S 0601 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB,DINc-EIIECTRICAL PERMTT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM PROD E T IDE,rvlCAl. S 0601
BUILDING PROJECT TDF\'1'IFIGTIO:V
SANITARY NO. APPLICATION SURIMTIAh DATIi
IIDILDINGNCHRESS:
Z(Ogoo flaal,11 4v(f-- �C
LIC N
PHONE: CONTRACTORISN (I'.
OW ER'NAMII: NIC CON'I'ROLp
0 5 ❑
' ARCH"FECENGI E EJC NO: ADDRESS:
Th 4 BUILDING PERMIT INFO
CONTACT: I'HONIi:
❑ Consultant Fees Paid by Applicant(Initial) BLDG EI.:Cp PLUMB MRCH
Plbk :I -292-7-el 366 ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
with Sttdnn]O(III�dD'viei heal it J n[mc Buunder<m as vnJ p clans of Chapter 9(eanune-ail
❑TL hereby : ro&scions Crile,send myli¢nse ix RESIDENTIAL
I'ERMI'1'ISSUANCI3 ❑SI9)WI. ❑KI'TCIIEN REMODEL
C F millet force and eRttt.
QFUU License Class Lor la APPhIANCf3-RIiSIDENTIAL ❑ADDITION ❑PLUh1N18G RI:-PIPE
NQ1 Date Commcu'r ❑MULTI-UNI'( ❑SI'RGCTURAI.
ARCHI rECPS DECLARATION PANELS MODiFICAT'ION
ZCV)zI umas m
ndenad my plans shall be used public read, Oil TO 4q1 AMPS
[I INTERIOR C2 CHIMNEY REPAIR
OZNz
F.4!Z Licensed Professional 201-10(XIAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I0bX1AMP5 ❑PATH RHMODEIIREPAIR C]DEMOLITION
C sea]Q I hereby afEmt that I am xcmpt from the Contra<mr's License law for the ❑UTHIiR
xaxO�U followingreaam.(Section 7031.5 eEnsire,and Pr..fesxlams Code:An,city,"a+muY SIGNS RLEMRICAL
W 3 U.N which festal res a permit In crmswca alter,improve,deroulkb,or repair any struaurc
b-'*0-1 prior it)its issuance.also requires the applicant for such lwrmn In rile a signed Ittearam SPECIAL CIRCUIOMISC.
�nW that he is licensed pursuant)the providom'of the C,nuaclors License Laos(Chapter 9 COMMERCIAL:
oa,, o (commencing with Section 7000)of Division 3 ofthe Business and lhofessionn Gdgo. 'IEM P.METER OR POLE INS'1,
a a ca that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW RhUG/ADUII"ION ❑UIiA101.11'ION
X Section 70315 by any applicant fur a permit suhjmts the applicant n a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not more than rive hundred dollars OINXq. IMPROVIiMlinl���1►�sMAQ
SD ❑Las owner of the pmpeny,or mYemploYtts with wages asthcir.aole compensation. SWIMMING POOL ELECTRIC [I OTHER �� IVWrnIL'
p. will do the work.and the sireamrc is not intended or offered forsalc Sec, Business
G1- used Prafcssions Code:The Cnmranor's License Low doe,ant nt+ply to an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or impmves thereon,and who drat such work himself or through NEW RESIDENTIAL ELECTR SQ FT.
his awn cmplayecs,provided that such improvements arc not intended or offered for SV;yT.-1. )R AREA 5/SV.FT
sale.IL bawevea ten bulding,rin+provemenl dsuld within ono year.(rnmplelim.me ft 1^^
r-builder will have the bmJem of proving that he did urn build or improve fix pun
pweofsale,. A e pJM��A�a
(] 1,as owner of me prorytrty,am exclusively eliminating with license wstroc m,ill
w O V ^\1`
.nslmcl lM1e project(Sea 7buL Re,inesx and Professions C.da l l lie
cense law does not apply ,,an...a,m,no,cnY who builds or impulses theremm,and QTY. PLUMBING PERMIT FEE V r
whoaommitxfor such projects with a contractions)licensed pursoanlmthe Contractors ,` VV
Liccnc sLaw. PERM]I'ISSUANCE \'`A Qt
❑Imo cxemptu Se .11&1'C tunhis rcumn
ALTER-DRAIN&VENT-WATF.H(EA) VALUATION
Done
V )RKER'S COMPENSADON DECLARATION BACK FLOW PROTECT.DEVICE
1 hent,y affirm under penahy Elf perjury one.(the following declarations
IM IEl have and will maintain a Cenificme of Consenunself-insum finWorkers Counter- DRAINS-FLOOR,ROOF AREA.COND. ti'I"ORIISS TYPE CONS'IRUM]ON
vvtion,m pNJlllad for by Sechan 3900 of the[.abut Code,for the pu!nnunec of the
work for which this permit is"('mad. 19X I'lJRliS-I'IiH'FRAI'
1 have and will maintain Worker's Compensation Insurance,as respired!by Section (ICC GROUP
3700uf the Laho"Came.fill the perfmmamceofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS JOIN
My Worker,Cnn+pen.wdnn In sun Inc.eamerand Policy nutnbarara. GAS-IiA.SYS'UiM-OVliR4(EA)
Came,: Policy No.:
CERTIFICATE OP EXEMPTION FROM WOR RUBS' GREASE/I NDUSTRL WASTE IW17RCEFTOH
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Mostaxamnnecdoollncotnplmed ifmcpcoun isforoichundreddoll... S106 GREASE TRAP PLANCHECK FEE
or less.)
