S 1256 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RATE DING-ELECTRICAL TEST NO,
BUn.DINc DIVISION APPLICA'PION/1'GRMIT PLUMBING-MECHANICAL J 12 5 6
BUILDING PROJECT IDEN'IIIF'ICAI']ON
BUIL DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
b5m a, 2 r 19 Ala
OWNE 'S NAN Hii C(its"DIACEDIpri NAMI': LI NO:
NIC CONTROLiI
AR TECVENGI 'is 11C NO r O ADD ❑
CONTACT. PHONE: BUILDING PER IT INFO
/__r /j',/ ❑ Consultant Fees Paid by Applicant(Initial) LD EL� PLUMB MECH
LICENSED CON'TRACTOR'S DECLARATION QTY QTY ELECTRIC PERMIT FEE JO{;DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
QWZ with Sedion]Ig11Drf Division 3at me Bueinessand Professions Cale.and my license is RESIDENTIAL
Rl O O PERMIT ISSUANCE
F�., in full fenced effect �/1Qd'9 ❑SPDWI. [I KITCHEN REMODEL
�UUUF License Class Lica -�—� APPLIANCES—REMUENTIAL El ADDITION El PLUMBING RE-PIPE
F ZZ W Date Contractor—
o,
ontr clor
o,Q C3 MULTI-UNIT ❑STRUCTURAL
F,7w ARCHITECTS DECLARATION PANELS
OZv2 ZK I unit csand my plans shall be used as public records Up'fU21N)AMPS MODIFICATION
❑INTIR'OVE REPATR
f-�(=W Licensed Professional 201-IDINIAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION BATH REMODEIIREPAIR (]DEMOLITION
6 1 hereby.(beta that I L exempt from the Contractors License Law for the
OVEk❑NTD AMPS
�qS O y U following a mon.(Section]Ion L5.Business OR m at Ire,d sio demolish,
Code:Any city nr conntY SIGNS F.LF.CTRICAL ❑OTHI!R
su O V.
which requires a permit to construct,olmr,improve,demolish.or repair any xwaure.
❑ prio Or its issuance,also regares theapplicam Bmwch permit lileaalgned statement SPECIAL CIRCUI UNUSC.
y�'y Nal he is lwcaral presunnnn thepetwo oesufthe Carl.,...e Liacnw Law lChaper 9W aG� (eoinmenei ng with Section 7000)of Division 3 of the Business and professions Code)or THMP MET OR POLE INST. DMMFR TAI:
C,N e, that be is exea i
attempt dwoub an and the hs for the alleged esen,alre.Any violation of ElNEW BLDG/ADDITION. El DEMOLITION
Xlaila� Section]031.5 by any applicant for a pcnm.subjects the applicant m a civil penally of POWER DEVICES ENANT ❑FOODSERVICE
not more than Else hundred dnllors($500). IMPROV
zG01,ax owner of the pmlwrY•onnyempinyees with wages as lheir,nleemmcnsmirn, SWIMMING POOL ELECTRIC
will dr the work,and the stmrare
cture is not Intended ornfd for sale(Sec.]DW,Business ❑OTHI?R
yp'j m and Professions Cale:The Comeactnr's License Law does not apply tq all owner of OUTLETS—SWITCHES—Rx ORES A /�_
property who build,nr impmvea thereon,and who docs such work himself or through
his
own employees,provided Ibat such imlmvemems arc not intended nr offered for NEW RESIDENTIAL ELECTR SQ FT.
.]a.If.huwevee.malrailding crlmprovnoem is sold within nneyearofanmpledogt¢ S l A AWSQ.FT.
owner-builder will have the harden offal that he did not build or improve for per- 1'1/
at str at aaled.
