S 0697 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIR BDING.ELECTRICAL PIRMIF NO.
IibILDINGUFI
rvISION APPLICA' ONFPERMI'P PLUM.BING-MECHANICAL S OG97
BUILDING PROJECT IDENTIFICATION
WIhUING ADDRESS,. SANITARY NO APPLICATI�SUBMITTAL DATE
zo - 2 D
( NCR' A PHONE: RACT S NAME: L C NO'.
.� r NIC CDMIROh#
CI ll"EC rENGINEER: LIC NO: b ADDRESS
R ..
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LIH'i ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTHACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Ilial l am licensed under provi,iam of Chapter 9(commencing JOB DESCRIPTION
O�Z Ili$emmn 7Odn).r Divi,ion3anne Ba,inn"aml ome„innscndo rd n,y tis<nci. RESIDENTIAL:
LL10C) tui PERMIT ISSUANCE
FUS in full force andu rtc7 O� El Mimi. ❑KI'I CHEN REMODEL
�UU Lie.,, la...l Lie.q APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PITH
N6 F Date Commcmr
❑m ARCHITECTS DF.CLARN'ION PANELS DMUITI-UNIT ❑STRUCTURAL
ypa,Z 1 andersnmdmy phms,hall beused it,publicm...i,, t MODIFICATION
O Z'4 UPT02110AMPS [I INTERIOR El CHIMNEY REPAIR
h�FW LlcevmJ Pnde,sional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
C .� OVER HS)b AMPS D BATH REMODELIREPAIR DDEMOLITION
<, 1 hereby a0irm Thal 1 um exempt from the Commcmr'x License Law notate
(3 L V following reason.(Section 703IA Business and I r...an,Cod:Any city or county SIGNS ELBCT'RICAL D OTHER
W v,H which require,a permit to conxlmcl,alley,improve,demolish,or repair may nmemrc
On' primoo its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT'7MISC.
F Y that he is licensed purmam topic IF visinrnaf the Comrai License Law(Chapter 9
m.CO (commend ng with Section 7000)of Division 3 into,Basins,,and Prolessiom Code)or TENIP METER OR POLE INST COMMERCIAL:
'Lty e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BI.DGIADDITION ❑DEMOLITION
X=ro Section 7001.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES El TENANT ElFOOD SERVICE
I mom than five in died doll...($5018.
F Z Y IMPROVEMENT'
fSOaDl,mmwner of the propenY•ormycnnployce,withwages axtMirxnleu,mpcnmlinn, SWIMMING 1'001.F,LIICIRIC
F will do fic,,i k,anJth That Cont is nuts License Law ed s not apply t oan.Business OTHER
tail�m_ and Profession,Code:The Cnmmepar's License lye does not apply m an owner o[ OUTLETS-SWITCHES-I4X'fURES
progeny who builds or improves thereon,and who does such work himself or thmugh
his own employees,ptnvlded that such inapmvanent,are not intended in offered lar NEW RESIDENTIAL ELEC'1'R $Q 1-. !zz
vale.IL however,the building or impmvcmenpi„old within one year ofermpletion,the SQ,IT FLOOR AREA $ISQ.PP
ownc
r-builder will have the burden of proving that he did not Wild or impmvc for pur-
pac of sale.).
I,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL: /1 '
e rc...I the pnjcet(Sce.7W4.Bnsinc,s and Professions Code:)The Commena,L i ®CT
^I D
cenvelawilnotapplytoanownerofpmpcnywhitbuildsorimpnrvesthemon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commands)licensed pursuant nn the Contractor's O�
Licen,c Law. PERMIT ISSUANCE L
l am exeman
pt tler Sec. ,B&PC fonhaa
is rcun /�/ �
ALTER-DRAIN&VENT-WATERI ,.,Ity/VAI A'DON
Owner Dae J'/�.
WORKER'S Woof crjur,on DECLARATION BACK FLOW'PROTECT DEVICE /4V
1 hereby affirm unJcc penalty of perjury one of 0c following declarations:
]have and will maintain a Certificate ofConsetn to xlf-insure for Worker's Cooper- DRAINS-Ft_OOR.ROOF AREA,COND.
