S 1479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - NUMBING-ELECTRICAL PHSO NO.
BUILDING DIVISION APPLICAT10NfIrERMIT PLUMBING-NIECIIANTCAL 1479
BUILDING PBOJECIIDKN1'IF'ICATION
lillll,l)ING ADDRESS:
SANITARY NO, APPLICATION SDBMITI'AI.DAPI;
O+ N o e l�'1 y o
ER'S N 1
AA : PHONE: Y) "RACIOR'S AMG: LIC NO:
_"7771 [L1 OND COAST 703 p2
NIC coN'rkol.a
ARCIIITI:CAdxGINEER: LIC NO: )DRCS// ^ Gr9 ❑ S�
C(INI'ACI':life, ^ PHONE: HUILUING PL" I'I'INFO
RMhM�•l ❑ Consultant Fees Paid by Applicant(Initial) 11. ELFCI' PLUNIB MECH
slog ElLICENSED CONTRACTOR'S DECLARATION QpY ELECTRIC PERMIT' FEE
I hcmby mr nt mm I a.T Been.ee ander prwi,inn.of C1m,er 9(emnmendng JOB DESCRIPTION
OCZ with Soulim+90(m)orDivine..3af The 6usine,mal Profession,Code,snit myliecnm is RF.SIDENTIAI:
Fes,= infullfmccandold". 1� 7o^i/1 ^� /-1 PIiRMIT ISSUANCE ❑SI'DWI. El KITCHEN REMODEL
QZU Licvn l,ic.N 1 .?GW d- AI'i'LIANCFS-RHSIDf:N'1'IAL pU1T10N [I PLUMBING RE.-1'll'fi
6 Y Dam Qmam.
ZONZ \RCI I I I'IC I':SDIiCI.ARA'UON PANELS AfU1,T1-UNIT ❑S'IRl1C'1'fJkAh
rot lterso d nry,ldn.c shall doused as puhlic rcc.nds MODIFICATION
OZ= UPT021x1 Ah11'S El INTERIOR ❑CHIMNEY REPAIR
Q�Fu] Licensed l'mfcoinn°I �S
201-1000AMPS IMPROVEMENT Vs'IMh11NG POOLS
OWNER-BUILDER DLCLARA'I]ON
OF 5 w Q I herchy affm+than I:nn exempt from the Cunvuch+r.c License Law tar the OVER Igxl AMPS ❑UAI'11 REMODEL/REPAIR ❑DE OLI'CJON
x O1 U toll.,i.,recon.(Section 911315.Business unit Profession+Codd:Any city(it county SIGNS ELECTRICAL ❑GFUER P�I V
W LL u.N which requires a permit m c u stmct.ohm,improve.Jem.lish,nr mpan any auucmre
F_OQ prier its i.swore.nlsat re qui ruthcap,d,anl fnrwch permit 1. deo signedmanmcm SPECIAL CIRCUITAIISC.
}� that he is licensed pamuant to the provioce-of the Cn no,oVe License l,;,. Cbapmr9
LL�QO (tx°^mdncing wits Section 9g10)ofDivisionJ oftheBminea and Pmfccpai...Code)... TRMI'.MIfHiR OR P6LI[INST I I'
eca e C chat he is cxmnpt thetefrmm anti the basic I'er the alleged exemption.Any violation of ❑NEW BLDG/Aj)UI'I'ION ❑DEMOLTfION
..m Section 1091 5 by any npplicnm for it Permit vunjcas the applicant to civil Penalty at POWGR DEVICES
t room man me nrndmn dnlmm(s5tp) �7�Irvi r UUr-rh I II�FooD sf:RvlcE
F Z' IMPROVEMENT
Q ❑ Las ownerol the pmpcny,or mY employee wits cages ate thdinnle wnnpen.cmion, SWIMMING POOL F,LECTRIC
x'O will Jolhewurk.Cole The Coeisnotlmenco Law dofnrsalut5m90JJ.Btniocss
F, 54: ❑OTHER
30o and Profir whob id,or The Cumnmi.,r,Leash Luwduct notapply manowneror OU'f1.ET5-SWITCHES-61X RIS
his o ny who nuiv,,P improves thereon,and who dins a his
work himself oreredf through
his own employee,,provided that such improvements am not inamJed orpletione for NEW RE.SIDEM'IAI.F.LEC:R 5 ],I_,
��oQQQRRRAAA
said.,:uddri- oll led it hebd,i Ioffro in,fila,hedihin one year nfcompleting , SQ, FL HIi.A SISQ II'.
,.1"led,will hove the burden of,owing Ihw hedid not bold nr inq+mvc fnr per- /1
Else of sale.).
