S0001C0411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERn>u'No00411 0 4 1 1
BUILDING DIVISION APPLICATIONAXERMIT PI.OMBING-MECHANICAL 50001 �7
BUILDING PROJI'1CBIDENTIF'ICAT'ION
SANI'PARYN) API-LICA'TION SDIIMI'TI'AI.DAT II
ISUILDINCIADURESS:
6121le
O NEWkVAME: PHONE: CONTRACIOR'S NAME: LIC NO: SIC CONTROLX
4ar ti ,
® �X
ARCIII'WMTT NGIN.'R I LIC o: ADDRESS:/ Lf IQ
CONTACT. PHONE: BUILDING PEIGHT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL�TUyy�MI B MECH
1:1 E] A ❑
LICENSED CONTRACTOR'S DECL R TION Q'IY ELECTRIC PERMIT FEE JOB DESCRIFTION
1 heathy anirm Nut 1 an licensed under provision,of ChafLLm 9lenmmendng
O=Z widb Sation]IlOI)µsf Division 3 ofthe Businessand Professions Calc.and toy haeme is RESIDENTIAL:
,cc infullctio a0000e _ PERMII'ISSUANCE ❑SFDWI. ❑KITCHEN REMODEL
�U~ Liccnw Class Li< X gpPLIANCES-RFSIDENTIAI. (]ADDITION C3 PLUMBING RI PIPE
N ZQa Du¢ Cot n ((// — a ❑MU171-UNIT ❑STRUCfURAI,
ARCHITECTS DECT-ARAT'ION PANELS MODIFICATION
ZO'nf lamR,,mnd my Plon,,hall he used as public record+ UP TO 200 AMPS
OZ—C ❑INTIiR10R [I CHIMNEY REPAIRFSI:ad Licensed Professional 201-100OAMPS IMPROVILMF;NT E]SWIMMING POLLS
OWNFR-BUILDER DECLARATION OVER IKOOAMPS ❑BATH RIi�A"10�wwDE..U!l..R..EPenAIR ODE/hA 1��ION2
IY Q 1 hcrchy affirm that I am caempt from the Cornwall;License Law far the DOTH R q-/ T
X O y U following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL
FWOy wM1 h4 ,%a Pam. construct,doer,oupoole,demolish, repair, ny sprcmre
moral a..1ol require,th app) ,fi,r,i,hpermit ifile a signedstateroom SPECIAL CIRCUIT/MISC. _ Q 645
fly thatM1 cn:cdpurs tit dh p vdsdm fh C m tar I c La (Chap¢r9 COMMERCIAL:
alnC (cammenemg with Secunl7(XX))af Division 3 nfthe Busine.,and Prom,,ions Code?or TEMP.METER OR POLE INST.
d 6 n ohm he is caempt therefrom and the facts for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I UEM01.1'1'ION
Section]031.5 by any afflicted for ape.it subjects the applicant o a civil pemlty of POWER DEVICES []TENANT ❑FOOD SERVICE
not marc than five hundred dollars ISSfNp. IMPROVEMENT
�YG0 La,ownenI'Ncprapcny,ar my cmplayccx wish wages as lhcir.wlle compemmiom, SWIMMING PODL ELEC TRIC
will do he work,and thmwemm is nodmmnJuJser uttered for sale(So,.Tt B ....- ❑O'fl IIiR
F OUTLETS-SWITCHES-LUXruRES
63 m anti Professions Code:The Contractor's License Low doe,not apply s en owner of
his cal who builds or improves rM1ereon,and who Jtus such ante himself or through NEW R�CLDI3N'fIAL[LF.CI'R FC
his own employes,provided dr m such mentis old w are not intended or offered fur SQ f4 FLOOR AREA ySQ.FT
owne.however,the buildinguren of
is sold withinone roarofmpulsetior the
crbuikler will have the horde,of proving that he Aid not build or impulse for Pur-
pu c of talc.). TUTAI.:
❑ I.as owner of the proper,sent exclusively contracting with licensed a.Vact as to
construct the Polies,(Sea TIW L Bu,iness and Profession,Coi lbo Commromr U-
nw Low does tan apply m an owner of p.peey who builds or improves(hereon.and QTY. PLUMBING PERMIT FEE
who commots for such pmjao wish a contractors)licensed pursuantto the Contractors
License law. PERMIT ISSUANCE -�
I.,a r ac pl under Sea. B k l'C for this remvn
ALTIiR-DNAIN&VI?N'1'-WATER LEN VAI DAfION
Owner nate 1
WORKERS COMPENSATION DECLARATION RACK,:LOW PROIPCT.DIiVICE
1 hereby eBinn under penalty of perjury one of the following declarations:
❑Ihavc and will maintain a Ccnificme ufCom a,I.,clf-imam far Workers Coal DRAINS-FLOOR.ROOF,AREA.COND. STORIES TVPE CONSTRUCTION
smion,m'provided for by Section 37M of the Lob Coale,for the pedo mance of the
work for which this permit h issued FIXTURES-PP,R TRAP
ybp I hove unI will ao admin Worker's Compensation Insurance,as required by Section
}700 of the LaMa Ctde,for the performance of the work for which this Permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLF-TS OCC.GROUP AM
My Worker Come t 1 su ncec "En
r and Policy GAS-KA.SYSTEM-OVER 4ERA)
Camcc�Policy No.:�""
C:RTIFICAIEOFEXEMPfION FROM WORKERS' GRE.ASE%INDUSTRLWAS"1'EINTERCEIIOR
COMIE;NSAT1ON INSURANCE BUILDING DIVISION FEES
This,mdanneeJ notlum.plcial it lheperntit isforanchundrcd Jpllurs(SI(X)) GRFASHTRAP PLANCHECK IPE
or les.)
