30181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,CTRICAI. PERMIT NO.
BUII,DING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL 301,81
}}11{1pppppp BUILDING PROJECT IDENTIFICATION .L 1.
�ING ADDRESS: ! SANITARY NO. APPLICATION SUBM�AL DAM
O •R _(_j
CONI'ItACfOR;S NAME LIC NO:. NIC 11 CONTROL# '
aRCHIILCT/ENGINEER: IV �LIC NO: ADDRESS: -El
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by AppEcant(Initial) BLDG ELECT PLUMB MECH
j
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEF,
I I nerenr alEtn,mai I an,u«n,ed ander pmdiaiuns or ehepter 9 m«nmcneing JOB DISCRIPTION
I�00 with Section WXXp of ulvidm]oflhc nosiness elullwrcrsimscalc.we myliccnm is - RESIDENTIAL:
F 0 full force arid eRm. IiRMIT ISSUANCE,
QW '�SFDWL ❑KITCHEN REMODEL
V U IJceme Cln, Lie.x
F APPLIANCES-RESIDFNTIAI: ❑ADDITION C3 PLUMBING RE-PIPE
y<a' Date ARCHITECT DFCLARATTION ❑MUI.TI-UNR ❑STRUCri
(YO m PANELS
vat Z d utdcrnard my plans CEII M T'S as public DECLARATION
s MODIFICATION
,C)'_� UPT0 200AMPS ❑INTERIOR 0 CHIMNEY REPAIR
F-FW Iicrnxd Rvfc,ai«ul NII-1001AMPS 1PROVESENT
YNJ' OWNER-BUILDER DECLARATION OVER 1000AMPS REMODEUREPAIR 0DEAIOLMON
y Q I hereby affirm Thal 1 an excmpl from the Comrac or's Liccme Law for the
x O L U following Iwwn.ISimnon 90315,losinc\a mid Pn,fcwinn,Cnlc'.Any city«cibioySIGNS ELFLTHICAI. ElOTHER
Til L 0 F which requires a pcnnil m c«uuun,alter,iltryrnva dcnwlish.or rtpair any swcture
F�O:7 pdorm it,isetsu oho lcquirt,de applicenlf«such permiuo fideuigemista em SPECIAL CIRCUR/MISC
�yY---7777 thadtr is liemscd pununnt to the povisiom of the Conoxlah license Law(Chi 9
W1 0 (commencing with Section 7(]00)of DiGuon 3 or be Bissities acid l'mfeniom Cooke)« TEMR METER OR POLE WST. ._
d o a ihe i,eeemp Ih...fnm moat the No—for the Wlcped seri Any violation of ❑NEW BLDG/ADDEHON ❑DPJNOLITION.
4• Smlim]OJI3 by anY u191icent furalslmii.whlatr the upplicani to,civil perelry of POWER DEVICES
Z y not muse thin five hoidred dollar,135110). IMPROVEMENT [I FOOD SERVICE
�Q �I.uow.cr of the Pxoleny.«my cmploym with wegevthc'v,ole smipenusiim. SWIMMING POOL ELECTRIC IMPROVIMPROVEMENTG war da the wm4,and the,oactue i,.intended«oBmed fin a (See 7U,I4.Basi. OTHER
a3$ W Di'fcssiinA Code:The ContmcliY,License Low does mI apply to an owner of OUTLET'S-SWITCHES-FIXTURES
Pmpcoy who builds ur iniptnves llicrtnn,and who die„och work himself or though
his own employm,pniviiled that such imptovermntn we not intended or oRcmt for NEW RESIDENTIAL ELECTR SQ lel'.
We.If,however,the building or is sold within arc Year of caatpinim be, SQ)ETMOOR AREA $/SQ.FT.
.-builder will hove ted boards.aprnG,that he did rot W iM or imlaove f«pt.
