S 0781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.Ei.EUTRIOM, PERMIT NO,
BUII.DING DIVISION APPLICATION/I'F,RMIT rLUMIBtu:.Mo-:cupNLcu. 0781
BUILDING PROJECT IDENTIFICATION O
SANITARY N(1. APPLICATION SUBMI"PIAL DNI 1;
BUILDINGN)DRESS'.1 , 9
OW :R'S NAME: �k ONE: C) OR'S li: LIC No:
r NIC CONIROLp
sd 11
%
ARCHITECT/ENGINEER: LI O: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLIX'i ELECT PLUMB hf❑1
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEEQWz JOB DESCRIP'T'ION
hereby muffin that]'am licensed under pnwlsions of Chapter 1)Rommmncing
W0 F, ith Seclion900(dof Division Sof the Bmincssund Prufcesions Gslc.undnry licence is RESIDENTIAL:
PIiRMIT ISSl1ANCfi
X l� ,)full furca,, c0' 11 - C SFDWL C Ki PLUM EN RE REMODEL
V Littnse CEu Conor APPLIANCES-RESIDENTIAI. ❑ADDITION ❑PLUMBING RE P]
,Fall Uate Comracmr_ % ❑h1ULThUNIT CSTRUCTURAI.
ARCHITECTS DECI.A0 QAV PANELS
zonKI understand my plans shall be used as public record. MOUIIlCAT10N
CZ-� UP TO 200 AMT'S ❑INTERIOR E]CHIMNEY REPAIR
W Licensed[',it.saioand 1111-Iq)OAMPS IMPROVEMENT QSWIMMING POOLS
a, 77j OWNER-BUILDER DECLARATION OVER 1000AMPS '/ ❑BATH REMODE1JREPAIR El DEMOLITION
C Q I hi affirm that 1 um caempt from he Comncmrs Lice Law for the ❑OTHER
3 Qa F following reason.(Section 7031.5.Business and Protessians Cale:Any city or county SIGNS ELECTRICAL
y which requires a permit to aon9md,alter,improve,demolish,or repair any structure .
l=�0s prior in ts issuance,also requiresthe ppl t for suchpermit l rile a signedstatement SPECIAL CIRCUIT/
S�+�of thath licensed lt Tb p rtl C t 'I L I' (Chiall9 �} COMMERCIAL:
mn�22 leo sang wish Section]Ig ))ul Dick M1oOhe Bitude dl f in,CWe)or 'IEMPMISI'IiRI .El
6 C e K that he is exempt therefrom and the basis for the alleged exemption.Any vinlauan of El NEW BhDGIADDITION ❑DEMOLITION
Www Section 703 L5 by any applicant fill or mit wM1jects the applicant loacivil penalty of ('OWER ADP CGS [I TENANT ❑POOU SERVICE
not mart than Eve hundred dollan(5500). SWIMN11ry6 P00 R IMPROVEMENT
f=O �I,us owner oh the properlY�nnny employees wilb wages as their.utic compensation, COTHER
d,ym will do the work,and the.drvclud is not intended or olfeted for sale(Sec.]M4,Business
Y 3 wa and Pmfessiona Code The Cunlrnnor'e Lmcnnc Law Aad nal apply to nn owner of U S, 1 C PIXB}IRIiS
property who bniId or intpmvca Iheamn,road who does such work himself of Through
his own employees,provided that such improvements am not intended or offered for RES N'I'Ip E 'R SQFF..
sale.IL loss ,,the building,),improvement is sold wilhinone ycarnfcnodoctim,he SQ.Ill FLOOR AREA LSQ.II'.