Icerify lbetinheperfnnamer of the work for which Nis the oker, d.lahall SEWER-SANITARY-STORM kA.2W FT. ENERGY POOR
n.i..1. any person iaany manner sgas)o p nJfe Lg�n w the Worl.cri Compen-
O,� smion I.a ufjyX._�li{ryrlla.DjOt� �(�I l WATER IiLATER WNENT/EL[CtR GRADING IPE;
O APPlict 1 (11
tz-t ti NITfICE'10 APPLICANT:11,alter making this Cenificate of Exan1Plinn,you.hatdd WATER SYS'I EMTREATINO soil's 1917.
F-I became sahjat to dhe W..oa,Compensation pmvluiors of the Lahur Code,you moa
Cat. fonhwih comply with such provi,ions or this Permit%hall be deemed revoked. WATER SERVICE
0. Q
SIDF,NTIAh
CONSTRUCTION LENDING AGENCY NEW RT•_ PLMB. SQ.IcIl PAID
I PDate Receipt p
U O I hcrchy.Miro Ill.hem is a construction lending agency for the Performance of
the work for which his peon is issued(Sec.YN7.civ.C.) TOTAL
LcnJer's Manu 'IYl'1'AL.
Lender's AAJrc,, BUILDING FIRE
L 1 ccaNy that I have read this application vad stain Nut the above information is
.. N
court Iagree.comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT IT'E SEISMIC PER.
U z building construction.and hereby auhotize representatives ofhi,city to enter upon the
uMvcmeniioned property for iml ,iun purposes. PERM1",'ISSUANCE ELECTRIC P19i
(We).,me to save Aamnily and kap harmlc„the City of Cuferino againstlia �rrYY''l'L
APPLICANT U.nts.RST, )SPe ND WILL f )MI' WITH ALL NON-Ed I City AI:Ililt OR ADD tt)MECII. IR.UMBING IT311 s 4J
IOM ex Yln any wayueoucu t
n APPliencLICANT
th Fn 'OhNT
AIN HANDLING UNIT(TO 10.IXX)CFM) MECHANICAL PEE
SOURC f TI
_ AIR HANDLING UNIT(OVCR 10A00 CFM) CONSTRUCTION TAX
Sig Irco APPEeon nnnl¢.¢rz Date EXHAIIS'I HOOD(W/DUCF) HOUSING MITIGATION FII!
HAZARDOUS MAI'HRIALS DISCLOSURE
Willthe afpleama,forum buildingtwempum,h,m.,handle hazardous rnmcminl HHA'I ING UNIT(TO I IN),IX()BTU)
as Jefinal by he Captions,Municipal Cale,Cbapmr 9.12,and the HceOh and Safety HEATING UNIT(OVER 100.00)BTU)
Code Section 25531_(a)?
❑Yes ' No VP.NTILATION PAN(SLNGLF.RESID) )ae '' t
Will the r,,licunt or to buddar,accupmt n,v aPpecal ser Jcvias which BOILER-COME(3111'Oil ❑N1,(XN)BTU)
.arid haemdans air comaminunds Is defined by he Bay Arca Air Quality Management GOA.:
District? I BOILER-COMP(OVER 100.100 BTU)
,]Yes • kNo
AIR CONDITIONER ICC IANCP.DATE
I have read t •homrdous materials rents under Chapter 6.95 of the Call-
land Ilculth k S t Cal pions 550 .25533 d 25534.1 mNcmm�J that if the NEW RESIDENTIAL,MICH, SQ,FF.
M1uilJingJrcan is v ulCimnLt of.C'lllycatoof theFanpant
of the 4 nfs� �h rot t tip noun sofa Cenilirnc of .pan v.
Ow ant ate TOTAL:
OFFICE