99110157ADI CANT TO EDI IN INFORMATIDN WITHIN RED LINES -USE BALL POINT PEN ONLY G G ( 1 01s°l /
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CITY OF CUPERTIN0 BUILDING . ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
INILUING i'RD,IELT IDF.M'IFICA'i'ION'
PHRMIT N
S0001 Agiffiniow
BUILDING ADDER
5 will 7-E L- F CumQrili
-
SANITARY NO,
APPLICATION SUBMITTAL DA'II
OW,SNERp'S NAMIP PI{ONE:
YY
CONTI AC,TOR:ti NHAMH: LIC NO:
Q„
`t C. i�
NIC
❑
CONTROL
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ARCHITECT/E'NGJNEER: LICNO
Svc WNI>� Ae�u/T�a% C2'38/
ADDRESS/.+
ii Dr,sioU C.Ar168L C� 9sva
coNTA(T: PRONE:
BUILDING PERMIT INFO
G Sia 527e9f',6
❑ Consultant Fees Paid by Applicant (Initial)
IB[.DG ELECT PLUMB, MUT
2 � ❑ E:1'
LICHNSEU CONTRACTOR'S DECLARATION
hereby uRmt mm Into Boer" l under insfslom of Chirpier 9 (wmmm,c6tg
QTY, F;LECTRIC PERMIT . 17FE
I -
JOB DESCRIPTION
1'IiRM1T ISSUANCE
with Scnion 9(NX))nb DivisionJof the liusincss 3Profev.ittns Cale.gnd mrliccnse ix
in full force and effect. I/Dp_�6I,JJ i1.
License Clens Lie _/
Dam 6mntucror
RESIDENTIAL,
❑SPDWL ❑ KITCHIiN REMODEL
❑ADDITION D PLUMBING RE PIPE
GMULTI-ONIT 0STRUCIORAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT GSWIMMING POOLS
APPLIANCES—RESIDENTIAL.
ARCHITECTS DECLA ATION
1 understand my plans shall he used as public recoNs
PANELS
UP'1'02N)AMPS
Licensed Prifessi no
201-10MAMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Ccntruclbr's License Law for the
following mason. (Section 91131.5, Business and Professions Code: Any city or county
D BATH REMODEURF.PAIR []DEMOLITION
-
[]OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
which requires a permit to constrict, altar, improve, demolish or repair any structure
SPECIAL CIRCULI'/h1ISC.
prior to its issuance, also requires the applicant for such ltermitto file a signed stmemem
that he is licensed pursuant to rhe provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
,but he is exempt therefrom and the lusis for the alleged exemption. Any violation of
TEMP. hI IDER OR POLE INST.
;W Of NOR ❑ DEMOLITION
Section 7131.5 by any uppllcaul for a permit subjects the aplilh onl are civil p:oully of
POWER DEVICES
NT ❑ FOOD SERVICE
not more than five hundred dollars (ills)).
D1, es owner of the properly, nr mycmployees with rages tstheir solecmmierationo,
will do the work, and the, structure is not intended oreffered for sole (See. 7044, Business
1X11'ROVEMENT
❑ OTHF,R
SWIMMING POOL ELECTRIC
unit Pmfcssions Gene: The Contractor's License Law does not apply m an owner of
OUTLETS— SWITCHES —FIXI URBS
NEW RESIDENTIAL ELF.CTR SQ FT.
,rips., who builds or improves t covar and who does such work himself or through
pis own employees, provided Nat such improvements are not imended munched! for
atde.If, hewcom the mildingor improvement issold within one yeornlcomplotinn, rhe
SQ PP, FLOOR AREA
$1 1,1
mer -builder will have Ne burden of proving that he did not build or improve for pur-
pwofsole.).
I, as owner of the civility, .,a esdusively cnngnctimg with licensed smal ors I.
-
- TOTAL,:
instruct the projcO (Sea. 7844, Business and Professions Code) Tim Comrunmr's
seLaw does not apply toanowner ofprogeny who buildsorimproves Neme,and
QTY PLUMBING PERMIT FEE
who commicliforsuch pmjenxwith a comractmcs) licensed pursuant m lne Commetors
PERMIT ISSUANCE
License Law.
D I am esempt on B&P C myth's an's
'
l,..
Do (11ZAN
Owner n^o^
RKER'S COMPE SATION DECLARATION�� T /
ALTER —DItA1N&VENT —WATER IFA)
VALUATION
D 0
[JACK FLOW PROTECT. DEVICE
I hcrehyel Neimserwingdereer'los:
-
maimmiderpenulryancof onsneof
❑Ihoveunovidedoi byeCcnifeue of Comm�noCode,lsurde Worker's Cmmpen-
sntloo, ns provided 1'or by Section 3700 of the L.hnr Code, for Na performance of the
work for which this pennon is issued. '
DRAINS—FLOOR. RDORARf!A, CON[)
STQRp?
