S 1465 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH,1) -ELECTRICAL PER{11T NO. 1465
BUILDING DIVISION APPIACATION/PF,RMIT PLUM NG-MECHANICAL l\�
BUILDING PROJECT' HENTIFIC'ATIIIN
BUILDING AUDItE55: : SANITARY NO. APPLICATION SUIlh11T1'AL/ATI.
OAWN'RS N MEN { NLiA�1V ONE: CONTRA
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CHTECNLIR
LIC NO: DURI:S.` (J ❑
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CONTACT. PHONE, DUILDING PERMIT INFO
— [:1Consultant Fees Paid by Applicant(Initial) BI DO IiLECT PLUMB MECH �
67
ftilo 9Z
LICENSE[)CO MAC—FOR:DECLARATION QTY. IiLECTRIC PERMIT FEE tacit-tom/ Ll/
1 hereby strict that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yOy1 C',Z with Section]Wp)of Eb ision3mus,Business snit lmdeninew Ctsde.andmy license is RFSIDENTI AI;
FOO a full l ince and vfpr PERMIT ISSUANCIi
�ULicense Cassmz ❑SFUWI. El KITCHEN REMODEL6 U / 1J0'a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
H Z W Date 12'1$ enm,acmtr
ARCIIFTECTS DECLARATION ❑MUI.T1-UNIT ❑STRUCTURAL
z0yz (understand my plans.shut he used av public records PANELS MODIFICATION
O Z4C UI'I'0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
F4~W Licensed Professional Cpl-ItgO AMPS IMPROVEMFIiT []SWIMMING POOLS
C C C Q I hereby affirm he,I mr,exempt boas he Con noon's License Law for the OVER 1000 AMPS ❑HAI 11 RF.MODEVRF.PAIR @ih101.1'TION
seat O A.U following reason.(Section 7031 S.Business and Professions COIc:Any city or county SIGNS ELECTRICAL ❑OfIIER
y13 p•F- which acquires a pemdl to connote,,alter,hnprose,dem, kh,or repair any swoon
priormitsissuaneG ala rcyuirex the applicant forsuch permit m flea signed statement SPECIALCIRCUU/M "
tbat he is licensed pursuant m the ptnviainn.Softie Coal,torn license Lmv(Chapter9
a�00 Immntencing with Section 70013 of Division 3 afthe Btomessend Professions P.C.almor TEMMITI ER OR POh: COMMERCIAL
1i) :
W c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW DG/ADDITION El DEMOLITION
�m Section 7031.5 by any appli, apparent
mre at for a penult subjects the appareno a civil Penalty of POWER DEVICES ❑FOOD SERVICESERVICEF. mnothan five handled dollars lSSWL IMPROVEME T
Hn ❑ I,mownor of the propcty,ormyemployecs with wugcva theirsolecommcnsaion, SWIMMINGM)OLELECI' ❑OTHER
will do he work,and theduchou is not intended or offered muscle(Sec.7009,Inoses
0.3 and Professions Code:The Contractors License Low does not apply to as caner of OUTLETS-SWITCI{F.S-FI%T
prnpeny who hnilds or improves thereon,and who does such work himself or through
his own employees,provided hat such improvements arc not imanded a offered for NEW Rli$IDENTIAI.ELNCTk
sola.If however,the building orinnmvemem is sold within one yearofcompletion.the SQ.IT.FLOOR ARli SISQ.11Kweer-huildm will have the buNcn of proving that he did not Iatild o,improve for pur-
po,e of sale.).
❑ I,as owner of the pmpert am exclusively contracting with licensed contractors m AI.'
mama the project(Sec.70,pC,Business and Professions Cafe:)The CwtrwU rN IJ-
censeLawdintno,apply mnnownerofprnperywhobuilds.,,impmve,,haddm,and QTY. PLUMBING PERMIT FEE
who contracts fm such Impacts with a connac ons)licensed pennant to the Contractors
License I... PERMIT ISSUANCE 3 r
1 um exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) ^ VALUATION
Owner Dte J
a
WORK17R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O 0 D /6/1
1 hereby eflinn under penalty of perjury one of the following declamation:
❑ I have and will maintain a Cenifeale mf Cor,iml to sell-insure for Workers Camped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES/ TYPE CONSTRUCfIOP
onion,as provided for by Section 3700 mf the Inbar Cork,Tor the pencrommca of he
work for which this permit is issued. Il XTURRS-PER TRAP
I have and will maintain Worker's Commemorate Insurance,as required by Section
37 lofthe Libor Cale,forthe Ferfmornmeufine work for wMchdo,permit isissued. GAS-IiA.SYSTEM-1 INC.4 OUTLET OCC.GROUT' APN
My Worker's Compensation In.vurance,trier sad Policy nyymhe/r.
