00010107 AP^LICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY00010107
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PR(1jEc T IDEN'OEICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
loq73 s - �,'nu �. _b/ <"
YNER'SN MF.: �{�p 1'I N/F:: ��cohi-f-RACIOk'S NAME: rr� LIC NO: � V�
�F(/0—�iS— Sot kkbrey Hea7'e S Men?` 1L 741 O NIC yCONTROLa
CHII'ECI%IiNGINEER; LIC NO: ADDRESS:- mess)by�FP lsa�le�- SIQ 9- ❑
CONYAC'I': PHONE: 11 O `ly BUILDING PERMIT INFO
❑ Consultant Fels Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ Q, ❑
LICENSED CON'1'RACTOR;S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Set:nonvXlO)td Division 3 of the Busine.ve and l'mfesdon.CoJe,.ndmy licence is RESIDENTIAL:
Ffull fort,and cfkct. I'HRMII'ISSUANCE RESIDENTIAL,
WI— ❑$FOWL, (3 KITCHEN REMODEL
QUV License Class Lic.M APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
1-'66 Dale Conlmcmr
f� ARCHITI=S DECLARATION ❑MULTLUNIT [I STRUCTURAL
FiAz l understand my plans shall be used as public records PANELS MODIFICATION
Oz�4O UPTO200AMPS El INTERIOR ❑CHIMNEY REPAIR
F 14.~.W Licenced Poecssir.al 201-100AMPS IMPROVEMENT SWIMMING POOLS
C"1 � OWNER-BUILDER UC:CLAItAI'ION OVI!R HXIBAMPS ❑BATH R17MODEUREPAIR ❑DEMOLITION
C -y I hereby affirm that I am,script from IM1e Contractor's License Low Tor the
xC LLU following reewn.(Section 7031.5,Business and Professions Cafe:Any city or county SIGNS ELECTRICAL ❑OTHER
y which requires o permit to comstructureloacl.alter,improve,demolish,or repair any structure
F�'0¢ prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUHUMISC. �•'Q-r
that he is licensed pursuant o IM1e provisions ofthe Canrintoei License Law(Chapter 9
W 00 (commencing with Section]Of1(hof Division 3oflhc Business and Professions Cods)nr TEMP.METER OR POLL INST. COMMERCIAL:
E tit,e C that he is uxetnpl Ihentrem tad the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Way
Section 7031.5 by any applicant for a pernal subjects the applicant to u civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars 1550X01, IMPROVEMENT
SD ❑Lsowner nl the propenA onnyempinyces with wugesaslMirsole compenaminn, SWIMMING POOLELELTkIC ❑OTHER
E- will do the work.and theswnnre i>notimcnJN oroRcrtdfor sale l$cc.]DW,
u
W1 m and Professions Gdc:The Contractor's License Law dies not apply to an smcof OUTLETS-SW'ITCHIS-MIXTURES
a 3 property who hui Ids or improves thereon,and who does such work himself or Ihm
his own mnpinycu,provided the such improvement are.,it intended or of NEW RESIDENTIAL HLEM R SQ FT.
sale.It,howevc,cm buildingnr improve in issold giMiannc ycnroI cmnpl SQ.FI' .00R AREA SISQ.FT.
er-buider will have IM1e burden n1'proving that he did not build or improv
pass ale.).
