S 0923 APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Rm1.DING-ELECIRICA], PERMONo,
BUILDING DIVISION APPLICATIONIPERMITPLUMBINC MECHANICAL v G
C' n �n�
BUILDING PROJECT IDENTIFICATION v
SANITARY NO. APPLICATION SUBMI I Al.LDAT(
BUILDING ADDRI:S.S: 1 O wf
OWNER'S NAME: /IIcko
V-•WT/ ('HONE CON'I'RAM Ok:S NAME: (�`'- LIC NO: ����
_ I' ' NIC CON}j{
L Call W LIC NO�j ADDRISS: ❑ J/L,�JaIyO
RCHITE -NGINEEH:
CONTACT: vHONIi: BUILDING PERMIT INFO
� ' �� ❑ Consultant Fees Paid by Applicant(Initial) BLD' 12111: PLG. ) MFCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Inco],air rcen.ed under provisions of chapter 9(emtnncttcing B DESC 11'TION
O.4Z with$fClianlWt)afDivi<ionlofthe xusiness and Professions Cisle,ane my license is F. TI 1'
PERMIT ISSUANCE
��� in full fora unJ cRca. IUWL D KITCIJ17N REMODEL
aUU Llccuse Class Lick APPLIANCES-RESIDF,N'I'IAL DA)DITION PLUMBING RIi-PIPE
F Z W Date Comrmmor
'tea 0. ARCHITECTS DECLARATION ❑MULTI-UNIT DSTRUCTURAI.
'D.
t=/1 Z I ondemund my plum shall be used as)antic records PANELS MODIFICATION
ZO EQ UPT02Ia AMPS DIN'FERIOR D CHIMNEY Rl:l'P.IR
r-. W
H�F-ul licensed professional 2111-IIXHas) $ BATH RI:MODEI DSWIMMINGPOOLS
OWNIiR-BUILDER DECLARATION OVER Has)
BATH RIiMODE1lItIiPAIR C:1 DEMOLITION
C C Q I hereby axiom Thu,I um extra"from the Counarlo's License Law fur the
W 3 a.U following reason.(Section 7131.5,B....us,and Professions Code:An,city or county SIGNS ELECTRICAL. D OTHER
y which acquires a Permit to consumer,alter,improve,demolish or repair any svucmrc
f O- Pnera,its issuance,.k.requires the applicant for such permit to file a signed statement SPECIAL CIRGDIT/MISC.
a) that he islicelsedpucmanrmtheprovisionsoftheConmecua',LicenseLaw(Chafer1)
u1=C0 (a°mmencing with$emion]INIO)of Division Tdthe Business and l'mfession>CNO or l'EMP.h11iTER OR POLE INST. �pTy ppb
6 if c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NERBILD�G/ADDITION DEMOLITI08
_4•
Section 7031S by any applicant for a permit objects the applicant to a civil penalty of POWER DEVICES D'HiNANT �� D FOOD SERVICE
not tome than five hundred dollars(851X). ���p
~=QI,as owner of the norm m to ccs with wa es as their wle cont tion, SWIMMING POOL ELECTRIC OTHER I)HRN9 PZ'0
2 rape y Ye P Y g penia El OTHER
P. illand
drab ssions Crud th The Contractor n Licaus Law
does
s a,,,apply
so an Business
W 3 w and Pndbssions Code:The Contractors Licenw Law Jica nm apply,o an owner of (IUTLE'LS-SWI ICHES-ITXTURLS
progeny who builds of Improves thereon,and who does such work himself or through C VVI-un-I
his own employers, hurah l that such impmmen
vels arc hat intended or olTered far NEW RESIDENTIAL.ELECTS SQ Fr.
-sale.lChoweveriliebuedingnriiopnivement isenlA within nor renrnrc„niplatian.ire AA • 1FLQOR $rSQ.Pr.