rte,-builder will have the burden of proving that he did not build or improve for par
pose of sale,). TOTAL:
I]1,as owner of the property,tint exclusively contracting with liemead GIDlmem d
m.Vud the pngua(Sce.9044,Looniva and Prnfexaam Cala)The Commit
cense Law does out apply to an owner of properly who builds or lmpmvs m- .and y, PLUMBING PERMIT FEE
Who contracts for such projccn with asommcm,h)licensed puna lIn the Can o's
License law. T ISSUANCE
C l ant exempt under Sec, .B h P C for this mall
LTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Doc
WORKERS COMPENSATION DECLARATION 13ACK FLOW 11kUTECL 1lEVICE
I herchy affirm not,penalty n1perjuryome ollhe following dealmodoes:
❑l have and will maintain a Certificate of Conscnuo self-insure for Worker's Compen- DRAINS-FIAOR,ROOEARIA,COND, FTORIIi, TYPE CONSTRUCDoN
smion,as Provided for by Section 37W of the Labor Codc,for the performance of the
work for which this suit is issued. FIXTURES-PER TRAP
[r}I have and will maintain Worker's Compensation Insurance,as required by Section
]....f lire Labor Code.for The prRormm�cc of the work lin whichmis vanno is issued. GAS-It SYS'1'F,M-I INC.4 OUTLET'S UCC P APN
My Worksy, y natio Inau((uncc curticr unA Policy nu I1y'r arc: 1998
C.riee 5�1� N/vl(1 PnIieY Na,; IS 1 / �1 6�3� GAS-IiA SVS'fliM-OVI?R 411iA1
CERTIFlC O OF SATIONI NLRAM WORKERS' GREASFJINDUSTRL WASTE IN ERCF.Pf(
COMPENSATION INSURANCE 1 LDING DIVISION PEES
('This section need not becrtmPRoad iDhe Permit is for one hundred dollan(51W) GREASETRAP B
ANCfIr:CK FIJI
to hot)I
cc )I
Icertify that othe dar(nrmanceofthewnrk lot which this Permit..kis c,C...shell SEW(?R-SAN]'T'ARY-STORM IiA,2lYJ PT.
not employ Tury Parson in vny nnT a.t meuhjca't tit the Warkcrs'GalnpaTl- I?NGRCV PILI?
O Z ..tion Laws tt!Colifurnio ,Tt WATER NEATER WNENVELECTIR a O
z 0 Applicant ; 1 GRADING 14]i
NOT ICIi T( I CANT:If, lerala gqfix Certificate of Exemption.you should WATER SYSTHM"EATING SOILS FEE
1% ^ M1ecomeabjectat it Waders Comas or
is provisions of inelabs Gyle,you must
LW ti forthwith comply with such provisions nr this pemtit.M1ull be Deemed revoked. WATER SERVICE
0. QPAID
CONS'1'RUCI'[ON LENDING AGENCY NEW RIiSIDIiN('IAL PI,M11. SQ,1'1'' 1). c Re'eipla
U O1 hereby affirm that construction is a consetion lending agency for The pshoulance of
the work far which this permit is issued(Sec"30B9,civ.C.) TOTAL:
Lenders Name
U Lends/.Addss TOTAL:
I candy that 1 have read this application and.state that the above information is HUIhDING FIili
a' s QTY. MECHANICAL PERMIT FEE
fin h c reit.1 ngrm w comply with all city and county onative cs and sem lows Waring ic 51?($MLC Fl?I?
U� Wilding ell,nmedon and heresy aamodae repre,eTtmlme.,)ani.ayl,)ever apom the
aMve-mentioned peopeny for inspection pumenes, PERMIT ISSUANCE ELECTRIC ITT
(We)agree t.save.indemnify and keep hall the City of Cupcnino.gain't
Iiabililies.judgmenls.costs and expenses which maymmer way accrue against said City ALTER OR ADD TO MECH. PLUMBING FI:
in iossmanee of the fictional of this permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO Ifight CFM) M ECHANICAI,IB:'
SOI RCE REGULATIONS
n AIR HANDLING UNIT(OVER 11.000CFM) CONS'fRUCI'ION'TAX
s.
Si oat oApplmanl/ clor'`� 9/ � EXHAUST HCOD(W/DUCT) HOUSING MITIGATION FEE
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant or future building trcupanl some.,handle husurdom material HEATING UNIT(TO 100.000 Hl'U)
as danced by the Cupenina Municipal Code,Chapter 9.12,and he Health and Safely
Calc,Station 25532(x)9 IIEATING IINI'P LOVER 1000N)IOU)
❑Ycs UjNo VENTILATION FAN(SINGLE RILSID) PAID
time Reccipl W
Will the applicant or furore building occupant use equipment of devices which BOILER-COMP(3HP OR 100.000 BTU)
emit hamrdous air contaminants as defined by the Bay Area Air Onto Management
Disnicl't BOILER-COMP(OVER 100,01X1 BTU)
❑Ycs C No
AIR CONDI'I'1 ONER ISSUANCE DNI I,
1 Love rcaJ the h.mrdow namrials odmoumnm under Chuplcr 6,95 of the C.I,.
humin Health R Safely Code,Sections 3505.25533 and 25534.1 undcom ed that if the NEW RESIDENTIAL MECIL SR FT a/
building dors nm currently have a tenant.that it is my responsibility m notify the acupam
of the reyuimunenN which mus he act prior m issuance of a CeniOco d of Oecupeney. _
Owner or umluni.J agent ITtc TOTAL: ISSUED BY. ✓ y�
OFFICE