�I of the pmpertY•am exclusively contracting with licensed ronmanrs to j
co.wit the project(Sec.7014,Business and Professions Gds:)The Conweror's
cense faw Jscs nm apply to an owner of property who builds or imprnvcs therton. Q FEE
who contests for such project with a comm,....s)licensed pdouantto the Contac �l
License law, O
❑1 an exempt under Sec. ,R&P C for th't reason
A /IA "' —D IN& ATER ) VALUA
Use
WORK COMPF: ON DE ,RATION CK R
caner1 gavEyaffirm un apcnahyofp,Bury one of cfollowingdecl
11 I have and will maintuina Cenilicm,of ConsennnselGinsure far Workers Cmnpe.- I3 f ' E STORIES TYPE CONSTRUCTION
vtniom as provided for by Section 3700o(the LaborCodu,far the performance of the
work Iia which this permit in issued. 11X'I'11RGS-PF,R'fHAI'
(] I have and will naimain Worker's Compensation Insurance,as required by Secf n
3]1X1 of die WhnrGde,for the performance ofthe work for which this permit is i. ed. GAS-L'A.SYSTEM-I INC.40I1TLET5 OCC.GROUP
My Workers Compensation Insurance carrier and Policy number are: (p
Carries Policy No.: GAS-EA.SYSTEM-OVER 4(EA) 0
CERTIFICArF OF EXEMP[ION FROM WORKERS' GREASFIINDUS'TRL WASTE INILRCEYI Ok
COMPENSATION INSURANCE BUILDING DIVISION FEES
(I his s,ctionneul not he,d i,letediIthe pennitlx on one hominid dollars(%IW) GREASE[RAP
m lees) PLANCIIECK F13P,
Icenifylha nthe peformumcoflheworkfnwhichad,permit is issued,[,hall SEW12R-SANITARY-STORM EA.2W FT.
not employ any pecan in any manner so as to become.subject In the Workers'Compen- ENERGY FEE
Z satin.Laws of California.Data WATER HEATER WNENVELECIR
ZQ Applicant \ GRADING EYE
(=
NOTICE 10 APPLICANT:IT after making this Ccniram,of Exemption,you should WATER SYSTEMOREA'TING
a +
becomesubjectm the Worker's Compensmion pa,kin o,of doe Labor Cute,you amen SOILS PEI!
fach,vith wn.ply wiih.mch proviorsor this permit shall be JeemedrevukeJ. WAYT:R SERVICE!
7 z CONSTRUCTIONLENDING
LNG AGENCY NEW RESIDENTIAL PLMB. SQ,FL PAID
U _Date_•_- Recti to
0 Ihercby nation that rn
then is lending agency for the performance of _
liP the work for which this permit is issued(Sec.3010.Civ.C.) 1�n
Lender's Nana III / \ ( ITOT L:
C.7 Leader's Address TOTAL:
Ly, y 1 edify the(I have read this application and ,;it.that the above infornnnion is BUILDING FEE
k. rp
sacred.!ogres wcnmpI,with all city and mtrntyordimmo.,andstag lawsrdedngm QTY. MECI IANICAL PERMIT FF,
V Z building construction.and hereby authorvc reprtsenletives ofthi.s city to enter upon the '
aGnx-mentioned property for inspection pou,nows. PERMIT ISSUANCE
(We).,,cc rat save,indemnify and keep harmless the City of Captain.against ELECTRIC FEC:
liabilities,judgmems,casts and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
consequencein of the granting of this perinit. O. PLUMBING.PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNI'1'('TO Io,mX)CFM) -- MFCHARTC:AI�FBB
SOURCEREGU TION `
l s / AIR HANDLING UNIT(OVER 10.00(i � \, CONSTRUCTION TAX Il l
fA I' Conwnur Date F:%HAUST HOOD t
ngramreu pPt / ) III HOUSING IT FE
HALARIX S MAT17RIA DISCLOSURE I
Will the applicant or future building eccupent store or handle hazardous material DENTING UNIT(TO 100,00B BTU)
as drained by the Cubeninn Mu tieipel Coda Chapter 9.12,anti the Health and Safety lull
Coda,Section 25532(01 HEATING ON['['(OVER 100,000 B'fU)
0Yes FNo
VENTILATION FAN(SINGLE RFSID) PAID I P.• [)an Recsipl
Will the applicant or future building occupant use equipment or devices which
ait ha,,w acs air contaminant ontanant ii Defined by the Bay Arca Air Quality Management BOILER—COMP(3HP OR IW,000 B'N) TOTAL y
Disuic" BOILER—COMP(OVER IIXhIXN)BTU)
❑Yds L]No
1 hams toad the hs mn matcntib,mcmr mems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
tomia Health&Safety Code,Sections 25505,25533 and 25534.L undersand that if the NEW RESIDENTIAL NIECE. SQ.ET. /
building does nal cunendy have o tenant,that it is my responsibility to notify the occupant
e he phi 'mmoZ nsy. �(
Owner orae it... agentAX 'aid 'COTAL: ISSUED IIY:
OFFICE