S0077 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.CTRICAI. PERMIT'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIL\N'ICAI. fylQ\J�
BUILDING PRO.IN(YI'IUENTIEICA'I'111N �J
ILUINGAIlDRE55: SANITARY NO. APPLICAONSUBMl'rl'AL DAI'li
_ 8 ONIi CON RA Rf IC NIC
-eW 'fyVAME' NIC CON'I'ROL0
�\ Cfi1TRCT/ENGIN F.R: LIC NU: AUURC: f ❑
ol&
COM'nC'I': PHONE: BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) DG HLEC'I' PLUMB MECII
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY EI.f:CTRIC PERMIT FEE
I hereby affnn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C=Z with Scdinn)(1001of Uivisinn3ofthe Rosiness anA Prof cions CnJu and my license ix RESIDENTIAL;
won in full lines wed cfca I'ERMI'I'ISSUANCIi ❑SFDWh ❑KITCHEN REMODEL
qWF
<—U License Class Lia# APPLIANCES-Rf51UFMIAL ❑AUIIITION [I PLUMBING KFiP1PL
hGG Date Contmam ❑MULTI-UNIT C]STRUCTURAL
ARCHITECT'S DECLARATION PANELS ODIIICATION
OZr=ZI understand my panscball be users,public recordx UP T(12101AMPS
O ❑INILA OS I MNHY REPAIR
r• _n 'W Licensed Prufeaional 201-1000AMP5
IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMT'S ❑RATH REMODEIIREPAI [I DEMOLITION
C C 6 I hereby affirm that I am exempt from the Concsaoh License Law for the ❑OTHER
�q d U fallowing reason.(Section 7031.5.Bmiimss and Professions Gds:Any city or many SIGNS ELECTRICAL
41'3 4 y wbich¢yuiras a permit In statistical.then,improve,demolish,or repair any sauclnm
Ua prior to its Issuance.also requires the applicant broach permit to file v signed statement SPECIAL CIRCUH'/MISC.
Ythat he is licenced pursuant at the provisions of the Contractor,License law(Chapter 9 COMMERCIAL:
ad0 (commencing with Section 7")of Division Sof the Business and Professions Cade)or TEMP.METER OR POLE INST.
q q c that he is exempt(baseman and the hasls for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC^+ Sedinn]O31S by any apPlicnm torn permit subjects the npplicannu,civil penalty til POWER DEVICES C'I'ENAN'I' [D FOOD Sit RV ICI:
y not more than live hundred dollars S500). IMPROVEMENT'
=Q01,ns rwner of the pmp<ny.or mycmployces with wagesaa hheirsulccomptnvtinn, SWIMMING POOL ELECTRIC [I OTHER
F-. will Anna wurk.and theswcmre is not intended unarmed for ste(Sm.7044.Business
L3= and Professions Gds:'rhe Cnntmnm'x License Law does not apply to an owner of OUTLETS
properly
properly who builds or improves thrust ,and who Jrwd,tach work Iinasdf or through
his own employees,provided that such Improvements are not intended or offered lin NEW RESIDENT[Al.ELEC'I'R � ' 1'
sale.If,however.the building of improvement is sold within one year ofcompletion.theowneSQ.1'I'. .l Aali$� SISQ.FT.
-builder will have the burden of proving that he did not build or improve for purr. - V
rise of soled. TOTAL: �y n
I.is owner of the property,am exclusively curtailing with licensed contracmhs J11
In Y1v 3 z4zj
construct the prover,(Sec.704L4.Business and Pnffcssinns Coodul The Contractor's l.i-
c sdose,e Law ds not upplymor owner of pmpeny who builds,,,improves Houma sad QTY. PLUMBING PERMIT FEECoy//11
.incarnation for xnch projewls with.connections)licensed P...t io tho Cc nlmcme, Vf LUY
License Lrw. PERMIT ISSUANCE
❑I tan exempt under Sec ,B&P C for this mrsnn
ALI ER-DRAIN&VENT-WA'f17R(EA) VALUXI ION
Owner Date
WORKERS COMPP.NSATIONDmLARATION BACK FLAW PROTECT.DEVICE
1 hereby atfmt under penalty of perjury one of the following dctlaration,
�Ihome and will maintain v Cmifcato of ConsenUo self-insure fn Workers Cmnpcn- DRAINS-FLOOR.ROOF,AREA.GOND. STORIES TVPECONS'IRUCTION
sati... ns pmvidcd for by Section A(NI tar 0c Lvhnr Cole,fur the ptrfnnreacc of the
work Iia which this permit is issued FIXTURES-1'BR TRAP
I have and will mountain Workers Compensation Insurance.as required by Station GAS INC.JOUTLEfS
3ADoflhetabor Cade.for the performance of the work for which this permit is iswN, OCCGROUP AIN
My Workers Corpcmahion Insurance carrier and Policy number are: GAS-EA.SYSTI;M-OVER J(EA)
Carrier. Polio,No,:
CE;RI'I FICATE OF EXEMPT[ON FROM WOR KE IRS GREASEI1NDUS'1'RL WAS'117 I N TERCEPTOR
COMPENSATION INSURANCE, BUILDING DIVISION PERS
(This section need not W completed ifthe permit is Torous hundred dollars(SIM) GREASETRAP PLANCHECK MF.
