S 0632 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECII RI CAI. P' HT NO.
BUILDING DIVISION APPLICATIONWERMIT PING PROJECTIDENTIFIC 0632
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPIJCAUON SUBMfITAL DATE
79SO -bu4L 8/2 2
OWNI!R:SNAME' PHONE E CO]VMACIGR'S NAME: LIC NO:
Rk C 16N Q N y , NrC CONTROL#
ARCIrrECf/ENGINEER: LIC NO: A D DRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ CtmguIumt Fm Paid by Applicant Hnirial) BLDGMU,MB MECH
IIS LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1-1 [LC 251,I henwy affirmmat I ata ficensal craft,ptovtam..of Chapmr 9(ammercmg JOB DESCRIPTION
M�Z with Stamm 70110)of Division 3ofthcBoxioosand PmfnaxiumEde,nalmyluen.sciv RESIDENTIAL
00 in full hxee arta effcn 1'I!RMI9'ISSUANCE
a.halls Cll ss (r2� Li,,. 0 IG�' ❑SEEWL ❑KITCHEN REMODEL
batt (;-); � Contractor AI!PLIANCFS-RESIDENTIAL. ❑ADDITION ❑PLUMBING BI:I'IPH
R.7 y ARCIIRF,CpS DECLARATION PANELS ❑MULTI-UNIT ❑ CT
STRUURAL
ZONZ ludnstardmyplw]raphe mpublcnawdx MODIFICATION
OZy-1 UP T031ID AMPS El INTERIOR ❑CH IMNEY REPA IR
r Ful IJcemed Pmfcsiatul 3111-II100AMPS IMPROVEMENT C]SWIMMING POOLS
zy$, OWNER-BUILDER DECLARATION oVIA I000AMI5 [I BATH RIiMOD111/R13PAIR ❑DFIs1QLRLQN
tY 9, 1 hi by k...Am I em exempt from the Cormcwt rs Liana"a,for the
x O L F following,saran.(Section 9111L.I.bu im,s aM Profevxionx Cede:Any city a aunty SIGNS ELECTRICAL 11 OTHER
LL1 n. which as tex a st an<unxwn,olmq itnpovc,dcmWieR or rtryir any structure
F'u'r Priorm a,ixsoorce,uta tcgaina'the applicant for such wood ,,fit--igrcl namtrent SIrECIAI.CIRCUIT/MISC.
that he is lian.ad pursuanuo the pooki.ofthc CconcttMe Ueensc 1aw(Chapta9
y�Q (ammsrcing with Sacks 7NI(Nof l)ivi,ian J mfthe Busimoand Prof,,aso,,Codi or ('EMI'.METER OR POLE INST, COMMERCIAL:
a a (t
e oC ut he is exempt thaeafx m and tewo on hIfor the illegN exemption.Any violatiof ❑NEW BLDG/ADDITION ❑DEMOLITION
u•= Smim703L5 by any applicant for a permit subjct the,applicant to a civil Penalty of POWER DEVICES rn ❑TENANT [I FOOD SERVICE
F,Z} rag more tlmn five hurc4nl dllon($$()()}
< l]I.eavm of the lmpeny,ormy empbyns with wagevth<ir sok cnnrvnrwksa SWIMMING POOL ELECTRIC IMPROVEMENT
f G will pmaxwsvrk.Cajl: he,Comintor', kerne iovdk .1.,Iy coon,Bu of ❑OTHER
W�� ed I'mfwions Cade:The CorumemMx Liceme I�w tkes rat apply In an awns of OVRETS-SWRCFiCS-IIK'IVRFS
Sit
pnlenY wed builds sur impmves thernm,end wM1n dot xuch ante{,himself a thrargM1
his own employees,pmvided tMt such improvements are rax intaded or offered for NEW RESIDENTIAL EISCfR .Q
sdc.It,however.the huildinB teintp ,,co—a it sold within mmycm Ofemtpk7im.tlte 9S)URA Q.FII
mer-builder will have the hunlcn of proving that he did ora hu Jd or impnwe for par- Lr
paa,owner of de prsryseny,on exclusively contracting with liceai contractors to TOTAL: L`rC
asmt he poSen(Sec](cLT.Busine.,x and Pofesicvc Cale:)Ts,CmtnetuYs L- h%irk,
we law acro oaapply to an mvrcr of legeny sbo buddut or impmva tkrmo.ad QTY, PLUMBING PERMIT FEE (✓
wdm conbace,for such I axjecu with a emttana(s)Puttied Iemuant to the CorumetKs
Ilam,law' PERMIT ISSUANCE
1 am exempt matin .B&i'C for this,sawn
f}wtsr Dem ALTER-DRAIN&VENT-WYFER(FA) VALUATION
r
WORKER SCOM of sijur,m UECLARAUON BACK ITOW PROITLT DEVICE
I haehy eRrm under pewlty of perjury Otte of the following Jcdamunns
Ilwve ural w0l mainmina CenilivataR Cumem In,elf-insure brt WtrtrlsCmtpen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
anion,u pot for by Sacs.3700 of the labor Code,far Ne PCAtrcmmce of the
work fm which this pemro I.raced. FIA U"-S-PER TRAP
1 bas<vd will maintain Workers Compensation Ino arcs,ix myuired by Savcri '
37M ofile liber Cost for the perfomvrcs ofthe wan{:for which this permit is issued. GAS-EA.SYSTEM I INC.1 OUTLETS OCC.GROUP
My WorcsCyymstd num
9Nion�Instuatec carticr Policy ber. o2:
Carocr._Lp1�K �fal{ry No.: GAS-EA.SYSEMI.OVER J(HA)
CERTLIIC .OIt EXEMPT10N FROM WORKERS'
COMPENSATION INSURANCE GRIiASF/INDUSTRI.WASTE IN'IT:NCFJ'IUR
BUILDING DIVISION FEES
(This_tato med nix he eontpincd it permit in Lr atmhunand dmllws1511X11 GRI3ASI!TRAP
nr lcµ.l � PLANCHECK II?H
I ccnify but in the perhmnncc ofthe work for which this pemit is issued,L shall SEWER-SANITARY-STORM E.A.200 IIT.
