S 1541 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILUING.MECIELEUPRTCALANICAI P'' ''NO 1541
BUILUING DIVISION APPLICATION/PERMIT PING R PROJECT
ENI IFIC
ItUlhlylNG I'RIyJ I!C'F IDBN'1'IFICA'I'ION
BUILDING ADDRESS: ;SANITARYD NO. APPLICAON SUBMI'PI'AL DAI'H
. O NAME: PHON,.-,. C(' RACIURS NAME: 'C NO: C(1NIRULp
ARCHI'FI:CI'/IiNGINI;i:R'. I,IC NO:
�\ 7 �.
CONTACT: PHONE: ` ✓ BUILDING PERMIT INFO
❑ Consultant pops Paid by Applicant(Initial) BLDG HLEC'IPLUMB MLCH
El E] e9 ❑
LICENSED CON TRACT(R'S DIiCLNinI'ION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under provision,of Chapter 9lcnommncing
WC)Z with Section 911001 of UiviziunJof the ltmsiness and Prnfoziuns QNe.IW my liccnm i. RESIDENTIAL'
W p O PERMITISSUANCE
a�F in force and effect. ❑$1'UWL ❑KITCHEN RIiMODF.h
QUU Licctme Cho, Lice APPLIANCES-RESIDENT AL ❑ADDITION JPBIUMBING I PIPIT
F-Zly Dam Conlmtlnr
o,Q ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
'Dot) PANELS - MODIFICN'ION
O Z=7•y I understand lily plane shill he used sea public record, UP TO 21NIAMP$
El INTERIOR C]CHIMNEY R17 AIR
FQ SnLw Licensed professional 211-1000AMPS IMPROVEMENT E]SWIMMING POOLS
CY g'' OWNER-BUILDER DECLARATION OVER IWIIAMPS ❑BA'fli RF.MOUEVREI'AIR ❑DEMOLITION
(y C{yah Q I hereby affirm that I:nn cacmpl total'the Comarnir'v I,ianse Law for the
xCCU I allowing reason.(Sadden 911-il S, monvrs Imd 11 fashions Coco:Any city ill comm, SIGNS IiLIfC'I LOCALOTHER
W LLy
which q Permit' I cootma, Ile P ae 1 M1 p y.trecturc
f�0� pr: I t I 4 thepplc' tf suchPe 'u file9atement SPECIAL Cl RCUIT/MISC.
y
�} Innh I dr . u II p , flu c l d L La (Chapter9 COMMERCIAL'
0 len ¢.g With Semon9W0)oflyYs 3ofthe Bmins ndlrlu:' d Coloo' 'I'IMPMITI'FItORPOLI:INST.
a a e C that he iz csempt Ihercfmm and the baso for the allcgvJ exemption.AnY violauon or ❑NI?W BLDG/ADDITION ❑OIiMOLI'I ION
X�m he.
701.5 by any applicant for apermit subjects the applicant a civil Penalty of POWER DEVICES ❑TPNANT ❑FOOD SIiRVICE
I,,(more than five To ]red call...(551X), IMPROVEMENT
=0 iM I.us owner of the prol'eny,arm In Ith we, thei f hole ctanmmntion, SWIMMING POOL ELECTRIC
ycmp ydedo goo, I ❑O'f11ER
F. willdnthcxvrk..nJl:The
is not intended offered does r,,,e(Seer,pt,1.m Business
of
L 3 w and Pndcssinns Gnlc:TI¢Comrucmr's License law J<Ks oat apply m un:nuns.of UG1I.FTS-SWITCHES-I'1%TURFS
pT,Woy who builds ser improve,Iherenn, aid who dna.such work himself of throughIt
his own employee,,provided Thal such itnpmvemam.,are not...retired nr ofiercd for NE RES HOENI'IAL ELIiCTR SIJ P
sale,If.however.the building or impmvnncnl i,mar within one yc.rofcomplclinn.the PAID FL'.FLOORAREA $/SQ.PI'.
er-builder will have the harden of proving that he did nut bui1J or improve for par- P A 1
I 1 are 1. 'IGIAL'.
