99090181 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. 1':RMTN
BUILDINC DIVISION APIaLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION slamm
SANITARY N(l. AVVLICATION SIIBMf?` DAT
OWNER' A /X/�/• HONE: CONTRACI'OH'Sf'�p1F� LIC NO. 9 L L I(/^r/
NIC CONTROL p
RCHITECUENGINF:ER: LIC NO. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) DL ELECT PLUMB MECH
❑ ❑
LICENSED COi RACf0RS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm the 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
G0Z with Section]0(1Division 3 of the Businessland l'ndessionc Cde.uod my limns is RESIDEN'PIAL:
'00 PERMIT ISSUANCE
= 1- in full facetted effect. O$FDWI, E)KITCHEN REMODEL
F,VF License Class Lic.x gYPL1ANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z w Dae Cantucv+r
ARCHIITCI'S DECLARATION 0MULD-UNIT ❑STRUCTURAL
F N 7 1 undersand my plans shall he used as public¢ants PANELS MODIFICATION
ZOO-M UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
F .Foy Licensed Professional 201-IWBAMPS IMPROVEMENT [3 SWIMMING POROUS
a, F� OWNER-BUILDER DECLARATION
¢•�
OVER["AMPS O BATH REMODEUREPAIR [:1 DEMOLITION
XC a I fiereby offinn thin I mm exempt from he Connector's License Law for the �]�yJ{OTHER p! �(t -
3 a following reason Section]1131.5.Business and I`rolcsinm Codi Any city or amnuY SIGNS ELECTRICAL .y 4^I A9 /ILl ! p 1
WLLQy which yi pe,.it to t i It r J r,b p y.t rare e�f l'!/ C !C
to et priors t l cyu c tic IPI' If hper It fl 'g Jstatement SPECIAL CIRCUIT/MISC. L
W '�
that he licensed P t t theI f the Contractor's L 1 (Chapter 9
7 COMMERCIAL'
cumnenvngwtectionXoP. . . & V'
d d e that he is exempt therefrom and me hasis for the alleged exemption.Any violation of O NEW BLDG/ADDITION O DEMOLITION
X^'+'• Seen 1703ISby mr,of,fi...I for a permitsubjccb fiw,flican too civil penaltyof POWER DEVICES
W^til not cmc than live hundred dallxrs($50f0. ❑TENANT ❑FOODSERVICE
F Z Y IMPROVEMENT
a Q I,us owner of Ne prupcny,mnny cn+pinyvc wit ergs ns thou ade compensatlon, SWIMMING POOL ELECTRIC
pT. willdo shear k,md tmmotelne ie nut inteodedorolRred l msalc l Sce o",lousiness L-1 OTHER
ail ee and Prnf"inn,Code:The Commemr'v License[.nw does not uIlly a+as owner of OUTLETS-SWITCHES-PIX'fURI'S
pnycrty who huildx o1 in tpn se,tb..—II nnd will)does such work hltmelfur through
his own employem',provided Ih:n 4ncM1 Itnpnrvenemn ore not Intended nr oil Lruf fur NEW RESIDENTIAL IiLEIa'H SQ
s:dc.If.hnwevuq the building or ln+pnrvuntvm le sold wllM1in one yeun+fmmplcninn,the SQ,17.IT.00R AREA SISQ.Ff.
`�e'�imiilder will base the harden of proving that he did rat build or Impmvc for par-
�.j1°J we')'r TOl'AI
Ly^ of the propcny,ant eselusively ca..loa ing with Iiw2aJ mntmew¢to `e
ran:Iron the Pmjat ISoc.]IWY,Nosiness unJ Iknfeaions Calc:)'1'hc Cnnracmr's L Y
cerse Law docs not apply it)an owner ofpropery who buildsor improves thereon,and QTY. PLUMBING PERMIT FEL? ,,��'�7X 1.1 L
who wmme¢fur,echp lets with a contractors)licensed Philmont to the COntra is (X-•1 O�w G
license Law. / PERMIT ISSUANCE ��JJ
❑ lam exempt an .B&PC fo_ihisr rM1
ALTER-DRAIN&VENT-WAT'EH LEA) VALUATION
Owner Dam
WORKERll COMPENSATION DECLARATION BACK FLOW PR(HECI'.DEVICE,
1 hereby affirm under Penalty of perjury one of the following declarations
I have and will maintain a Ceri&u¢of Consenuu self-insure for Workers Compcn- DRAINS-FLOOR,ROOF.AREA,COND. ST HIES TYPE CONSTRUCTION
fila,hs provided for by Seainn 3700 of the laMsr Coale,for the ner armance of the
work for which this permit in issued. FIXTURES-PER TRAP
O 1 have ad will maintain Worker's ComPenution Insurance,as require)by Section
37W of the later Code.for the performance of the work far whichthis permit is issued. GAS-EA.SYSTEM-I INC.S OUTLETS OCC,GROUP
My W'orker's Compensation Insurance earlier and Policy number am: -
Carrier: P i fast: GAS-EA.SYSTEM-OVER 4(EA) O
COMPENSATION INSURANCE GREASEINDUSTRL WAST
CERTIFICATE OP F.XEMITION MOM WORKERSE INTERCEITOR BUILDING DIVISION FIiIS
(This section neat not he completed irthe fiction is for one hundred dollars is 100) GREASETRAP
or tells)(This
I+EE
I certify that in the performance or the work for which this Permit is moved.Ismail SEWER-SANITARY-STORM EA,200 FT.