TYPE, CONSTRUCTION
-
FIXTURES—PER TRAP
D I forward will maintain Worker's Compensation Insurance, as required by Section
3700 of [lie Libor Cade, for the performance of We work for which this permit is Issued.
'
OCC. GROUP -
APN
GAS-1!A,SYSTEM-IINC.40UTLETS
My Wort 'x Crnnpc YQn lou ricers nand Policyntmher erc:
Cartier. �Policy Nu: �T
/� /1'/
✓16�VL�/
GASB— EA. SYST'EM-OVER 4(EA)
GREASOINDUSTRI, WASTE INTERCEPTOR
C . I' rl > F S I: PfION rROMMMIZEAiRS
COMPENSA'I'IONINSIIRANCC
BUILDING DIVISION FEES
(ILissectionneed not heeompleed ifthe p:mtit is become hundreddollars(SIM)
or less) -
GREASE TRAP
_
PLANCHECK FEE
SEWER — SANITARY —STORM f:A. 200 IT
I certify nation the scuhnmanceof Ne work tier which this permit is issued, I shall
e subject e Workers Cheaper -
not employ any person in any manner so as to becomm N
WATER I [EATER WNENTA LECI'R
-
ADIN �,-L>ts. 1
senna Laws of California. Date
Applinmt l
NOTICE TO APPLICANT: If, after making Nis Cenifi.l. of Ewmagmm you should
inion
become subject no flue Worker's Compensation previsions of the Luton Code, you must
WATER SYSTEM/IREATING
ILS FEE
_
WATER SERVICE
Rmnwidt comply with such provisions nr this permit shall he deemed resulted.
NOV2. 1Na,^NN
V
NEN' RESIDENTIAL PLMB. SQ. FCEtPAID
CONS'TRUCf1pN LENDING AGENCY
I herchyamrmthnnhem is a evormiction lending agencyfonhe perfnmmnceuf
yyS�
Dote Receipt If
TOTALc
line work in which this permit is issued (Sce. 3099, Civ. C.)
Lender's Name _
TOTAL:
Lenders Address
information is
ILDIN ..
-
I emay that I have read Nis application rand state Nut the above
necnlagree tocomply with all city and county ordinances and state Iowa clatingto
buildingconstruction, and hereby autharire reptesenmtives of this tiny no enter upon the
QTY MECHANICAL PERMIT I7HE
SEISMIC FEE
PIiNMIT ISSUANCE
ELEC'IR IC FEL:
.hove -mentioned pmpeny far inspection purposes.
(We) agree m save, indemnity and keep harmless the City .1 Cnpmino agmnst
A ULER OR ADD TO MECH.
PLUMBING FL•ii
Nhilitimx,judgmene, costs and expelass which may In any way sccom against said City
in consequence of the granting of this Permit.
'Al It IIANDLI NO UN I'1'(TO 11.0111 C17M)
MECHANICAL FL6
APPLICANTUNDERSTANDS ND VILL COMPLY WITH ALL NON -POINT
SOURCE REGU S.
/�N
AIR HANDLING UNIT (OVER IB,000 CPM)
CONSTRUCTION TAX
+ L+'
Signature of Appluant/Cenwmor Utaa�T�
HAZARDOUS MATERIALS DISCLOSURE
BXIIAUSTHOOD I WIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT TO 100,000 B' TU)
Will the apnilunto,future building mcupnm stmen, handle hanuhms material
us de(Inad by the Cupeninn Municipal Cade, Chapter 9.12, and the Ile.lm.1111 Safety
Ctuh, Section 2553200/I ♦
HEAHNG UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESIDI
❑Ycs K.
PAID "—
Dere Receip N
. BOILER— COME UIHP OR. 100.010 BTU)
Will the applicant or future building occupant unit equipment or devices which
emit hamnluux air terminal as defined by the Day Arca Air Quality Management
Dion'tR 1 _
D Yes No
IOTA TZN
BOILER— COMP (OVER 100,0)!1 BTU)
AIR CONDTI'IONER
Ihwh readthe h edc. Slmateriel.5,30.1menss under Chapter 6.95 of the Call-
fomin p Health & S.fcty Cy a Section. ..115, SJl and 45534. I undcrqund that i(Nc
hull lding.)res no u ly have he tNm'ts my rcsponsihility to bmf encu t
ISSUANCE QDATE
Q r
NEW RESIIJL*NTIAI. MECH. S PI'.
Q
of there int rife Ccnifcalc Of npanc
`
� 1
ISSUED BY:
TOTAL
Ow boors.) .gen - Dam
OFFICE