S 2104 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPY OF CUPERTINO BUILDING l`J ELEcrRICAI, PEI E`NO. 2104�� �
D1J11,DING DPFRMFI•IVISION APPLICATION/ PLUMBING MECHANICAL L
BUILDING PROJIiC'I'IDENTIFICATION
BUILDING ADDRESS: 3164`7 SANITARY NO. APPLICATION SUBMITTAL.DATE
OWNINVS NAMF3 PHONE CONI' 1'1' K'S NAMIF. I IC r--- -�
/ ki /'�4"/) ., + �` �I �3�/ N/C COKfkt1LN
ARCHITECT/ENGINEER: IAC NO: A D ENS. lf""I'Y/ C-" ❑
S"J Glncp (ter '�} v�
CON C4
n ` PHONE Consultant Fees Paid by Applicant(Initial) RLDG DUI ELEECCTT PLUMBN1�0 MECH
LICHNSEDCONTRACIORS DeC1.ARA'1'ION QTY. ELECTRIC PERMIT FEE
I herehy antrnt that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIP'T'ION
pC)Zwi,h Se,,,.7NXrynfD...arm3 of the Brium,ssand Pronasions Code.and my Ecerve is RFSIDENTIAI.,
alOp PERMIT ISSUANCE
Fes- nfidl Rncc and yi
�UF I.iccn.w Clat G Lic.p �^ �/ ❑SFDN'1. C1 KITCHEN REMODEL
Q U _•�1+� AI'I'LIANCES-RESII3ENTIAI. ❑ADDITION El PLUMBING RIi PIPE
ut<Q auto cnmmnmr
Fpr,, ARCHI'FECr'S DECLARATION PANEIS (_1 MULTI-UNIT El STRUCTURAL
hZ I understand my plans shall be,used as public record. MODIFICATION
c z N- UP TO 2W)AMPS
¢4,F„ ❑INTERIOR L1 CHIMNEY REPAIR
IW Liccmcd Proo,"ioaal 201-10(s)AMPS IMPROV17MENT []SWIMMING POOLS
OWNIiR BUILDER DFCLARAIION OVER I"AMUS ❑BATA REMODEIJREPAIR Ll DEMOLITION
Q I hereby am 0irthat I um exempt Em
on the Comnor,License Law for the
3 LLF following reason.(Section]031.5,Business and Professium Galas Any city ❑OTHER mcoum, SIGNS ELECTRICAL -
r,, which 9 M l t t i h p d fist p y a lure
iF.�pryQ
TanoroI itsI' I 'tl ppl' tl ht ai,II F Lc®ncn SPECIAL CIRCUIT/MISC.
'barI Ifect,sed,pontrama civ provrwo: in tie Contractor License Li(Chapter 9 M FR 1 1:
W. 0 (nmtmemm�g with Searon]fMXOof Dmiwan3afMeBmines.and Pmfesainro GJQ nr TEMP.MLTER OR POLE INST.
a L e 5 that he is exempt memfrom and the bast.hn the alleged enemption.Any vinlaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xmas Semon]03L5 byany applicants lin a Mrit suh3m,a thevpph,am m a civil Pcraft,of POWER DEVICES
W^m ❑TENANT' El 1-001)SERVICE
n(1.0,owne five hundred y.or s y aro l
sd❑ (] do the nmof the rmilbopenyonan ompinyeaswilM1wrgea fferad rsale(sulec:nnpB.,itsn, SWIMMING POOL ELECTRIC OTH17RVY.MI?Nl'
L, will Jathssion,undc:The tmniacturN License
an owner os ❑OTHER
3 m and co,who
Gala The Contmaors License law docs not apply m an owner of OIrTLETS-SWITCHES-Fl%TURFS Ze
pnrpeny who build-,improves thereon,and who cines such work bimsc.nr through
his own owever,the holding chit arch inrpnry sold w um nm intended of oltcmd toe NEW RESIDENTIAL LhgC'IR SQ PI'.
sale If h will
holding g p t Id within y r pl[ the SV FI'.FLOOR AREA S/50.1'1'.
.na
builder rds theburden provingfthth did tt Id -improvef put.
