S 0944 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P ITNO.
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBING-M ECHA�N'ICAL � 0944
B1111.I)ING PROJECT IDENTIFICA'1'IUN
BUILDING ADDRIISS: x tiANITAItY NO. AI'I'LICAI'IUN SIM h111TA1.DAL
ZO ( O 0. 121 ^) 1 So9
O ER S NAME: "y�c� `T, X PHONE;.: CONTRACTORS NAME: LIC NO: NIC CONI
G,C- V
ARCHITECT/ENGINEER: IJC NO: ADDRESS: ❑
CONTAGI: 1 PHONE: BUILDING PERMITINFO
R U b ii 4 1� oQ / / - 31
Q 1 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG EI.ECT PLUMB MECH
7 l `� ❑ ❑ ❑
hICENSIID CON TRACIOR'S DECLARATION Q'rY. ELECTRIC PERMIT FEE )013 DESCRIPTION
1 hereby affirm that I am licensed under pmvisionc of ChaPler 9(commencing
azz with Section7000)nf Division 3 nfthe Business and Pmfesslom Cale,and my license is RFSIDENTIAL:
I'IiRMIT ISSUANCE DSITIWI ❑KITCHEN REMODEL
CW F- i Tull fora and eBccl.
st Cs pian, Clan Lica AI'i'LIANCES-RESIDIiNTIAI. []ADDITION [I PLUMBING k1>PIPIi
yZa Dute Cemmmor ❑MULTIUNIT C3 STRUCTURAL
< ARCHITECTS DECLARATION PANELS MOUII'ICAI'ION
Doo
Z~pnZ I understand at,plans shall he used as public retial. UPTO20(IAMPS [I INTERIOR ❑CHIMNEY REPAIR
OZ-'O
Fy~u1 211
Licensed Pndesxional 1-I01X0AMPS IMPROVEMENTSWIMMING POOLS
asi ' OWNER-BUILDER DECLARATION OVER IgM)AMPS ❑BATH RELMODEIJREPAIR C)DEMOLITION
a a 1 herchy affirm Thai 1 um exemp from the Contractor's License Low for the ❑c THBR a
xLx W U folloxing rends.(Section 7031.5.Business and Pmrexsinns Cade:Any city m county SIGNS IiLIiCfRICAL
LL1314 vFi which rewires a permit to construct,olmt,improve.demolish.or toaster any strvnure
FaJ C; ire to foc,.....v,toloo ca,mor,th PPIicand fill suchL nO II aged stem nett SPECIAL CIRCO IT/MISC.
y
bar he licensed .vat a the previsions fthe C t m L Low'(Chapter9 COMMERCIAL:
a0,MC that he ix exemp with
thmfin licaad Ito aDivision 3 fel Bu'es dP f ms Call or TEMP MITER OR POLE INST.
y any front and the bull,for the illegal exemption.Any ns Code)
oI E3 NEW BLDG/ADDITION ❑DEMOLITION
x�y Sceiem 703L56 rout aducal,tlaapplic.ttoacivil penaltyuf POWER DEVICES ❑THNAN'I ❑FOODSERVICE
onscone than five hundred dollmx($500). IMPROVI?M tlLn K) C�
SD Lan owner of rhe PmpenR or my emPloyces with wagah as their sole nniTemad,n, SWIMMING I'UUL ELECTRIC 13 Of HER YY/ 6�Q.
F. will do the work.and the onom pe is not intended or uttered forsale(Sec.I6w.Business )UTLLTS-SWITCHES-FIXTURES
tai]'-gym and Prnfcssions Crile:The Conouclor's License Law does not amply to in ownet of
a 3 property who builds or improves thereon,and whit does such work himself or)trough NEW BLSIDENTIAL ELECfR SQ PT.
his own employees.Provided that such improvements are not intended or offered for SQ.17..FLOOR AREA $/SQ.Fn
sale.IL however,the building or inmr(lvcntant is sold within oneyearof completion,the
mvnn-builder will have the burden offspring that he did not Wild or imPmve for Puts
p cw of oll..). TOTAL:m pp�kk p
H
I.a ouster of'he known,known,aexclusively contracting with licensed conal,lon.to r I n
cdnmrvcr the Project(Sec.7044.Business and Pmfersinnx CWe:)The Coal maor's Li-
ca se Law does not appy nYs an owner a properly who builds or improves thereon. QTPLUMBING PERMIT FEE
who contracts for such provers with aedmractouO licensed pursuant mule Coatmeuds �a ���
License law. PERMIT ISSUANCE V
(] I um exempt under SCO. .B&P C for this reason
ALTER-URAINSVIi - Ts (EA) ut- �yAl`ATIUN
Owner Dam
• WORKER'S COMPENSATION DECLARATION BACK FLOW 1'ROTIiCI'.IDEXC
1 hereby affirm under penalty of Perjury one of rhe following declarations:
I have and will maintain afenificacof Consenuoself-moure lir Workds Cnmpcn- DRAINS-FLW F,ARFA,C( D. STORIES TYPE CONSTRUCTION
sution.at Provided I'or by Section 39W nl'thc LOMB Cudc,for tlm perfnnnunce of the
work far which this permit is issued. FI%T URF_S-I'li RA'
0 1 base and will maintain Worker's Compensation Lattimore.us required by Section GAS-ISA.SYSTEM-)INC.J( OCC GROUP APN
TAXI of the IaMn Code,for the performance df the walk Tia which this i orlon is issued.
