S 1757 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD
ING-EI.ECTRICAI. PER�7ITN0. 17r� �
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. \V kVA
NUILDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1101(0 L�nalw Vis Dr:uc C �R"°� C� 9Soly (:341
DW .R'S NA E: r� K1 PHONE,: c p C��C^h1����'RAC'IORS NAMMH. LIC NO:
/sIG E�12A<<11+ L74� Z - S-D 780 r/'4✓k NIC Ise ARCHITCGp/ENCt1NEER: LIC NO, A )RESSS: I ❑ �\D t.)I
CONTACT: F PHONE: 1 h V dUILUIN`O PERMIT INFO✓
A•,IC. F4 i9 4%- 04 I2 ❑ Consul ntFeesPaidbyApplicant(Initial) PIRG ELECT PLUMB MF.CH
LICENS.E.D/CONTRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE �}L�\o- ��—yF•'
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OaZ with Section7mo)ofDivivinn3 of the Nosiness vnA Professions Code.and my llmnse is RESIDENTIAL'
W 00 p� PERMIT ISSUANCE
in lull force and effect � ♦ ! // 3t7 ❑SI'DWL ❑KITCHEN REMODEL
�UU 1.icenSe Class Ism# ..0 7 Y' APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMPING HE PIPE
F-ZW !)an
ammeter rn6d R III 'ECI'S UECLAR [I MULTI-UNIT ❑STRUCTURAL.
F y Z 1 undcrsnnd my pinnn shall he used as Puts d PANEI S MODIFICATION
Z O m„� Pu re rcart s up TO 2,o AMPS OZ�� M ❑IMPROVk ❑CHIMNEY RIiI'OL
Licensed Professional 201-BXIf1AMP5 IMPROVEMENT � WINNING W)OIS
sX OWNER-BUILDER DECLARATION OVER I"AMPS ❑HAT'H REMODEIIREPAIR MOLITION
Xy Ci
W
1 hereby affirm men am exempt from the Convector's License law for the ❑OTHER
O O U following reason.(Section 7131.5,Business and Professions Cale:Any chy nr county SIGNS ELECTRICAL
W 3 O y which requireits a Permm eonsuhm,alter,improve,demolish.m repair any emucere
HartI prior to its issuance,also requires the applicant for such Pemtiuo file a signed statement SPECIAL CIRCUIT/MISC.
than he is licensed pursuant to the provisions of the Contractors license law
lChupmr 9
id0 (commenei ng with Section 70(KEofDivkion 3ol the Bminessand Professions Code)orTEMP.METER OR`9";INST. COMMERCIAL'
a a e z that he is exanpl Nercfrom and the basis for the alleged exemption.Any violmlon of ❑NEW BLDG/ADDITION ❑DEMOLITION
ke Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DE ❑TENANT ❑FOOD SERVICE
Fq. or
t me than five hundred dollars($51X1). IMPROVEMENT
M
2 LJI,asownar of the po"ca"or at,nnployeev with wages us their sole compensation, SWIMMING ECI'RIC
yyi�p.,ro will do the wmCmel themnicturc is no itermledoroffered for late(SxJ044.Business El OTHER
u13 and Professions Coca Me Commences License law does am apply m an owner of OUTLETS-SWITCH 1IXTURF_S
property who builds or improves thereon,and who does such work himself.. through
his own employees,pnwlded that such Improvenietns are not Intended or oll'ered for NEW RESIDENTIAL on, BLEC!' FI'.
sale.If,however,the mucur improvement issdd withinore ycarof'o'b'Ietithe SQ.FI'.FLOOR AREA $/SQ.FP.