pose ia.ulcJ. _ I
Fl I,as owttm of the Mm ny,am exclusively conlmeting with 1'wenscd conwaor,w 'RITAL JUL
rL O
mastruct Its,Project(Sec.701 Busirc+\ar-0 Professions Code,The CoaMlor's Li. ^ V V 1996
wmelawdoanot.'Iywanowlur of pmpeny who builds m impove drieorrid QTY. PLUMBING PERMIT FEE
hoco ,,fi«,uchprojectx c muran«f,)liccn,edpmsumttotheContran�, ITYOr
Lic_ sur
El Win ca code c. ,ERECT«mi,rtawu PERMIT ISSUANCE Chllryu
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Date
WORKER'S COMPENS O DECLARATION BACK FLAW PROTECT.DEVICE / A�✓
I lWebydiirmunder penallyefperj ofthe Wflowine dminannii ✓VV
•0 l hove and will mainlain aCenificateof Consent msclf-ituum fm W'nrkers Compco. DRAINS-FLOOR,ROOF.AREA,COND, STORIES TYPE CONSTRUCTION
wtisu,as provided for by Section 17M of the laboir Cock.for the Pcrbirborice of llc
wedf«which do,Fuson is;. -d. MIXTURES-PER TRAP
1 hove and will maintain Wahefs C«tlpernation Imuramz,as mqulted by Section
3900 oflhe labor Costs,f«Incpmfornm.co a the wort for which this Permit is issued. GAS-LA.SYSTEM-I INC40UTLETS
OCC.GROUP APN
My Wnrtcr'a Compcnxetnn Imumntt returner"a Policy eumbm vrt:
Cemim. Policy Ninl GAS-EA.SYSTEM-OVER dHO) •
CER'I'IIRCATE OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE GRIASETINT N,WASTE INTERCEPTOR
BUILDING DIVISION FICC
(This smionlort be cmnpMcd iflhm
cpnit ufm o« 6ssl hulvrotators GREASE TRAP
«ksa) lmPLANCHECK ITL+
I cenifymm in the perfixew«enfthe work fix which this llantit is iNom.I snail SEWER-SANITARY-STORM IID.2(K)FT
Inds employ any Panus in any ltient,,r m ns to bmWoW suhjm,to the W«trn'Cnmpem ENERGY FEE S
Z ,Z ocid.Lows of Catifarnia.Done WATER HEATER WNENT/ELECTR
Q Applicant - GRADING FEE ,
N NOTICE TO APPLICANT:If,after mating this Cenificate of E.scmintm,you siwld WATER SYSTP.WIREATING-
a become subjml to the Wo4m,C«npenaation provisions of the labor Code,you must SOILS FEF,
foMwilh comply with such pmvisiiur nr Ihix pertnil vhWl he v<rmedinvoked. WATER SERVICE
o.
az CONSTRUCTION LENDING AGENCY NEW RFSIDFNTIALPLNB. SQ.FT. PAID
C.10 IhercbyaRrm tMtthleuacansuucdon krtNng aSencY far the R*fareutKe of Date R,/,,l#
P. F the wo,1for which this .it is issued(Sec.Wim.Ci,C)
O U Lendmi,Nome TOTAL:
WL
Lender's Aothc
M. , TOTAL: -
” 1 cer ify that 1 have read this application and sbte drat Ik above i rksobb inn Is BUILDING
(A cmrca.l alarm to comply with all city and conn ordilurre,nidswe law,mining to QTY, MECHANICAL PERMIT FEC
C„) Z building rnnstrvctimi,and hereby con i ives ofthis city to repre,cir enter upon t SEISMIC
abovemsntbtcd pnpcoy for in,pe,rinn'rpc,,es. I'IEHMI'T ISSUANCIi
(We)at.ni w,'e,indemnify and keep haindes the Cay of Culenibo it ELECLRI
IiabiliussjWgltcm,,msuaM cxpcmcs which may inanyway«crueogainstwid Ciry p1,TER OR ADD TO MECH. PLUMBING FEE
in conse9ue«e of tic gmntine of this pmnin'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MIECHANICAL I. OIAS
AIR HANDLING UNIT(OVIR I0."CFM) CONSTRUCTI( TAX
Sitinaturto'AWicanaColmx'tar Dare' EXHAUST HOOD(WMUC) HOUSING GATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant«future Wilding occupant m«e«hmliRe turnabout material HLATING UNIT LTO 100,000 BTU)
os dcrined by be CuWninu Municipal CWT:,ChapWr 9.12.and the Ilcullh Wind!Samy
Code.Scot.255321,1^ - HEATING UNIT(OVER IW.UXI UI'U)
El Vies E]No
VENTILATION FAN(SINGLE HESID) PAIU
Will the Date Receipt 0
er cob.«amort building occupant use squi it Q or ok ao which BOILER-COMP(3HP OR 10011(10 BN)
flail hnennlous air canimninants as ikOned by doe Buy Arta Air Qmry Mmegmrnm '
TOTAL
UstrscR
BOILER-COMP(OVER 100.000 BTU)
AIR CONDITIONER
I nave read the hvwve
ardcus nils mgoirt« urd
lnunder Chapter 693 of the Ni-, ISSUANCE,DATE
l filmic Health&Sabe,Cock,Smioru 253(15,25533 and 23534.I utdmslard thus if the NEW kFS1ULNfIA1,MLCH. SQ.PT.
huilciog iku Ix,I swemly have a W.I.dim it in my rtN orroW lily to ratify the.,nt
id aie rt,gdlemenu which mv,r tc and prior to ha,uarce of a Certificate M fA vpa«y.
Owliermeumori>m atSent Date TOTAL ISSUED BY:
OFFICE