,alio.,..provided for by Section 9700 of the Lubar Code.for the a rlonni nce of the S'fOHI1S TYPE CONS'IRUC'HO[
work for which this .it is issued. FIXTURES-PI7R TRAP
D I have and will maintain Worker's Compensation Insurance.as required by Section
37M of the le.or CosR,for the performance mine work for which IN,pc"'al x -am,11 GAS-EA.SYS TEM-I INC,4 OUTLH'IS OCC.GROUT' APN
My WnrarElynq�garhrn fRstgyge•r(Pycr aldy Policy r ' GAS-EA.SYSTEM-OVER 4(EA)
Came, ��T1""�T LL CC 1'IIArUJ
CERTIFICATE,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INT'ERCEPIOR
(This sxtinn ncW oat d:complepeJ i[tM1e pcnnip is for one hundred dollars 15100) BUILDING DIVISION FEES
or less.) GREASE'[RAI' PLANCHECK IgHi
Icenifythat inlheperfennanceofthe wick fe hibn tho,emnit is issued.I shall SI?WER-SAN)TARY-STORM UA.200 FF
not employ any person i.my,...,so ax m became't Ajnl .,he Workers''Cnmpen- IiNIiHGI'FEE
O z ,ration law,of California.])am WATER HEATER WNENTELECIR
nzt Q Applicant I GRADING IRE
NOTICE TO APPLICANT:If,after making this Ceniliente of Exemption,....hould WATER SYSI'EMOREATING
a , heca an oAi Wmkcr'x Compcn,ation pmvisinn.of the L.M1ar Cole,yen most SOILS FI?E
a
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q \\
7z CONSTRUCTION LENDINGnG agency NIiW RESIDF,N'I'IAh PLMR. SQ,FI'. PAID
(.)Q Ihereby adi dr,thatthemissued Svc.
nlending agency for the perfonnaneeof Dape ccipt#
� F the work(nr which thin nonoil is issued f$m.709J.Civ.CJ
O Under',Name TOTAL:
r Lenders Address, TOTAL:
I cedify his 1 have real this nppliemmn and,mm thc,the move intimation i, BUILDING Flil 6
F h correct.I agree mmmply wim all shy and county nrdinmcex and sole law,minting m QTY. MECHANICAL PERMIT FEE
V 4 building.omenion,and herchyuuthorire retrcavionme,ol t loo,ily tit r.mrupon that SEISMIC FEE
move-mentioned property for inspection impasses. PERM]I'ISSUANCE
(Wc)agree to rave,indemnify and keep harmless the City of Culagainst IiLF.CTHIC
Coliseum,
IiaM1niues.' gmems.eons and expenses which may in anyway accrue against said City gL'fEH OR ADI]TO h1ECH.
in cnroeyuennl'the gmming of this ennit. PLUMRINGI :
APVL CANT !UE ST N0. ND ILL. D LY WITH ALL NO AIR HANDLING UNIT(10 IU.O00 CFM) MECHANIC .Flili
SOUR]ERE U AT UN al
AIR HANDLING UNIT(OVER IO.Uf10 CF.M)
CONSTRGCI'IONX
Sigmtre ofppllenVCommcmr ate EXHAUST HOOD(WMUC) HOUSING MLTIG 'PION FEE
HAZARDOUS ' ALS DI. 1,05 RF,
Will the applicant or future Wilding occupant spore ansuchaimmusmmcrial HEATING UNIT LTO 100d00 BTU)
.,domed by the C,amm.Marietta.]0.11,Chapmr 9.12,and tae Health and Safely
Gxle.Section 25532(a)J HEATING UNIT(OVER H h.mus)BTU)
❑Vex DNn PAID
VENTILATIONIA (SINGLE RESID)
Willow applicant or future building occupant use equipment or Devices which Date ceipl#
mil hamnfous air mnmminunk.a,defined by the Bay Amo Air Quality Management BOILER-COMP(RIP OR 100,000[11 U)
DinderITOTAL:
❑Ye, F1No BOILER-COMP(OVER 100.000 BTU)
111
I have real the bavvdons trurtdals t,uI&,Chapter 695 of thc Cal i- AIR CONDHONER
rc,25533 n ISSUANCE DA•I'E
bumiugdoesn Sukty1xlc.eamSeelso,.255(15.2553)and 8500.1 undcrstwd thiniftM1e NEW RFSIDPN'I'IALSUCH. SQ.FT
oftheng Jlcsnsid,et mentlywhich have be 1Finatiti,myce,aaof.,Cediymnotifythupam,m
of the reyuiremem,which mon Ix mat prior m'nsmnce of a Cenifrcum of Qcupancy.
Owners authnriu agent Date TOTAL: ISSUED 0Y:
OFFICE