S 1708 APPLICANTTO FILL IN INFORMATION WITHIN REO LINE USE BALL POINT PEN ONLY
CITY OF CUPERTINO i BUILDING-ELECTRICAL 1'1;81TND
BUILDING DIVISION APPLICATION/I'IdRMIT ` PLUMBING-MIlCunNICAL J 170
BUILDING puoiF.CT unissl IPLCATION
I3U I LDING ADDRESS,. SANITARY NO, APPLICATION SUBMITTALDATE
[4 C"14.3
\ OWNF. 'NAME': I'410N.: /�tA
NT CIOR'S NnMfr LIC NO:
�r _ RIC CONI Ko l.9
�i ARCHITECT/IENOINF.ER: ,LIC NO DRIISS:
CONTACT: PeDNe: - - BUILDING WITINFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELFCT PLUMB MF.CJi
W LfV 1
LICENSED CONTRACTOR'S DECLARATION QTY. ELIiCTRIC PERMIT FEB
1 te7.ny ah..a hal I nm hem,cal under provisions of Cha m,v hmmneneing JOB DESCRIPTION
mQL
With Section 7000)of 3 of the hinders,mal Prolusions Gxle,andmy license is RESIDENTIAL:
u100 w - PERMIT ISSUANCE
I,Ly in full torcc�J 'e' 3 ❑SPDWh ❑KITCHEN REMODEL
QUV LleenseC acv Lit. APPLIANCES-RESIDENTIAL []ADDITION LJ PLUMBING RE-PIPE
Z ale Contractor
ARCIIDECPS DEC RAIION [I MULTI-UNIT Ll STRUCTURAL
b,p IA PANELS MODIFICATION
Z O n I understand my plans shall be troll.as publi...cords
O kG„OOil'IU2lN)AMPS ❑IN'TIERIOR ❑CHIMNEY REPAIR
W.4 Licensed Prol'm,irnal 201-INXIAMPS IMPROVEMENT E]SWIMMINCi POOLS
C C Q I herch ffirm Oath ant nemln Bonn he CLDER 1omlmnces License Law for he OVER lots)AMPS ❑BATH REMODELIREPA1R ❑ MOLITION
EX:31a F following recon.(Section] Business and Pmfessim,Code:Any city or rummy SIGNS ELFQ ICAL ❑OTHER
F.LL,O to which requires a mennit m consensu wvH uhec improve,Jnnnlish,or repair structureany steture
pried t tt allopestl pplr If vchi tt fl .g Jsmtenent SPECIAL CINCUI'I'/MISC.
CluPle,
Ila,tract S dISrnl I]IXXoolI 3ianon vier mIPouv, �C Inlm I'HMP METER OR POLE INET,
u�Ia� COMMERCIAL '
2y o yOm Thal he s c uc an therefrom and the ba' t th II gcvl cl pl Anyviolation of ❑NEW BLDG/ADDI'DON ❑DEMOLITION
xmN Section 7031.5 by any.11filem for u peeaasuhleels he appiicuouoo civil penvhy of POWER DEVICES ❑TIENANT ❑FOOD S17RVICE
¢] t e than Me hundred!delta,LS5IMPROVEMENT
gy=p ❑ more
owner of he progeny,rr mY anFloyecs wish wvgas as heir.xdemmpensaioq SWIMMING POOL.ELE [I OTHER
1- will do he work,and he hwcmm is not intended.....Bend!sele(See 7044,Bmineao
and Professions Ctnle:The Conloverms License Low dew not apply it,all owner of OU'1'1.ps-SWI'ICUtisFI T
properly wI bunds rr improve,(III and who docs suet,wed hleuelror Ihrongh
his awn employres,provided that such improvements arc not intended nr altered for NEW RESIDENTIAL I!LEC'IR
sale.14 however,the building nrintpm
mvecm is will within one ymr of nsmplclion,the SQ.FI.FLOOR ARRA EISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for Purkz
-
pose of sale.).
❑1,as owner of he Formerly,ton esclnsively connecting with licensed conlruclnrs to I'0
construct he pr ject(Sec 7044,Business and Profession,Code:)The Cnmrucmr's Li-
meLaw dewnotapply to mo um It properny who hands m improvcv fervid,and Q'I'Y. - PLUMBING PERMIT P.
who coronets for such projm,with a cnnlmctorls)liwnsed pursuant o theCo lm ors
License Law. 1117RMIT ISSUANCE!
