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APPI If ANT Tn FI I IN INPnBMATInN WITHIN BED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - ELECT RICA],
BUILDING DIVISION APPLICA'NONAERMIT PLUMBING-MECHANICALJ
BUILDING PRO.i icr iDENaTFICArwN
PESITNO. J 240
1
BUILDING ADDRESS
SANITARY NO.
APPLICATION SU IiMITTAL DA' 1E
OWNER'S AME: I PHONE:
CO '1'RAC�1 'S NAM 3: r LIC NO:
cdNS' _ a ..
N/C
CDNTRQ1.k
AR 1 '1E /F.NOINEER: LICNO:
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CONTACT: uoNe:
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BUILDING PERMIT INFO
��
GAR by � to s — 1 518
❑ Cnnsullant Fees Pahl by Applicant (Initial)
RO F.LO El MOH
LICENSED CONTRACTOR'S DECLARXrlON
I hereby affirm that 1 am licensed under provisions n1 Chapter 9 (commencing
QTY ELECTRIC PERA11'I' FEF.
JOB DESCRIPTION
FERMI'r ISSUANCE - -
with Seninn]qgp ofOivisionJuf the Business and Professions Ctde, anA my licenw in
in full forceand ellen.
RESIDENTIAL;
❑ SFDWL ❑ KITCHEN REMODEL.
APPLIANCES - RESIDENTIAL
License CI u Le 0 L
Oale Co Initua
❑ADDITION ❑PLUMBING RE -PIPE
Ll MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
HITECGSDECLA'fION
iOt AI
I undenmmi my plans shall be used as puhiic rccnWs
PANELS
UP TO 200 AMPS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm to., I am esene, horrific Ceramic is Liceme Law for the
following mason. Section 7031.5. Business and Professiom Codc Any city or county
LlBATH REMODEUREPAIR ❑DEMOLITION
El OTHER
OVER IINOAMPS
SIGNS ELECTRICAL
which requires a Permit to commict, nlmt, improve, demolish or repair any swemrc
SPECIAL CIRCUIT/MISC.
priorm its issuance. also requires the applicant(orsuch p mmiuo file asigned statement
that he is licensed pursuant to the provisions of the Contractor's License Low (Chapter 4
(commencing with Stationer 7000) ofDivision 3 ofthe Business and Profession. Code) or
Nm he is exempt therefrom and the basin for Ne alleged exemption. Any violation of
'rEM, MITER OR POLI! INST.COMMFRCIAL
-
���
[I NEW BLDG/ADDITION DEMOLITION
Sectinn]031.5 byanyapplicam forapermil subjects theopplieam nracivil pcmeltyof
POWER DEVICES
UT ANT FOOD SERVICE
not more than five hundred dollars (SSW).
❑ Las rwner of the prnpeny, or my employees with wngesm their sole mmp[mmiom
will do the work.and the tructum is not intended Incanted lir sale (See 7044. Businns
MOVEMENT
OTHER
SWIMMING POOL, ELECTRIC
and Professions Calc: The Comeacmrs License Law does not apply III an —net of
DO I Llrl S - SWITCHES - Iq%TURPS
NEW RESIDENTIAL T:LECfR SQ F -E-
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended lar offered fill
sale. IL however the building or impmvencm is sold within one year of cmnpleiomtho
SQ. FT. FLOOR AREA
EISA. FT.
owner -builder will have the burden of proving that he did not build or improve for fam,
TOTAL:
pose of sada).
❑ 1, owner of the cnmmning with licensed i.
u Sec. 70y. , BusinessCounselors
Professions Calr impro Conoauvs nd
answer the es jet (Sec. "/W4, Business property
cemelawdtxnnaapplyman ywhosedPrs improves thereon. and
QTY. PLUMBING PERMIT FEE
who cnmmn5 for such projects with u camrvcmHs) licensed pursuant to the Contmcuv's
ithaonfirs
PERMIT ISSUANCE
License Law.
'
❑ I am exempt under Sec. . B & P C for this maxim
Owner Dale
ALTER -DRAIN & VIiNT- WATER CA)
VALUATION
BACK PLOW PROTECT. DEVICE
WORKERS COMPENSATION DI:CetolloION
I hand wal sunder really of
at Coneneofthelnllowior W okef'iom:
Ej Ihnve and will mainwinu Cedilic:nenf Consent to lin Wnrkcr's Compel'-
tylion, m provided lire by Section J]W of the Lulmr Ctale. l'ur the pennnnuna of the
work for which This pemrit is issued.