My Worker's Complication lnxumnce carrier and Policy number are: GAS-EA.SYSTEM-O (EA)
Carden_Policy No.:
CERTIFICATEOFEXELOPTION FROMWORKERS' OREASI NDUSTRI.WAST It CEPTOR
COMPENSATION INSURANCE e L G ISION 'EIS
('I'la,,cction Bred not beetmplcled life Permit is London Eudreddollam($IW) GREASE*1 RAI' PLANCHECK E
or It
Iccnify that in the anoffy paner to std the wad for olmaohis permit..ker,cd.l shill SEWC:R-SANITARY-STORM F.A.3110 FT ENIiRG) TF
cot employ my permm in any munnerso as ns harsmc suhjcct nt tM1c Worketd CnanPen-
Z sution laws of Cu6fomia.Date WATER HEATER W/VENT/IiLECfR GRAUI. 1ItiF.
ZQ App icam
N NOTICH TO APPLICAN'L H.aflcr making this Cel illcum of l?xempl n,you should WXI,i SYS'rp o TRIiATINC, SOIL5lgeli
F' ^ become subject to the wmkcts Ca dlemmion prounion,of @c Labor Code,you mot
�� Iimhwithcootply with such pmvisionc ortbis Lwarmsholl be deemed revoked. WATER SERVICE
PAIU
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh111. SQ.loll one Racipr p
UO I herchy afftrot that there is a amstrumlon lending ageacy Iia the perfdmtanre of
D. E. the work for whichthis permit is rss.W Not.31X)],Co.C.) TOTAL:
O lender'.,Name 'TOTAL:
rUIsnder's'Address BUILDING
Iy I candy that I have rtaJ Ihis application Ond sec¢that rhe above information is PEE
A enroll.1 agree it)comply with all city and county ordinances and state laws relining to QTY MECHANICAL PERMIT SEISMIC FLE
(.) Z building commation.and hereby omhoria representatives of flus city'it mncr uptn the
above-memimad Perry for inspection purpssys. PERMIT ISSUANCE ELECTRIC FEE
(Wc)agree m.avas indco nify and keep homeless the City of Culaminoaagainst
Iiabilltiesjudgments,cosis and expenses which may many way accme again Y ACF11 OR ADD TO MEC II. PLUMBING FEE
in rac equenec of ghp granting of this Permit.
APPLICANT U NDRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'r(T010.0lo CPMI MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFT11 CONSTRUCTION TAX
Signature of Apphcala Cdnvacmr Dam E%HAUS'F 11000 W/DUCT) DOUSING MII'IGArUN ITIS
HAZARDOUS MATERIALS DISCLOSURE
Will he Plicam nr fnmre briding occupant slue or handleM1vavdnus matmial HEA'T'ING UNIT(TO I00.1)(MI BTU)
as defined by the CuWaso Municipal Cade,Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Code.Section 25531(a)'i
❑ PAIUYes Also - VEN'Fl1.ATION PAN(SINGLE RESI D) Dme Receipt a
Will the applicant or future building tscsvpum use equipment or devices which BOILER-COMP(311P OR 100,0ol BTU)
emit lajoiccmm air contaminants m defined by the Bay Amu Air Quality Management 'I OIAh:
Disbud? BOILER-COMP(OVER 110.0f10 B'rU)
[I Yes FAN.,
AIN CONN HONER ISSUANCE DATE
I have re:ul the Code materials 5,2.5533 m,1255r CM1aind rsta of rbc Cdi
lumiu Hrallh a Sil'cty GoJc Seatimtc 25511.5,2$533 unA 2553A.1 rmdcmmnA thal if rho NIiW IiDSIUIiNTIAT.MISCII. SQ.PI'.
Ituildmgyl nt,.tntlY IN learn,aha it my m,,onsibiliy to allay the occupant ,
of lhv .1 rcrjtemc which dryR>!e n norm i... ce of a Ceom t /f/Gk{ Parry.
k f-�Y 4�7f r I��a=g TOTAL: ISSUED BY:
Owner or authonmd agent
OFFICE