M,,a f I )
� I nth p ply ly contract,with Even l I Lto
,
rt Yat 11 apply
7044,13 Prof L J omp Connector,unit
s 1 J such
prof fp pen) M1 ti dp p eComm m's QTY. PLUMBING PERMIT FEE
who u:mmns for weh prolecrs with a conuaaoga)licensed pursuant ns the Cammnor's
License law. PERMIT ISSUANCE
It un asem,ondcr Ser. ,B&P CIiur rams
A]:1 -DRAIN&VENT-WATER(EA) VAI.UAT
Owner Uma
10
rdN
N' COMPENSATION DECLARATION BACK ROW 1RUfLCI'.DEVICE
I hereby affirmm under under P cnahy of perjury one of the following declarations:
❑ Iha,c:md villoadmam.CcaiOcam of Conscm mxdGinnure for Wake-Cout DRAINS-FLOOR,ROOF,AREA,COND. S'r(1RIE4 'I'YI'E CONS'1'KI1C'1'ION
Nminn,as mvidc 1 fur by Scetian 99X)of 0c Luton Cod,for the palm urnc,of the
w: kl which this pemtit it isweJ. FIXTURES-PER TRAP
j]r rave and will maintain N'mkers Compensaion Insurance,as myuireJ by Semion
J Iofthe labor G.Ic.for the performance offe work for which this peril is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (K('.GROUP APN
My Wnrkq{,cj/i.x/fiepami nyrHwc9fa:rivnmdy No.:mnPhtyOLa��
Currier, el 7A�EX/ 1/ 9 PION FROM
l.J LI GAS-Eh$YS'IIiMOVER J(13A)
CERTIFICATE OP EXEMPTION FROA1 WOKKERS'
COMPENSATION INSURANCE GRGASUINDIIS'1'RI.WASTE IKfERCF,PIT)R
(Thu wclinn need not he eonrplcmd if the parit is for one hunJrcJ Aollao(51 t%0 BUILDING DIVISION FIFES
or Its..) GREASETRAP PLANCHECK PEE
Loy any mat in me pal manncenf,10Isamwork s,which Into theamortis issued.Tehall SEWER-SANITARY-STORM EA.IX)FI'.
not employ any person in any manner so as ur Mrome subject m the Workeri Compem ENERGY PEE
Z Adan laws of California Data
p O A li,um WATER HEA'TIiR W/VF;Nf/EL[CTR
pp cw5rnnc Flan
NOL'ICI?'TO AI',I the dltrmaking thisCerifi-wolvisio ,.1h Laboriode,yuhmust WAI'IiK SYS'T13M/THEATING
>
become..comp m the Worker,chprCompd,u,.,do n provision,hal oe,de Labor vole,you matt SUITS RC
� forthwith comply wish such provisions or this .it shallhJeemcd revoked WATER SERVICE
4 0
U z CONSTRUCca is 11
ontractNDfNGAGI!NCY NEW RIiSIDGMIAI.YLM111T. SQ.17. PAID
U Q (hcrcby Umon ..tot II'ef iso .sa(Sca.30 len ding agency ler lM1a pcn'ur:mac of IJwe ItcreiptN
[LP the wad:for which this permit isiswal(Sec.J(Y➢,Crv.C.1
0 Lenders Name TOTAL:
W Lender's Address TOTAL:
Fr-t y 1 crafty mm 1 have rend this application and.mtu th n the above inkcartien is BUILDING FEE
rn ,...rail agree(o comply weh n11 city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
UZ building construction.and hereby authorize repruenatives of this city to enter upon the SEISMIC FEE
ahem meat tJ pm,rty for inspection p,-. PERMIT ISSUANCE
grtt car rya J Y and keep humane,the Cly f C pert n gains( ECIRIC FEE
(01
' f. l d ns,a ( d P .acs whichy'nvryway acnugu nsl said City e
ucyuen r the n g J a per
ALA HE OR gDU'1 O MliCll. PLUMBING Flili
ICAN' l' UI' AND.. ND 4 J.COMPLY WI'T'H ALL ON- OUST AIR HANDLING UNIT IT 10.000CFM)
C13 ,G d NS. / MECHANICAL FEE G
AIR HANDLING UNIT(OVER HL(XXIC19N1 CONSTRUCTION TA%
tine of ApplicanVContacmr Date EXIIAUS'FHOOD(W/DUCI} HOUSING MI'fIGAT10N PE5
HAZARDOUS MATHRIAI S DISCLOSURE
r
Will the applicant or future building Occupant store err handle baralloustun¢Tial DEAL ING UNIT 0 OIo(LumBro)
as defined by the Cup,man Municipal Code.Chapter 9.12,and the Health and Safety
Gxlc,Section 25532(a)1 `� 1417NI'1 NO UNI'I(OVER I(XL(X0BTU)
❑Yes L�rv,:
VENTILATION FAN(SINGLE RI!SID) PAID
N5d the app(odou or nn a(wilding occupant use Area
Air Quality
or dMana emelt Date Recerpr n
emir harnMous nn contnminams m defncd by he ray Aren Air Quality Management BOILER-COMP(111P OR l0(LXX)BTU)
Dint/icl? \h:
�Ycx 0� IiO1LHR-COMP(UVL'R IfX1,IXMIBTU)
T t thLh nalo¢yuimments under Chapin,6,95 of(he Cali- ' AIR CONDITIONER
ISSUANCE DAT
hr 11 hh&S ra255fL5,25533 and 2553ilu dcrxmnd that i[thc NEW RESIDENTIAL MECI I. SVP.. /� G�IIp
hal gh of u furnil ya"'epumihlllty alit' he, upyn
of tnrer pnona issuance of SFir�i cap of Xe�we/R p n
authortuJ ngcnt / / Dme T ' rA S7_4Y
ISSUEDBY.
OFFICE