rbuilder will have the burden of proving that he did not buil)lir ina"Le for par- V r `
,weeof'idra)
El 1,as owner of the propery,am exclusively contracting with licensed wnvce,ors m
coasuuet the p,,,jet,(Sec.9044,Business and Profcsiom 1ma,1 the Cammanr's
cerw Law does not apply to an owner of property who builds car Improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a coutchaorfs)licensed pursuant to the Contractor's _
License Law. PERMIT'ISSUANCE
❑I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN iM'-WATER(IiA) VALUATION
O Date �#
war WORKERS COMPENSA?'ION DECLARATION BACKFLOW E )1 ICE
1 hereby aRren under Penalty of perjury one of the following declarations: (�
�Ihavc undwill ntainminuCenixcatmd Consent to sell-inzurc for Worker's Compact- DRAINS-FLOOR,ROOF CON . STORIES TYPE CONST14UMO
nation,as provided for by Section 37Nt or the Labor Code,lot performance at the
work for.'1twn this permit is issued FIXTURP_S-PER TRAP
❑I have and will maintain Workers Compensation Insuranre,as rtyuired by Section
37N)ohheLabor Code(.the performance at the work for whidt this)coni,is issued. CAS-EA.SYSTP,M-1 INC
LETS (ICC.GROUT' APN
My Workce)t; Ytya Insumr ccsme rand Policynumlmr1rp: Qgd
Carne — Policy Nu.: /9 1 L GAS-EA.SYSTEM-0VER4(EA)
CERTIFICATE OF EXE.MPIION FROM WORKERS' GNEA51lINUU11'RI.WASTE INTIiNCEPTOR
COMPENSATION INSURANCE BUILDING DIV.ION PEES
Tlfiissection neednntMcomplchediftheperchn is foronehundreddallms(EI(XB GREASETRAP
sir leas.) PLANCHECK IYP. ` /e
Ic,amfythal in he pu,fomamuolhe work for which hispcnnit icustied,IK hall SI?WER-SANITARY-STORM I?A.2nd FT.
not employ any pner ui Iverson in any manos m become,abject m ar Workem'Co.,.. ENERGY FEE �e
Z cation Laws of California.Dae WATER HEATER W/VENTnEI.El GRADING ITIS
.Z O Applicant
NOTICE TO APPLICANT:It,after making this Civolicae of Eseolpmom,you should WATER SYSTEM/I'REATING
become subject to the WoNces Compensation provisions of the Lala Calc,you must SOILS FEE
W forthwith comply with,arh p...jor,or this penitis shall be devoted revoked. WATER SERVICE
� Z CONS
LE )I A': Y NI7W RF_SIDENI'IAL PLME, SQ.FR PAID pate ept
UQ Ibembyaflir 0cal at is ditfkalgerocC)'(lort peHnrmance of
W F the work for which this permit Is sum n nC.—rC-_, l`
C) U Lender's Name c. 'IOTA L:
Ud Lcuba's Address
1 verify that 1 have read this mppliedion and are that the aMrve information is BUILDING 19::
sorsa.Ih,ow,u comply withoil city and county ordinances and sum laws saluting or QTY. MEC H ANICALPERMIT FEE ^
U Z building construction.and hereby mandate representatives,I this city to cmrrupnnmc SEISMIC {—
above-mentioned property for inspection purynss, FERMII r ISSUANCE
ELECT 1:1717.(We)agree It,save,indemnify and keep harmless Oe City of Cupcnino against
liabilincs.judgmems.costs and expenses which may in any way areme against said City ALTER OR ADD TOMECH.
PLUMBING F:E
theganting this pmit.APPLICANT UNDERSTANDS
AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0X111 CPM) M13CIIANI AI.FEF,
SOURCE REGULATIONS.
? AIR HANDLING UNIT(OVER[LNX)CFM) CONSTRU ON TAX
.igmamrerf Applic: ort ser Dare EXHAUSTHOODOVMUCT) HOUSING MITIGA NFEE Z
HAFARDOUS MATERIALS DISCLOSURE
Wills applicant or future building occupant store or hamlle hamrdous material HEATING UNIT(TO 100.0110 BTU)
as cleared by the Caths in,Municipal Code.Charter 9.12,and the Health mad Safely
Code,Section 255320)! 1]HATING UNIT(OVER INMm)It I'U)
❑Yes DNo VENTILATION PAN(SINGLE RFSIDI PAID
Date Ree apt p
Will rd the air comeifuton building by the ht Bay
oea Air muordManaes whit, BOILER-COMP OHP OR IOB.000 B'TU)
mit hazardous air conmminunts as Ikfined by the Bay Arca Air Duality Management TOTAL;
- Distinct? BOILER-COMP(OVER 1111.000 BTU)
DY- DNo
I have read the hvmdnu:mamrials requircmems under Chapr,6.95 of the Cali-
AIRCONDITIONER *ISSUANCLEbain Health&Safety Coda Sections 25505,2553)and 25534.1 understand that if the NEW RESIDENTIAL MF,CIL SQ.Il'h rildng docsnotcuoenlly have a,cnna.tea it'killy respmsibility to notify tnc t.uPmuof the hamiremans which must he met prior to issuance or a Certificate ofOccupancy.
Owner or nulnon,wd agent Date TISSUED OFFICE