w
memploy any pawn in ans
y tsars, as
r ,so ton hamic ttt m whjfirs,Workers' om
Cpcn- ENERGY FEE
O Z orlon Iswx of Califomin Dae WATER HEATER WNENfALECTR
Znppt w GRADING FEE
�
N NONCE TD APPLICANT:If,sfmr making this Certificate M Examptise,you should WATER SYS LTREATING
ans
(• besabeet to the Worker's C ncremation provisimu a t s Lala Cock.you mum I SOILS ITS
� ? faMwith comply with such provisions or this mond stall be threat revoked. WATER SERVICE
a �
U CONSTRUCTION PNUINO AGENCY NEW RPSIDENTIAL PLMN. SQ.FT PAID
O Dam Rcccip x
LoobyaRrm tNtt then:i.e ,d(S ction ,ON.agency for the pcHcmancwf
the work far whicM1 this pcmtit is ixwcA(Ste.JIM.Civ.C.)
O (~ latdefs Name TOfA I,:
Lcndcfs Adble ( TOTAL'
(~ 0. 1 amity Brat 1 hnvc,cad this application sola sac that the rds iofamatim is BUILDING FEE
rn comes,lvgrte to comply with all cityadrnmryaNimnmatwnmc law,relmingto QTY. MECHANICAL PERMIT FEE
L) Z baik4ngcrosmmtion.a,dhereby auJmtiss tcptncntativca nfNucit".'amer.'ra de SEISMIC FEE
` shove-tmatimed property fat buffetion purpor 1'P.ItMRISSU/�CE
(Act apcc to ma imkmndy ml kccp Iwml¢a the City of Cupcn'un agalnq ELECTRIC FEE
Iubilitin,jdgmentt couxaml exlen.ses which may in any way accrueagainst said City ALTEAORADDTOMECH.
in corued ram
clorms of tgnting of this petil PLUMBING FEE
APPLICANT UNDERSrANIIS APO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('ID 100))CFM)
SOU EGULA )NS. CONSTRUCTION
AIR HANDLING UNIT(OVER III(Xp CFM) CONSTRUCTION TAX
Mill of AppliceMGmartor Done IX HA UST HOOD(WNUCD HOUSING mrMGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
WHl the epPlicant or firma,drain,occupant time or handle ba,todato,tttwcH.1 HEATING UNR(TO I(YI,"BTU)
v deftttd by the CuPenino Municipal Cede.Clutper 9.13,ed the Health surd Safes,
Cods.Scrim 25533(x)' HEATING UNIT(OVER 100.000 IITU)
p Yea No VENTILATION FAN(SINGLE RISID) PAID
Will the.,It ant or noun,M1uiddar, t ase t nr&icas which Dam RaeiM R
gPan cyuiptnrn 111111,1!R-COMP(3HI'OR IIXI,fXX)NTLI
emit M1nrmJuus sir cumantinvnu ns def ted by ted Ifny Ana Nr Qmdiry Manngenem
INVrPC TOTAL:
[I Yea 0 N HOILF'RR-COMP(EVCN IIXI,IXX)BTU)
I have real the hasadtesmaterials mlmuaannVs sort Chapter695 d de Cali- AIR CONDPHONF,R ISSUANCE DATE
ha nix Hasa th&Safi,Code.Smions MM5,25533 and 255]1.1 u,tdnnsaed the if the NEW RESIDENTIAL MECH. SQ.En
buildin6 Jou ria anenly have a tit,thew it is my tcsportsibility to ratify the mavpaty
of rteo acre scar,which roanIN,ton it issuarce ofa Crnifrvc of t]avleay.
0,iscror soaaara xgcm Doc TOTAL] ISSUED RY:
OFFICE