or less)
Iceda"Ia ntheperfa tancenr Wewor fiawharloth pe tisi.csved,l shall SEWER-SANITARY-STORM IIA.21X1 IT. ENERGY TLE
not employ any �anallou r{vu not '�Y:Wr�C�t�pmt-
O z ,Nino Lvws n bfnrn�l , ��TM�.I t Y9 / WATF;R HEATER WNEMIELECTR r GRADING FEE
'¢Applicata a
/Z— '�, NOTICE hp APPLICANT.If,dlvr making this Cenincmc of Exabor ,Co.you should WATER SYSI'EM/TItGTING SOILS 11:E
F Income subject y+the Worker's Cnnrpcmuuon envisions of the Labor cokere,you must
fonhwlth comply will Csuch ONSTRUt un tar this pcnnil shall he dcmncA revoked. WAFER SERVICE
PAID
CTION LENDING AGENCY NEW RESIDENTIAL.PLMR. SQ.PC 'cipl#
UQ I hereby a0mt that more is a construction lending agency for the performance of
f1. the work for which this perms is issued(Sec.3097.Civ.C.)
0 O U Leader'N Name RYIAI.'
U Lender's Address
D. I certify that 1 have read this application and state Nat the above information is
Fto impact Iagreeto aanply with all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE V Z building construction,and hereby authorize representatives of this city,+enter upon thenNoa-n¢mioned mpedy for inspeelion purposes. PERMIT ISSUANCE(We)agree to save,indemnity and keep harmless the City tat Capetian ausistIiabillties,judgmene.tsts andexpenes which may in any way woorcagaind omdCity ALTER OR ADI)TO MECH.
I conuyuencc of mining of thi>permit.
APPLICANT C 9 RSTAND. ND WILL COMPI 'WITH ALL NON-POINT AIR HANDLING UNIT LTO I0,(l dCFM) MECHANICAL FEIS
SOURCE RE- MONS.
AIR HANDLING ON]r(OVER 11,100 CPM) CONti'IRUCHUN'IAX
SN�
Signature o(Applic IrIV, tracna f c EXHAUST IIO(lD(W/DUCq HOUSING AII'I1GA'TION PFiIi
HA]ARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupantuom of handle haaarduus material HEATING UNIT LTO I Of"BTU)
as delinul by the Cunci loo Municipal Cods.Chapter 9.12,and the I Iwlth and Salcey BEATING UNl'I'(OVER 100.000 RTU)
Calc,Section 25532(a)'f
C]Yet ❑NoVENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or fumte building saturation use computer,or devices which BOILER-COMP(3HP OR 10,1100 BTU)
mil In colon,air tumnmiarm,as Mtined by the B.,Arm Air Quality M....anem 'TOTAL:
Dislrictl E(IILER-COMP(OVER I(0),(KK)BTU)
pYa, F1 No
AIR CONDITIONER ISSUANC17 DATE
1 have read the haamdous noes 255 5,255 3 an under5 .1 and rsta of the if the
, Gsmiu III&Safety Cade,Sections 25505.25537 and 25533.I understand that if the NEW RESIUEM'IAL MECH. SG.FT.
building Jttcs not cumm�ly bucca mnenL Ihun it is my resphntcihilRy lu ramify Ihaeenpan
of hhc rcquiremtnts wbich must be tan prior m issuance of a Cmillcae of Occupancy.
Uwner or authorized ugem
Date TOTAL: ISSUED BY:
OFFICE