DHAINS- PLOOH, ROOM'. ARCA, GOND,
ST IF_S
'TYPN. CONSTRUCTION
PI%'IUNIIS-HR'IRAI'
I have and will maintain Worker's Cmnpensadon Insnranca as required by Scetiun
3700orihc Labor Code, fnnhe performance oflhe work for which this pennil is issued.
GAS - HA, SysHim-I INC.4 OUTLETS
OCCGROUP -
APN
My Wm- a r e a�dr Insurance carrier trod Parer�11=lher atto _��-,s�•,�
Carrier NVt Polley Nn..".�{y
tIAS- PA. SYS'ICMOVER 41P.A)
OR EASEUIN 'US "TRI. WAS 117 INTERCEPTOR
CERTIFICATE OF IXEMPI'ION )ROM Wf RKEI s'
. COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Thissectianneednol annplemd litho pomnil ix lar one hundmldulbm (EIWI
lar least
CREASE TRAM' '
PLANCHECK FEE
Icalifythalint , onnunu of thu wad for which Ibis pcnnh is issued, Lvhull
not employ anypereo h r nurnneren m'mhucor •rb'..rm the W..kcrx' Cnrnlw•n-
SI?WER-SANT"I'AItV-S'IONM HA. 200IN.
-
ENERGY HE '
WATER 1WA'1'UK WNENTVLE"C'E'IR
GRADING_ PEE
radon Law.cof I
Appliama -
NOTICE'I PII t aEA C r 1plr IY shall
hcnsneambica h, Rbc Wink. a L r p al p I he I It C ta,ynonotel
WAI HR SYS'I LM(PRINTING -
-
SOILS FEE
ndhwnh comply with Inch provisions orhis flannel 'hull be icannad revokci.
WAI ER SHItVICH t
CONS] RUCI ION LENDING AGENCY
I hereby aflrnrht themnammauuioo lending agency to, the perfnn.tw of
NEWRESIDLNHALPI,M9, SQ FF.
PAID
Dale 2eccipl11 M
Mho work for which lhiv pnnnit is issued (Sec. 3097. Civ. C.)
Lando', Nan a
TOTAL
TOTAL:
-
Lender's Address
is
BUILDING FEE
1 certify that I have read this application and mac that the above inlinmatinn
- -
Greer I agree to comply with all city rod county on imunces rod same laws relating m
buildingwallerian,and hereby am[ rimrcprme.nati yesoI Thiscity m enmr.upon the
QTY. MECHANICAL PERMIT - FEE
SEISMIC FEE
PERMITISSUANCE
ELECTRIC FEE
shove "mentioned property for inspection purposes.
(Wil) green, save. Intic in y and keep humdess the City ml Cupeninn agalml
ALI ER OR ADD To MECH.
PLUMBING FEE
Imbilitiesjudgments, costs and expenses which may in any way iecnm against said City
in comcyucnce of the Granting of This Pvolit.
AIR HANDLING ON] F(TO I0,000 CFM)
ME H LAICAL FEE
APPLICANT UNDERSTANDS AND Will. COMPLY WITH ALL NON-POIN'1'
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10.00 CFM)
C STRUCDON TAX
Signammol'Applicam/Commcmr Dale
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future buildingmcupant store or handle h:minhusmmerial
EXHAUSI'000D(W/DUCT)
H 5 I IGATION HE
I IRA]'ING UNIT(TO 1(X),1100 B TUI Q
as defined by the Cuper iso Municipal Code, Chanter 9.12. land the Health and SafetyI
Cala Section 25532(«)7
t Lt I
IIiA'rING UNIT (OVER afl.(N0 RTU)
VIINI'I.ATION FANS I NGLE RESID)
-
❑Yes ❑No
PAID
Dae Receipta
ROLLER - COMP (31 IF OR If0.g0 R1V)
Will the applicant or future building occupant use equipment or devices which
emit fi.odous air contaminants as defined by the Bay Area Air Quality Management
T
- COME(OVER IWxW0 BTU)
Distrix?
[3y. FIN.BOILER
AIR CONDITIONER
h ms 255 5, 2553ants under Chupmr G93 of the if the
1 have read the h ode. Sachems that if the
foredo gHealthdoes & Safety Cafe. Sections 255(15, 25533 and 25534.1 umlrnly the
building nismyresptmsCenifimsonify Ibemanpmt
building dmsurncurmndyhave a¢nam,
ISSUA^NCqAT-E,
~/ 2 -Oft('
NEW RESIDENTIAL MECH. SQ. IT.
or
of the reyuircmenm which must be met pdormissumcc ala Cenificae ill (kcupanmy.
ISSUEDBY:
TOTAL:
Owneroramhorized egem - Doe
OFFICE