not emp[ey any Poona in any manner so as u+hcconte subject to due Werkcrs'Compel)- ENERGY FEE
0 Z cation Laws of California.Dare WATER HEATER WNENT/ELECfIL GRADING PEE
Z 2 Applicant
Lilly NOGCH TO APPLICAN'p IL after nuking this Certificate of Exemption.you should WATER SYSTEMTRGTING
hca+me abi me Worker's Compensation provione,a1 the Labaf Code,you must •. SOILS FEE
fonhwinh comply with such provisions or this permit shall be detailed revoked. WATER SERVICE {e•� \ II 1,,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. t)'\iPAID t
Ilmrehy affirm that then isa constmetian lending agency fnnhe Perfimmm�ce of L I Dae n Af1kJNtPt�1 I �
the work for which this Permit is local](Sea 3097.Civ.C.) 11 [ (d J v'1
D" U Lenderc
's bloom E TOTAL:
Leri Address TOTAL' �•I
'D'1 0.. 1 eanify thin 1 hove read this upPllc:uloo had lune that The above infonnaion is r BUILDING FEE
tFn h emi=m l ugmcm comply with all city and county mdiaatacs and roam laws mining to QTY. MECHANICAL PERMIT FEE
U Z building mnstrectiun,and herchy uuthnruc reposcnlntive— nhis city former,upon the f SEISMIC FIiE
above-rentiored papery 1111 inspersion purports. PERMIT ISSUANCE
(We)tutee or eve,In le iify and keep attitudes,the City of Ciottiagaina fIi1C 11HC
illbodoeo.' ems,sous and rXILcoses whicn nuty in hay way uccomaguiaa suit City ALTER OR ADD TOMECH.
PLUMBING 1'1:1:
1.muse a cI D !ITtingnl'CA Permit.
APPL 'A 'LINO TANUS AND WILT,COMP WITH ,1.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
ri_
SOUR' :G L R S. / /1� CONST UCAIONT
�✓LL// AIR HANDLING UNIT(OVER 10,00OCTM) C(INSTRUC'1'ION TA%
igwmrc til
HAZARDOUS
URE Dae EXHAUST/FOOD IW/DUCT) DOUSINGMITIGATION FEE
IIA%AHDOUS rbor,ece.S l,boroDISCLOhandl
Will the apPlicanl or lucre building oacupum score nr handle huruNous material HEATING UNIT(TO 100,00C)BTU)
as defined by the Cupcdino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)! HEATING UNIT(OVER 100.0i BTU)
O Yes (D No VENTILATION FAN(SINGLE RESID) PAID -
Uaa RttciptX
Will the air comm or filum building by the
use equipmQu nr devices which
a harmonious air cmutninanu as defined by the Hay Arca Air Quality hlanagcmem BOILER-COb/P(JHP OR 100.000 PTU)
TOTAL'
met, BOILER-COMP(OVER[00.0110 BTU)
E]Yet 0N
PIR CONDITIONER
I Health
Safe, hvmdns mamda 5 reyuinments under .1 and 6.95of ifivethat Calle ISSUANCE DATFy�
fomia Hcdm&tomo Qdc.Satins 255115.15531 amt 25331.1 understand that Have NEW RESIDENTIAL MECH. SQ.FT. V C.� y
building drcs nolxurmntly have atenant,the it is my mpmsibilitI to notifythe acupant I
of c m is muss not Prior e+issuance of. ifcm of Qeu my.
to ate TOTAL: ISSUED BY: O
OFFICE
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