[cenily that in the anyl manner oa,t wink for subject to par mnivers'C,lshall1per- SF.W[R-SANITARY-ST ORM IiA.21X1 f"f. IiNF,RGY 191E
not employ any person in any manner so ns to become subject to the Wnrkcrd Gmtpcn-
Z cation Iaws,f California.Dam WATER HEAIT:R WNENT/ELECIE GRADING IEE
ZQ Applicant
ti
NO]ICE TO APPLICANT.If,alter making this Cartillcale of Ilxamplion,you mould WATPR SYSTUM?RENTING
a ' become suti ttt 0. O S(IILS 19i1i
ICom tion provisions f the talar Code.you mull
n the Worker's
1 Provisions
Permit
fnnhwith comply with such Provisions.obis permit shall be Jemncd revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RIESIDEN'I'IAL PI,MB, SQ.1.7 ('AID
7 z Dale It...
V 0 thereby aRmis that issued(See 30leadin.agency for the performance of
W the work for as inch This pvrm+l is issue)(See.Jf19].Civ.C.) ( 1;.
O(~ Lenders Name 'I(H'AL:
,r Lenders Address ITU ILDING I: E
{{rr W I tardily Ill.,I have mad this application and state that the above mumar a ion is
F ) anre'Llagrced+wntply wild all dry and county unllwncav and xm¢Wwa"dotingm QTY. MECHANICAL PERMIT FEESIiISMIC I+I?I
V Z building construction,and hereby authlim representatives of this city u+enwrupon the
above-mentioned pmpcny for iml'eedon purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agrae m.mar.indemnify and keep harmles the City sof Cupenin,againsl
limbbities.jui, am,.colo and expenses which may in my way acerae against said City ACTOR OR ADD*10 MECIL PLUMBING PF.
in consequence of the granting of this permit.
APPLICANT NDERs"(ANDS DWILL CO PL 'TNA '-POINT AIR HANDLING UNIT(TO I0,0N)CFM) MECHANI AL ITiIi
SOUR'i R . LAT S.
AIR HANDLING UNI'F(OVER RLgX1 CFM) Ct,NSIR1 :IION']'AN
Signatureof plieant/Convae64 Um ESMAUST HOOD(IMMUCI) HOUSING TIGATION FEE
HAZARDOUS MATERIALS I SCI SUHIi
Will theapplicanlnrfuontm buildin,oce.p. lore or handle homNous material HEATING UNIT(TO 100.010 BIH
u as defined by the Cnpertinn Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.00)BTU)
t Cola Seclin i 25532(x)? PAID
❑Yes ❑No VEN'FILM ION FAN(SINGLE RESID) Date Reeeip #N
' Will the applicant or future building occupant sew erluipmew ordevices which BOII.CR-COMP(3HPOR I(XMXX1 RTU)
mit h:vardoum s air cnntu+nnumv, defined by the Bay Area Nga
Air Quality Mananert IOIAL
e ;
UmricR BOILER-COMP(OVER 100.1100 BTU)
❑Yes Fl No
AUR CONDITION l ISSUANCE DATE
I have read the hommoves mmedmis rcyuiremcnts under Chapter 6.95 ill the Cal-
1 !natio Health&Safety Code.Sections 25505.25533 and 25534.1 uwlersto that if tM NEW RESIDENTIAL MECH. SQ.Fr.
building doss n t curandy have n tenant.thin it iX my respomibilily m nosily me rxivpont
of the"notemcros w'hi,h rm,l be tact prior In issuance of a Ccnilicatc ill(kcupancy.
Owner nnmtburiacJ,gem
Date TOTAL: ISSUED BY:
OFFICE