,however,the building or improvementmq th
is sold within one year ofmpletioe SQ_IeC FLOOR ARI! S/SQ.FT.
owner,hudder will have the burden of proving that he did not Wild or improve for put- I�A' G'
ryxofsale). JUN 5 Al
I ❑1,as owner of the property,am exclusively convecting with licensed comments m I
est,annet the project(Scc.704Q Business and Professions Cale)The Connector's 1.i- CITY / t-
wnttlowdoesnotapplymanownerotpmpenywWhuilds m improves thereon,and QTY. PLNB t ERMIT FEE V VUf ClylllV(�
ho eostraets far such pmjan with a andool qo licensed putsmam nth the Commemes
License Law. PERMIT ISSUANCE
1 am exempt,unit Sec. B&P for this re son
Owner a Doe ALTER-DRAIN&VENT-WA'TER(CIA) VALUATION
O . of . ,AT'ION DECLARATION BACK PLOW PROTECT.DEVICE
1 Mtehy aR under penal,of perjury one of the following declarations: CJJ V
I have and will maintain a Cenifczmof Conserv lunell-iname for Worker's Cn aper. DRAINS-FLOOR,R(X)F,AREA,COED. STORIIS 'TYPECONSTRUCTIOP
salion,in provided for by Section 3/1X)of the Inbar Code,tin the ten anacv:of the
work for which this pcmiin is Nomad. IXTURES-PER TRAP
1 hex and will maintain Workers,Compensation Insurance,as inquired by Section
3]00 ofthe labs Cole.for the lrrmarmaccofthe work for whichdr,permit is issued. GAS-IiA.SYSTEM-I INCA OUTLETS OCC.GROUP jP1
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Pal icy No, GAS-P.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASE/INUUSTRL WASTE INTERCEPT OR'COMPENSATION INSURANCE ILDIN'D SIGN FF:IIS
Clhis section need not be completed ifthe pemtit is forms,hundred dollars Sot) CREASE MAP nr less! PLANCIIEC F i
I certify than in the peHormancenfthe work for which this permit is issued,l shall SEWER-SANITARY-STORM IiA,200 FT.
not employ any person in any manner m as to become subject the Workers Compete ENERGY .E
0z scion Laws of Coffman.Dam WATER I]RATTER WNENDELECTR GRAD
C
z Q Applicant
IA) NOTICE TO APPLICANT:If,after making this Cenifcee of Exemption,you should WATER SYSTCmC REATING
E"t , beene subject to the Worker's Compensation provisions of the Labor Cale,you must SOILS FEE
o
WI unmeant comply with such pnwiomns of this permit shall he deemed revoked. WATER SERVICE
0
p" CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQPE PAID woDam Rccciptp
L) O I hereby affirm that there is a consamction lending agency for the performance of
�-I the k for which this permit is issued(Sec.JOY],Cil.CJ
0 Lender's Name TOTAL:
�-t U Lenders.,Address T(H'AL.:
0. I codify that 1 have read this application and them that the above information is BUIL. NO FEE
Fy coned.l agree no comply with all city and county ordinances an([state lawn refit,. o QTY. MECHANICAL PERMIT' FEC
C.7 Z building construction.and hereby authorize representatives of this city to enter upon the SETS .IEP.
above-mentioned property for inspection purlwses. PIiRMIT ISSUANCE(We.)ngrce m sive,indemnify and keep haralms the City of Cupeniso against ELECTRIC
liabilthenjudgmeals,cosnand expenses which may in any way acenhe against said City , ALTER OR ADD TO MECH.
In amscqucnce of the geeing ofthel mit. PLUMBING FBS
APPLICANT UNDER TAN 5 I WILL COMPLY WITH ALI.NON POINT AIR HANDLING UNIT ITO I0,000 CFM) MECHANICAL FEE
JSOUR :GU e /� —� �/
{/7 a AB HANDLING UNIT(OVER IO.(g11CFM) CONSTRUCTION TA
mar Date EXHAUST HOOD(W/MUCO HOUSPOMII'IGATION 'EE
HAZARDOUS MATERIALS DISCLOSURE
Will the upPlicumor future building nccupantstnre ar handle huzardoas material HEABNG UNIT IT 01110!100 Bl Of
as defined by the Cupenine Municipal CCdc,Chapter 9.12,and the Health and Safety
Code.Section 25572(n)? HFATING UNIT(OVER I00,11(X)BTU)
❑nn 0 N VENTILATION PAN(SINGLE R+ESID) PAID -
Dae cited a
. Will the applicant or furan building oz.,a,uu equipment or devices which BOILER-COMP DHP OR 100,000 It TO)
emit hv.:udnus air connotations as definal by the Bay Area Air Quality Managenmal TOTAL:
District? BOILER-COMP(OVER 100,000 TOOT
Oyes ON.
I hread w
avethe had ,quireous materials is audit,Cha ter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
Ibmii Health&Sale,Cede,Sections asm.that i 25531 and 255111 t onotsmnd that if the NEW RESIDENTIAL MECH. SO.F1'.
building Jas nam"whic y have a are 'tow o is ua responsibility C ni to notify the heency. t
nl'the reyuirmnentx which run W ma prior to issuance 0La Cenificam of Qcup:mcy.
Ownerormth itch agent Data TOTAL: ISSUED BY:
OFFICE 771