S 0426 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILD:NG�IlLECTRICAL P151T NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMB NG.MECHANICAL 0426
___BUBDING PROJECT IDENTIFICATION SANITARY NO. AT 'ATION SUBMITTAL DAD
BUILDINGADDRESS: Ama Bfud. q1
S SN
NA F -VHLTNE� 10 ZME: LIC NO: NIC CONTROL 4
LIC NO: DRESS:
HIT, 'GIN is 44 ALI
air V-2
CONTACT; P ONE BUILDING PERMIT INFO
11- [] Cons.1tant Fees Paid by Applicant(Initial) BLDT] ELECT PLUMB MUCH
T
LC-NSED CONTRACTORS DECLAR�ATT" menting Q ELECTRIC PERMIT FEE JOB DESCRIPTION
"C
I hereby"fir"Oat I am livereasal under provisions( Ch.upt (com
Mal.a3mf1he BtainessoustfronfiMskso'ClAs.inid rn,limemci, PERMIT ISSUANCE
Z. -iihImimitl I'll RESIDFNTIAL
a',F ar ED SFDWL [3 KITCHEN REMODEL
e
to . onam. e ter.
License Class—Lic.# APPLIANCES-RESIDENTIAL DADDITION [I PLUMBING RE-PIPE
Date Common. [I MULTI-UNIT 0STRucrURAL
ARCHITF�S DECLARATION PANELS MODIFICATION
ZO Z cp
0z— UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
OWNER-BUILDER DIECLARKITION 201-1000AMPS IMPROVEMITIN swim
9 i R-, OVER BICIDAMPS F1 BATH kEMODEL/REPAIR D DEMOLITION
I moda,itffirri'lon I am estop,I..at the Cmurramra License Law for the —- [_1 OTTIER
f It manson (Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
TO 01 Owl Inguars to coursoveL,aller,amprove.demolish,or repair any structure —
w m
t ss ance.also reopums the applicant for such Permit to file a signed statement SPECIAL Cl RUG ITIMISC.
o,, on,.Is i
That he is licensed pursuant to The provisions ofthe Contractor's License Law Ulm,wr 9 AL:
TEMP METER OR POLE INST.
El NEW BLDG/ADDITION C1 DEMOLITION
Out he is a.ropt donsfirrour and the basis for The alleged..M,ahari.An,violation of
,camon To,,*,by say applicant I a pasmailTubjecus he applicant to a civil Penalty or POWER DEVICES OTENANT [I TOO[)SERVICE
Fo4net romm Thu.rise Wrialreal dollars(S50B. IMPROVEMENIT
= T-1 SWIMMINCTOOLELL RIC EJOTHER
70W.Business
and Pormssions Code:The Contranctors License Law does not apply to To own c r(if OUTLETS-SWITCHES-FIXTURES
property who Infilds or hapirmea marema.and who does such wark hansaff Or Tight NEW RFSIDEN'HAL ELECTS SQ ff.
his own employees,provided that such impeavements am not intended or offereal for 004WEA VSQ,FF.
sme�If.however the Wilding or imphaveraml is sold within one year ofoompledon,ffie ,so,IV
owner-builder will have the burden of pm,ag that he did not Wild or improve for put. CITY
'ce of salt.). T L:
C] 1,as somerof be Irmpen,-in muchusilidY careaunin'with licensed Coronations 1. UtAIL-
construct W project(Sm.70U,Business and Professions Code:)The Commenov,Li-
came Litw dres not apply loan owner cu'proptry,who builds or improves themon.and QTY. PLUMBING PERMIT FEE
vah.'Miname,es for such projects with a contractors)licensed pursuant tq the Contractors —
License". I PERMIT ISSUANCE
am exempt under See B&P C for this reason —
ATTE-R-DRAIN VE -WATER(EA) VAT UATION
Done, Dan,
WORKER'S COMPENSATION DECLARATION BACK FLOW PR DEVICE
I hereby affirm under Family of serjur,one of Oc following dachumflons: —
I ninamud will imormirt a Certificate ofConsed novelf-insure for Worker's Compior. DRAINS-R. R,ROO COND. STORIES TYPE CONSTRUCTIC
,.hot, a paresuded for by Section 37M of the TANT,Code.for the laar prince of the —
work for which his Term'is ialmal. FIXTURES-PER'
C]I have and will maintain Workers Compensation Insurance.as required by Section —
3700cifffieLaboarCod"for TIT ifinan c I the vo&for which'his .it is issued. GAS-EA.SYSTEM-I I I.. OCC.GROUP APNI
MyWmr Can, T,;; Tcpe be arandPolicyq�
GAS-EA.SYSTEM-OVER�4 G'
Came, Policy Nor:
CERTI ICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRI.WASTE TNFTERCEI;�OR FEES
COMPENSATION INSURANCE
or It.)(TIkaeclearessi.hot beenumpleted ifffic Permit is fourne lanodmitdollara($100) GREASETRAP PLANCHECK FEE
Icintify1hosiddic�Kc)manceofthe�orkforwhichthi�Nmit sissued,I shall SEWER-SAN,rARY-STORM EA.200 FF ENERGY ITE
not employ any'mon in any mapper so as to become subject to the Workins'Compert,
Z ntlion Laws mfCalif..�i..Data WAI ER]TENTER WIVENDELECTR GRADING FEE
Applies., ICANT,.If. for emi This Certificate of fismarplion,you should WATER SYSTEMaREATING SOILS FEE
NOTTICETOAPPL.