owner builder will have the burden of proving that be did not build or improve for pur-
Easee° TOTAL /^�
1 u Downer of the property,am esclmivaly contracting with licensed contractors ut W 410
consume,the p..ject(See 70H4.Business sad Professions Cudca The Comment's I., -/ro-
c e law docs not apply to an owner of property who builds or improves manna,and QTY PLUMBING PERMIT FEE /1! y
who contracts for such projects with a commands)licensed Persian.the Commemes /II/(
License Law. PERMIT ISSUANCE
I am exit; ler Sec. _,B&P C hada,reason VH 'q>C7
O nor / D, ALTER—DRAIN M VENT-WATER(1iA) '-r VALUATION
WORKER'S COMPF. DATION DECLARATION BACK FLOW PROTECT.DEVICE
Thereby affirm under penahy ol�alury one of the following declumtians:
❑ I have and will maintain a Certilicam of Comenuo self-insure for Worker's Cmopco- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONST RUCTION
onion,as provided for by Section 370)of,he labor Code.for the parformmexce of,he
wmk for which this Kate,is issued. FIXTURES-PER TRAP
1 have find will maintain Workers Compensation Insurance.as required by Section
3700tiftheTimor Code.mine continuance of the work for which this peruniv,issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carnam Policy Ne.: GAS-F.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE,INTERCEPTOR
COMPfiNSAI'ION INSURANCELDIN NVISION pit IS _
or Ica")
(This.secom nodn t be completed if the pernll is for I'LANCHECK i
one hundred dallars($1(XB GREASETRAP - -
I certify that in the performance of the work for which this permit is issued,l shall SEWER-SAN ITARY-Sl'ORM EA.200 Ft.
no,employ any person In any manner so as 6t Income subject o the Workers'Cormano ENERGI
Z cation Laws of California.Date WATEk HEA'1'IiR WNIiNT/F.hECEN CNA
70 O Applies. T!C
q NOTICE TO APPLICANT:If,after making this Cenifir m of Exemption,you should WATER SYSTEM/TREATING k�FEE $
� became subject.the Workers Compensation Provisions ofthe Labor Cole,you mustforthwith comply with such anvisions or this period shall be deemed revoked. WRIER SERVICEz CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.PC I hereby affmtled there is.commeunt lendingagency for the performance ofweiprMma work tor which this peri,is issuel(Sec.3197,Civ.C.) TO'I'AI:Lenders Namelender'sAddress TOTAL,I cenify that 1 have madthis application find smmmauhe above inbnmationis I°(4 correct,1 agree to comply with all city and county ordinances and stem laws relating to QTY, MECHANICAL PERMIT FEEbuilding conswetion,and hereby nnhorize opresematives of tio city.enter a,.,beabove-mentioned property for inspection purposes. PERMIT ISSUANCEliabilities,judgments,costs and expenses which nary in any way accuse against mid City AITERORADDTOMECH.
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10,M)CI'M) MECHANICAL FEL
SOURCE REO r.AT10NS. 92
�'. AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TA
Signamrc ApplicandC7mtracmr to EXHAUST HOOD(W/DUCT) HOUSING MITIGATION !E
HAZARDOUS MATERIALS DISCLOSURE
WiR ate...lwout mrfuture lambing occupant smmnr handle btzuNous material HEATING UNIT(TO 100.008 BTU)
e0ned by the Cupcninn Muaiuipal Code,Chapter 9.12,and the Health and Safety
1Me,Section 25532(.)7 HEAT UNIT(OVER I,NI,BIXI li'IU)
❑Yes ❑Nn PAID
VIiNTILATION FAN(SINGLF.RGSID) "—DataR�eipttt Will the applicant,,,there haddingnce.....use cquipmer,or devices whichyO1LBR-COMP(3HP OR IIXI,INXI H'TUlemit haun tum,air ccolmoinants as defined be,the Bay Area Air Quality Management
Districtl BOILER-COMPIOVER 100,O0(i
❑Yes 0N
11...road the hazardous mnerialo raptircnseas tuck,Chapter 6.95 of the Cali- AIR CONTI'IIONER ISSUANCE DATE
fomin Health @ Safety Cade Sections 25505,25513 and 25534.1 undemund that if the NEW RESIDENTIAL MECH. SQ.FI'.
building docs me currently have a tenant,that it is my responsibility to nmify the oecupant
of the requirements which must b,mart poor to issuance of a Canham of(kcupawy.
Owner or auuhodem agent Date TOTAL: ISSUED B5':
OFFICE