Gnrus7rY1 AA Policy N.,492-4 OAS-EA.SYS'1'FM-OVIiR4(EA)
CERTIWCA'IEOFEXEMPfION FROM WORKERS' GREASI%INUUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
tar Ics,.) mt
(Thissichumednat be completed ifhe permit is formnehundreJ dollarx(SISH GREASETRAP PLANCHECK IZIi w
1:J
I cenify that in the latrforemare efthework forwhint this pma it in iaved,I0a11 SEWER-SANITARY-STORM PA.209 FT.
not employ any person in any manner so as to bmrome subject it)the Workers CompYPi1
en- WR ?i 0
O Z nation Leov,of California.Date WAITER IIEAT17R WNEN'VELECTR GRADING FEE
Applicant
(q NOTICE TO APPLICAN'C 11;title,making this Cerifcne of Exemption,you should WATER Symix/rREA'fINO r�
F hcanme object ,,the Worker's Compensation provisions tithe Lobar Cork,you must RR
'S '(�
W�.t forthwith comply with such punicinn.v nr this me do ildtall he deemedrewded. WATER SERVICE
Q4'
CONSTRUCT[ON LENDING AGENCY NEW RESIDENIIALPI.MI3. SQ,<N'. -' IVT �"'O51e Q Recci tk
U0 Thereby u(Emtthunhcm isaeonswninn lending agency(nr the pedbrmanaal
the work for which this permit is issued(Sce.7097.Civ.CJ
U. ULenders Name
Lendds Address YfAI.'
W 1 cenify nbat I have aced this implication unit ante thm the above information i, BUILDING R: O
nF•t taA ottrea.l agmewmmplywiW all city anA cmmtynNinanca and sora lawsrelating v' QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building comuuction.and hereby-amhmdarepresentatives of this city to enter upon the
,Mme-mentioned property Icer hopection pugwaes. PERMIT ISSUANCE
(We)bacc move,indemnify and kip h aalesn the City of Cupeout,against ELECTRIC FEE
liahilities,judgmenm.cmts and expenses which may in anyway accreeogainasaid City AI.TF.RORADDTOMECH, PI.UMBING I'G
inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY Willi ALL NON-POINT AIR HANDLING ubarfTO 10.010CF10) Q
MECIIANICA .
SOURCE REC,(ILAI'IONS.
AIR HANDLING UNIT(OVER 10,010 CFM) I CONS'TRUCUON ' %
Signature of Applicarm7onaacmr Dote EXHAUST HOOD(WMUC) =1AID
HAZARDOUS MATERIAI S DISCLOSURE
Will he applicant or future building necupant store or bundle hazardous material HEATING UNIT(TO I(0,M)BTU)
a defined by the Cu,mno Municipal Calc,Chapter 9.12,and he Health and Safety
Cafe.Section 25532h)'t HEATING UNIT(OVER 110,001111'U)
ED Yes ❑No VENTILATION PAN(SINGLP.kP_SID) T/WilltheaDPlicam nr fmurc Wilding nrcupam use equipment ur devics whichemit hazardous air contaminant.us defined by he flay Area Air Quality Management BOILI!R-COMP(3HI'OR IOQ00BTUIDistrict? I
C]Yen [IN BOILER-COMPfOVER IpO.(NNI BTU)
I have lead the hmamoux materials mi,iremetns under Chapter 6,95 of he Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25531,1 understand that if the NEW RESIDENTIAL MF.CH, SQ.Irl'. s /t 'y 9�
holding does not crummy have u tenam.droo is my resmonsmility mmmify the acuparn
aide,reyulremeats which must be met prior to issuance ofa Certificate of Occupancy.
Owner or aullmou J agent Dam Tt 1^ ISSUED BY:
OFFICE