becormand,ject to the Workers C..,..Ii--parasol...of he Labor Code,you must
forthwith comply with such primisions or this permit shall la,devoted revoked, WATER SERVICE
PAID
D z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.ET Date Rectild
U 0 1 hereby affirm that them is a construction lending agency for the performance of
— 'he work for hich,his Permit is issued(See 31197,Cis,C.) TOTAL:
0 Leader,Name TOTAL
Lcoder',Add.. B 11 TEE
I certify that I have mad this application and state that the above inforoutdon is
CL and state laws misting to QTY. MECHANICAL PERMIT PEE
IA coural.I isiscm comply with.11 ci y and county ordinances SEE IC FEE
r) Z building construction,and hereby ap:honra representatives of this city to enter open'he
sharse-rustamned rapsoll I",inspection Fairfories PERMIT ISSUANCE ELECTRIC E
we)halite:".,_ imleram.,,andam yi,,,,t Ciy.fCapromigamst
w Thom be I
'p;a y'e
imill ad-nom . ad s, 'ishishme, ash,,vaysserce.,itinsismatCly ALTER OR ADD TO MECIL PLUMB C.FEE
0"he do 0 his Permit.
0 -P IN AIR HANDLING UNIT(TO lfl,"CFM) MUCI NICALFEE
be.
AFpJ I IN'T UNDE1 ITAIE"AND WILL COMPLY WITH ALL N 0 T
4?/
SO?RC i IIEGUL, S. 39[
ME T e AIR HANDLING UNIT(OVER TO."CFM) CON TRUCTION TAX
0* T7 -
Sig fA,,Ii, C ZZ 11.1c — EXHAUST HOOD WIDUCT) HOU,ING MITIGATION FEE
D"Zr
""mose
X: U MI HEATING UNIT(TO I00.00s)BI U)
IIAI�Al TERIALS DISCLOSURE
ducand ITT d,
in
Will,hae apponal is I�diir,,..Fsamt none or handle hosarbous materal
.1 hial by the C'umenion,Municipal Code,Chapter 9.12,and the Health and Safely
Cc c.Seelin.VE53200? HEATING UNIT(OVER 100.00()BTU)
[]ye., n Na VENTILATION PAN(SINGLE RESID) PAID Data
Will ase applicant Or future Wilding occupant use equipment of devices which BOILER-COME(3liP OR 100.000 B TO)
emit hantarnims air i,mummunints as thefitual by the Bay ATM Air Quality Management _
District? BUTLER-COMP(OVER I 00,0(XI B rU)
El yes No —
I have manna,hatmartimis imaterall,ropornatrits under Cloutier 6.95 of the Cah. — AIR CONDITIONER ISSU NCE DATE
fornia Health&Safety Code,Sections 25505,�5533 and M.�.I understand that if the W RESIDENTIAL MECIF SQ.Fr.
Ta'a Luminap � ZP
building does nor Minimally have a tenant,that it is my rescapsibility to malfdia,oceupoint
nor to a, di
ule cy
TOTAL
e,use I ISSUED BY:
Owner or aniffinfired agent Date I
OFFICE