❑1,as caner of the property,atm exclusively contmming with licensed comranots to UUrr�l
construct the project(Sec.70,14, M
i,Business and Professions CcO The Contractor',Li-
se Law does not apply to an Toner of pnspery who builds or improves thereon,andQTY. PLU I sPF:RMFF FEF, llg�
who commas for suahprojects withamr(s)clailis licensed Fall o the Conoaemel
License Law. PERMIT ISSUA
I am exunpt undm Sec. .B&P C for this reason
ALTER—DRAIN&V '—W EA) VALUATION
Owner Dole /91/Oft
WORKER'S COM P17NSATION DECLARATION BACK FLOW PROTE
1 hereby affirm under penalty of perjury one Cf the following declarations:
Fl have and will maintain a Certificate ofConsem to self-insure for Workers Cooper- DRAINS—FLOOR.ROOF,AR. , D. STORIES TYI'F�ONSTRUCf10.
sation,as provided for by Section 3700 of the Labor Cade,file the performance of the
ssu
work for which this permit is ied FIXTES UR —PEE TRAP
El I have and will maimoin Workers Compensation Insurance,as required by Section
37M more rC for the parfonnanceof the work for which this lwmtit is issued GAS—I?A.SYSTEM-IINCAOUTLBES FICC.GROUP APN
My Worker s 'on ho mace tericrand Policy nu
m policy No.: GAS—EA SYSIP.M OVCR 4(HA)
C17RTIFICATE OF EXEMPTION FROM WORKERSOREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE ILDING ISION REIN
(This sectioo need not hecompluted it permit is for hundreddollate WOR GREASP.IRAP
or less.) PLANCH Plili
I cmity that In the perfcrtnancc ofthe work(ur which this permit is is.sred,l shall S17WER—SANIVARY—STORM EA.200 FT,
not employ any person in any manner so as m become subject to the Workers'Compen- ENBN
,z sation laws of Culifonia.[)are WATER HEATER WNENTIELECI'R
GR
Z Applicant F
NOTICE'TO APPIJCANT:If,aper making this Certifcwe of Exemption,you shout] WATER SYSTEM/IRF.ATING
a become subject m the Worker,Compensation""Ideas of the labor Cale,pm must SO FEE
forthwith comply with .all pros,teal rrthisµunit shall be deemed evoked WATER SERVICH
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.FT. PAID Date Receipt p
U 0 1 hereby which
thi tha oral i is s ed(See 30 lending Cheney for the perhmnnnce of
ITa the work for which this permit is issued l.S'a.3(19],Cie.C.)
O F' TOTAL:
Lenders Name
L) Ltmlee'e Addrea TOTAL:
r Lkl I ra ify that 1 have read thin applicmiun end nate that the above information is BUILDING PEE /t
F.
comm.l agree to comply with all city and county oreimnces and stale lawsrelming it QTV MECHANICAL PERMIT F SEISMIC FEE
U Z building coordination,and hereby authorize representatives of this city to tome own the
above mentioned propery for iaspretion locators. PERMIT'ISSUANCE is ELECTRIC I7EE
(We)agree to save,indemnify and keep hornless the City of Cuperlion against G
Eiabilhies,judgmcnm,coats and expenses which may in any way name against said City ATTER OR ADD TO M ECK 6 PLUMBING FEE
in cfthe
is t.
APPLICA cna NDe. ST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO H).0IDCFM) MECHANICAL TE
S UR PION.,
3, A AIR HANDLING UNIT(OVER IIhINNI CPM) CONSTRU"ZION A
S' nature of plicam'Comnt or Data O EXHAUST HOOD(W/DUCT) HOUSE II GATE NFiE
HAZARD S MATERIALS DISCLOSURE
Will the applicant orfum buildingswcupanarrou nr handle hamNrus material HEATING ON['TOLD 110,001 BTU)
as de it by the Captain.h tiaipal Code.Chapter 9.12,and the Hard,and Safety HEATING UNIT(OVER 100,Bg1 BEV)
Code,Sec
[2 Yes El No VENTILATION PAN(SIN GLE RF.SID) PAID
Data eceiptM
Will the applicant or Coen hi ilding occupant use equipment or,devices which BOILER—COMP UIIPOR 11100041 BTU)
.mit hazanloe.air comuminants as defined by the Bay Area Air Quality Management TOTAL:
Dinrict? BOILER—COMP(OVER 100.00011*1 DO
I Yen Fla.
I have read the hazardous materials requirements malar Chapter 6.95 of the Cali- AIR CONDITIONER / ISSUANCE DATE
fent,Health&Safety CMe,Sections 25505,255]3 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.IT.
building does not currently haven anon,that it is my responsibility to notify the occupant
of Ne requirements which must be mat prior to issuance of a Certificate of Orcupancy.
Owner m authorized agent One ISSUE[)BY:
OFFICE
f —