❑lam esempt under Sec. - .B&PC for this..mon
ALTER-DRAIN&VENT-WATER(LAI VALUATION
Owner Dare
WORKER'S COM PENSATION DECLA RATION RACK FLOW PRA17C'I'.DEVICE a.IFa, �
1 hereby dR..It under anallyal wUncy erne u1'hu f dlmving d.abusnians-
❑Ihvve vnA will moinminvCenilicmm�fGmseman,cif-imurefor WnrAcr'oCnnnpen- DRAINS-RLOR.ROOF,AREACON STORIES TYPE CONS'IRUCI'[ON
moon,as provided rot by Section 3701 of he Labor Code,for the performance.Rbc
work for which his permit is issued. FIXTURES-PER TRAP
❑1 have trod will maintain Workels Compensation Insurance,as required by Section
3700.0 the Tribal Code.for he merfonnnnreof he walk for which thisperoul is issued. GAS-EA.SYSI FM-I INC.4 OUTI,ITfS f1C Rfjlll' AI'N
My Wmker' Cm pen atirn Ins d Policy nun Mr arc: q' /{
Caricr Pnllcy No.',��� y � GAS-13A.SYS'B!M-OVER4dA) / p
CIiR PTION FROM WORKERS' GkBASFIINDGSTRI.WASTE INTERCEPTOR COMP17NSAI'[ON INSURANCE .111 G DIVISION FEES
(Thisecaion need not be completed How pemht is for one hundred dough,is 100) GREASETRAP -
nrlcss.) ?.,)N IIECK FEE
Trinity that in the perliamence ofhe work for which this man is towed,i shall SEWER-SANITARY-S'IORM IEA.NXI ET,
not employ any person in any rammer to as to become subject to he Workers'Compen- ENERGY F rr'
0z cation Lawsal Cnitllorma.Dom WATER IHAI HN W/VEN T dzI.ECI'R
.Applicant GRADING PEE
y NOTICE.TO APPLICANT:If,after making this Cenilicae of Exemption,you should WATER SYSTIEMlrREA'rING MwI S FIEF!
a ? become subject in the Wodels Compensation previsions of the Labor Coi you must
W arthwih comply with such provisions or this Permit shall be deemed tevrked. WATER SERVICE
Q
z CONSTRUCHON LF.NDTNGAGIENCY NIEWRESIDENIHALPI.MR. SQ FT. PAID Date
L) 0 Iharhyallorm.nhem Ila eonvtmenlon lending agency mnbe lwrl'nrnnnccof #
f~•t he work for which his penne is issued(Sec.3097,Clv.C.)
Linde(,Name TOTAL:
0 V Ixnde/a AAJres.v TOTAL:
'�"' y y 1 cerh that 1 have read this application had state that the above information is BUILDING P'
F r7n correct.)agree no comply with all city and county nomads s and state laws redaling to QTY. M13CI IANICAL PE`RMI'I' FEE
U G hrilding cun.umctlo I,and hereby authorize remresenmtivev orchis oily m thom.pnn he SIEISMICFEE
,hove-mei uaucA an"Ay for in,Fecdon purposes. PERMIT ISSUANCIi
(We)ugrce mav
se,iademnily and keep hmndcss the City.1'Cnpenino ugudml RhIiC'I'ItIC FEE
linbllities.judgmcros,cos,and apenses whicM1 may in any way accme against sail City ALTER ORAUO'IO MECfI.
in ocqucnce ofhe granting of his permit I'LIIMIIING FF.
m
APPLICANT'UNDERSTANDS AND WILL COMPLY WI FIT ALL NON.POTNT AIR HANDLING UNIT(TO III,IXXICPM)
MECfIANICAI.FEF.
SOURCE REGULATIONS.'
ism'"9
Dani!
AIIt HANDLING (W/DU VGR IB,INNt CPM) CONSTRUCTION TAX
Slgnalurc of AmmlicaHAZARD Dom I!XIIAUST HIVID(W/DUCT) HOUSING MITIGATION PE
HAZARDOUS MATERIALS DISCLOSURE
WillbytePCapertonMunibuildingee Cha no12,andhanthe
Hinhhund Safety
IIIEATINC UNIT(T(I IIXI,LXp IITID
c de,Sed Section
the 32(a)?no Municipal Cade,Chapter 9.12,anA the Health nnJ Safety
Code,Seninn 25532(2)] HEATING UNIT(OVER 100,000 BTU) it
E]Yes 0N VI!NTILAlIONIFAN(SI NOTE RIES I II) PAIL)
. _ Dom Iicccipt#
Wilfuldows air contaminants
or future building by the nt tiny
cea Air Qulo. Mara Which BOILER-COMPOHPOR 100,01X)B"I'LL)
emir haaaNnu.v air conmminanls as def red by the Itay Area Ali Quality Management TOTAL.
District? BOILER-COMP(OVER 100,000II11))
El YIN C]No
I have read the hvunlou,munejhls rapnitchwit,l de,Chapter 6.95 of the Culb AIR CONDITIONER ISSUANCE DATE
f mi.Health&Safety Code,Sern; 25505,25533 r, 125534.1 understand Lha 11'he NIEW RESIDEN'HA%MECIL SQ.Irl'.
htildingdoes not currently have a lenull.lung Il by resp'nsibilky m inufy dmoevpaat
of h wpm: en,which mon be ton Ddm m imuance of u Cenific of xuryn Y
r err cut nriz d,gem TOTAL: ISSUED BY:
OFFICE