El L as owner of the Svx.704,am excessively contmeting with:icthe Cmmmmnrs m '
noses the pnjmt(Scc.1WJ.Unsincxs and I'n)I'essionc Craft:)the Commnnr's IJ-
sense law latae not apply man owner of property won builds or mproves Nerson.and QT'y, PLUMHING PERMIT F,
who contracts for such projeat+with a commolu r(s)licenced pursrnm u+the Contractor's
License law. In'RMI'r ISSUANCE
Iran exempt under See .H h P C for this reason
Owner Data ACBR-DRAIN.0 V121,11'-WA'I'RR(EAI VALUATION
WORKER'SCO,,ot ,'1yON UECLARACION HACK FLOW PkI1TGC'I'.DEVICE ' �1
1 heathy adeno under penalty OI Nrlury one of C u%RATimg due larvtinrtpa `
❑ I have and will maintain s Cedificate of Cmncm toself-inwic l or WudcA Comsat. DRAINS-I:LOOR,ROOIIARCA,CONO. STOMPS TYPECONSIR UCTION
sation,as provided for by Section 3700 of the IaMn Cold,for the perfonoance of The
work for which tdry permit is ircue 1. FIXTURES-PER"BAP
❑ I lease znd willonanoel n Worker's C......n, aliun notiraneu,as mqui,,d by Seen
Jlq)of the laMa Code.for Perfonnana of the work for which this permit is isaad. GAS-HA.SYSTEM-I INC.4011'ILETS OCC CROUP ANN
l My Workers Qt Insurance carrier and Policy nm
957/.97 5'rexr�nZAuO Policy No.: GAS-IiA.SVS'CEM-OVI?RJ(EA)
/ CERTIFICATE( FXIiM11DON FROM WORKERS' Q7
COMPENSATION INSURANCE 07 GREASHJINDUSl'RL WASTii IN'TERCMIOR
BUILDING DJVlSI(r Iris
(Thissealonneed not heronPlacdifthe Permit is formehnndreddollaoi$IW) GREASE'TRAP -- —
oi IudJ PLANCHECK PEIi
Tetnifythntimhe Perfnrmmncmdthe work on which thispennit is issued.l shall 9SEWER-SANITARY-SlORMEA.?DIIT.
ern employ any pT•m n in any m,nnu sn spa m Mcnme wbjcct m the WOrAcn'O+ml":n- ENERGY FEE
Oz sation Law of California.Dam WAI ER I]]:ATIik W/VITMT/F.I,I:C'I'R
z 2 Apphm
cn GRADING FEG
y NOOCETOAPPLICANT.If.ad,crmakid,this Ccnilwateof'Exeunt,.......yon choold WATER SYSTEMO REATING
a ; warned subject m the Worker's Com tion f the Lahr Cod..you inns, 50145 FEE?
1 acme provuiotn n
� BmM1witn canply with such provisions or his pdrtnL Mull be ordered mrdAdJ. WATER SERVICE
d
CONI, I'IONLENDINGAGIiRCNEN'K151UIiNT1Al.I'LA10. SQ FI'. PAID
l ndny arrmthat
ere Ia.n eatuweenn lend..,agency
n+nhe nenn+t
oandenr num ReeeiPtw
U. O m
the work ler which this mut,,Issued Sea.3091.Co.CJ
O Loder's Nannc _TOEG.;
r LU Iendve,Address TOPAZ.:
I cenifY that I have read this applicminn and state that the above information is BUILDING R:
F N emren.i agme tocumply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
Uz huildingvr . nd hereby awhn mpmenmtive,or Ihiadlyr+enterupnrthe SEISMIC F:
aM)ve-mentioned propvny for inspection Prip ses. PI!Hh1II'ISSUANCIi
(We)agree u,sere.indermtHy and Ace,muffles,the Chy.1 Cu,enino ngainat IiLGCTRIC PEI$
Iiarahnes.judgmcnto costs and expenses which may in any way aseeme against said City ALTER OR ADD TO MECH
in con encence of the granting of Its penult. PLUMBING PEE
APPLICANT UNDHRSTANDS ND WILL COMPLY VITH AEI.NON-POINT AIR IIANULING UNIT(TO IILUM)CFM1)
SOURCE IL IONS. MEC11ANICALI Ji
GI AIR IIANDLING UNITtOVER 10,11ICFM) CONSTRUCTIOP fA%
SI .ture.fAnNivn 1mwRr D.", EXHAUST HOOD(\V/DUCT) IfOUSING MIT .ATIl1N PIiH
HAYARDOUS b/ATGR1Al S DISCLO,URC
Willihca,,h.morl'umruhuilJing occupant gorc.r hunJle haraNnus material HEATINOUNIT(TOIUkgx)BTU)
ac defined by the Cupenin0 Municipal Code.Cluan-932,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER I OQOOO BTU)
❑Yes FIN. VENl'II.AUON PAN ISI NGLE RESIDI HMD
e
Will thea applicant or future huldln•twea t use et n t nr devices which Dam Kee p
PP b the
1 prQu BOILER-COM P(31 IP OR 100,t�BI 13)mit District,
u+air cnmmniwms uz AcEneJ by the IDY Area Air Vtmlity Managennent 'i' I',\L
Di+trin°
❑Yuv E-1No BOILER-COMP(OVER 1M.00013 FTI
1 have mvJ the bvnrJws materialsad,,Chu t+uAIR CONDITIONER
m 15533. pto 695 of the C:di- ISSUANCE DATE
lomiu fleeted h Sudety Pdd,Sections 25505..3533 and 25534.I understand Ihm it the NI[W RGS[[)ITNTIAL MECH, SQ.TP
building drwdn nut s x0twiy to
a rec,P tout o is my ce of a nllity m notify Ind psuCy.m
of the rtquirnncros which nmpat be amt poor m issuance nfu Ccnihruc of Ott'upnncy.
Owner or authurved agent Dam IOIAL:1 ISSOI?D ICY:
OFFICE