I f Ili P pent exclusively t ilg II licensed t coon m
Constrictan project(S T)4d If dl Ess Cod ITh C t mraL. PR t`?il
ve 1 J t apply to n fp pony h h 'Id. P .til on and QTY, PLUMBING PERMIT FEE /I�(ne0
wl:v team f .c,,P JO,,dL;mon Iert,)1'u d.W puts:um antic CnnwvmL, /U{'�
Licence law. PERMIT ISSUANCE 1
❑ I an extend trader Sea ,B K P C for this reason GlI Y yr L�Jr
AurER-DRAIN AT VENT-WATI s(EA) LUATI(lN
Owner Dane
. WIIRKEMS COMPENSATION DFCIARATIUN RACK FLOW I'RO,F.Cr,DF ICI:
1 hereby affirm under Penalty of perjury one of the following de"Iarmmnz
nILoc unit will maintain a Certificate of Conse..0nsclf-insure AnWorker',Conal DRAINS-FLOOR.ROOT'.AREA,COND. STORIES T YPE CONSTRUCI'ON
,admr.nv provided for by SecYinn 3700 of ma LaborCode,for the PL•.furtiamee of the
work for which this Permit is issued, FIXTURES-VER'I'RAI'
El I have and will malnmin Winos s Compensation Insurance.as required by Sectio
37IN0 of the Labor Calc,for the performance refthc work for which this permit is issued GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP AliN
MY Warkc'- ninixt saline It rutj)/)c}y1(�is e I'nEuy nyumhunuu:
Comer: F ti [a [Policy Ws:I--G�a�4L d� CAS-BA.5Y.S"fICM-OWRd(17A)'IiRTIPICAI'EOF DTINFRIM W'ORKIiRS' GREASEANDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEPS
1'fhia welion rid
and lwamtplctW it Ille,nnit is for onall undreddolln.s(SINI GREASE'IRAI' I'Iw\NCIIIiCKFEE
or lczn.)
Toy a n,pro,
the pr,n,am,,,r ,tobehe kfia whin tt to he titislo,'Coued. ale,shall SIiWER-SANITARY-STORM EA.20)PI'.
ern mnpiny n..Y Penna in any manner sl'u,m beumm whjecd to tM1e Workers Cnmpen, ENIiftGY F[li
�Z sution L.awsofcmili:min.Dula WAFER I THAI ER W/VIiN'I'/ELf:O'IR GRADING FEE
Z Q Applicant
NOTICE 10 APPLICANT:It,after making this CmiOcate of Eacmptinn,You should WATER SYSTEMOREATING
F ? ame rers Ca
sunicct¢d the Wok ' mpemmlon provision,of the Labor Code,you all 5(1115 FEE
bec
fodnwith comply with such provisions or thin pormid stand tie J"cndedmvoked. , WAIER SERVICE
n'
CONST'RUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ,FTPAID. -
Uz Ihrrch l,,a dial there isa conam..ion lendln,agency for the Perrnmmnce of Dan Re<etpte
U O aLL f-' clicwork Ill,Na which Iii,Nor'isnxueA(See 31191.Civ.C.)
C) Lender',Name
'I(TIAL:
U IsnJcis Address I TU'fAL:
I"Icy that I hate.cud thp
is trplle:aian are ov
On.than the..na Inl'onnnlion ix Bf111,DING FEE
F` N rune Iagree to"Imply with Ill anyanI] ,army erdinalce,and.uta lawn relating to Q'I'Y. MECHANICAL PERMIT FET: SEISMIC FEE
UZ buildingv'unstrclum.undhcreby euthorirc mprcsenmtivez of lhin<ily toemerupun clic
about-nmminnul Pmpvny for iropamion pu.puscs. PERMIT ISSUANCE ELECTRIC PER
(We)agree do cove,indemnify mW keep hunnle,s the City of CuPenino against
Iiabilidic,.judgmenu.costs and expenws which may in any way Beane ugnlna said City ALTER OR ADD1'0 MITCH. I'LUMFHNG FEIF
in consequence of the granting of tri SS permit.
APPLICANT UNDERSTAND' G D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL FEE
S(lIJItCG RE 111A DNS,
AIR HANDLING 11Nl'I'(OVER 10.000 CFM) CONS"TRUCTION'1'AX
Signor Al Icum/Cammcmv Dtrte IiXHAUS'I'HOOU(W/DUCT) HOUSING MITIGATION IP.
HAZARDOUS MAI'1?RIAIS DISCLOSURE
WILL We applaunt ar future IsmI ingaccup.m one,nr handle ha...mal macdA IIFATING UNIT(10 IIIB,0(M It I OF
as defined by the Caliendo Municipal Cale.Chapter 9.12.and the Health and Safely
1 Corfu,Scotian 25531(.).? HEATING UNIT(OVER 100.01X)BTU)
❑Ye. [-1 No VENTILATION FAN IS INGLii R ISIDI PAID
Date Iteecipl p
Will dthe aoPlortarorfuwrc building:ncueanay Areequipment
uadity aral,rses eed I{OILER-COh1POHPOR Iq).(Xp BTUI
..nil hazardous air vnmammunlh os refined by the Bay Area Air Quality Management '1D'fAL
Di elel? BOILER-COMP(UV ITR I011,IN111 BTUI
❑Yes [-I No
I M1uvc.ctrl the IN 11 Is re}ryr cnendn under Chapter 6.V5 of the Cull-
NR CONDR IONER ISSUANCE DATE
loon.Ilcalth 5 Safely GJe,Sll 2$i�65/,,Nr'533 and 25534.1 underhis I Ilett it ilia NEW RHSIDFN'I'I Al,MECI1, SQ.PI'.
building Jues nn y R�.tena r(t t(' myrt prrtlFl6ilitydo notilythe acupam
❑fin he os edac —Date y.
Own moaual gem
Lll�• 177�am Tcmn1� Issul:D nr.
OFFICE