S 1190 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIT I1I NO. q 19 O
' BUILDING DIVISION .APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIh'ICA"1'ION
- - ;SANIARY N(l. APPhICKION SUBMITfAh DAfC
BUILDINGADDRESS.
0')9-2 ORAlki 4 `}� .Z—
OWNERE: E_
OWNERS PHONE. CONTRACT'OR'S NAM ' LIC NO . CON'I'IiOLX
(3o3 ,a SfL�u AltanN 2S-7 3z
WGLL{TACL/BNGINEER: LIC NU'. ADURESS'.
L•AIZA WJ:j 5 '366 >03Sr •$ Aii kJvt.rne /+td Ger?
CONTACT: PHONE: BUILDING PERMIT INFO
S J••-?`7_Q9 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLGf PLUMB M111?CH
(G ❑ ❑..
LICENSLU C(INTRACfORS DI CI ARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I humb,affirm that it In hearted modprovisions DI Chapter 9 moularamull
M=Z withSection 7000)DI'Divisonal 3oftlocBmincisruridP 1 mC I J yliccn%ais - RESIDENTIAL'
Fc� of If J a PERMIT ISSUANCE El STEVE [:1 KITCHEN REM(IDFL
�UU I:u Cl I Lie.# S4 7$�� -
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)Eric C^mnm—I���y APPLIANCCS RESIDfiNTIAL []ADDITION ❑I'LUMBINC RF.PII'li
{{nn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
FmZ I understand my plan.,shall be used u.public raonls MODIFICATION
O'Z�p UP TO 2N)AMPS ❑INTERIOR _ El CHIMNEY REPAIR
p:4.E'.a1 Licenced Pmfc,sinnnl t 211-1000AMPS IMPROVEMENT �SWIMMING POOLS
OWNER BUILDER DECLARATION Contractor's
OVIiR I(IINIAMI'S ❑BATH REM`D.LIRFI'AIRZ DEMO TICK
d I hereby m(Srm..a m Burin from the Cntn....Co I Any
a Low co the ❑OTHER
Wy U following rcmm,.(Section 91131 S ct,alncs,and P e,dearns Calc:Any city Err county SIGNS ELECTRICAL
W a 1 y which requires a permil ea construct,ulmr,impmvq demolish,or repot,any mmaurc
�j
Primus t I: 4 the applicantf hpermit t II g d.f tcmem SPECIAL CIRCUIT/MISC.
WAVE T
,>.
'bar h I :Jp It tit p (of be C I v L Law'(Chapter 9 COMMERCIAL
'
Icon g thSect 7000)(11 Division J of the Holmes, JP f ,Cdc)a IF.MP.METFRORPOLEINST.I
d that h e pt'h ref d tM1 b . f tit II 6 J pf A y lai on of ❑NEW BLDG/ADDITION ❑DF,MOLITION
"N
Section 7131.5 by any applicant for a pamnubp.us the applicant to a civil pcourt, It POWER DEVICES []TENANT - ❑FOO[)SERVICE
not more than five handled dations($500). IMPROVEMENT
O ❑ I,n,owncrot'hc n ycmp yeas wi ger as pensu SWIMMING POOL ELECTRIC
pmpc y,o,in w fM1wn fhei,solc mm 'iou' C1 OTHER
1..� will do the work,and lha,he Calif.,,,),,
alif is not,Lica r,Laos costsor all
apply in an Busimcof DOFEBT'-SWITCHES-FIXTURES
GC and P I C wit,:The C ' t 'n L L I>4.t t pplY t owner of
5� prop y ho hldsor imprntao,hurcon. oil whod.c,Loch vooll,h' If ,through NEWR NTIAL VLECTR SQ ET.
his ply .,provided that b imp 1, ret'intended tffcrcd'tor SQ.FI.FLOOR AREA SISQ.Fr.
sale.If,however.the building or improvement is cold within one year^rc^mplcdnn.the
er-hrodder will have the burden mf proving that he did nm build o,Improve for par ^
pu cofsalef. • . � TOT r A I D
(]1,ns owner
.1 the property,am exuhu,lvcly commuting with licensed cnmmaors to
entrance,the pJ t(See.9114 Business and P I s CodI ne Commicon:Li-
a 11.1 does a.,apply to an owner of property who builds(it improves thereon. nd QTY. PLO IN .RMIT
who nt I.fi-mohp Iva,with rOadocutq)licensed itl he C....tr on" m '®
License Law. PERMIT ISSUANCE
(]I am crump'under See ,B&P C for this reason -
ALT'E.R-DRAIN&VENT-ONNI EN(EA)', C (pUrc�INr�ul'AI'ION
Owner Data
WORKER'S COMPENSATION DECLARATION - BACK PLOW PRGTECC DEVICE
I hereby of oro under penalty of perjury one of the following deelmodicom.
�Ihavc and will nmimainu Cafifcun of Consenno,elf-insure for Workers ComPen- DRAINS-BOOR,BOOP,AREA,GOND. STORIBS TVPE CONSTRUC'PIOD
a
tion,ac provided for by Section 3900 of N,Labor Code,for the performance of the
r whhh this permit is issued.. 1'I%TURFS-PER THAI'
I ,
w have end will maintain Workers Compemmion Insomnec,a,rtyuired by Section -
3900 of the Labor Code,per the pelormtmceof"'ha work for which this pemtit is issued. GAS-EA.SYS'TEM_1 INC.G OUTLETS OCC.GROUP APN
My Worker' Cy�mpensmigpynsu,anec toric,and Policy or
Curia: �TAT� f•%✓n Policy No.: ?Y GAS-P,A.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA5IJINDUI'I'RL WASTE INTIiRCEPEOR
COMPENSATION INSURANCE - BU .I N DIVISION PEES
(This ecaion Iced tort be cumplacd if the permil ie for unchunJrcU Jnllun($Iq1)
GREASE TRAP PLANCIIEC IP
or IaxJ
I ccnify thm in lite perlorm:mctorihewnrkliawh¢hthis Wnnit is i,,wed,Ishall SEWER-SANITARY-STORM EA.21X1 FL BNCBGY Eli
not employ any person in any manner so as to hecon a subject to the Workers Cmmpcn-
,n ,:Erin.Laws ml California.Done WATER HEATER WNEN'I IF,LECTR GRAD F
ZApplicant 1
rn NOTICE TO APPLICANT:IL after making this Cemlfcam of Exemption,you should WATER SYSTEMIEBEATING 5011 FEL
fti loom,euAjmt to the Workers Campcnsmion Pmvisiuns mf the Lub...Code,you rmtsf
k>w r>•t fodhwith comply with such pnrvisnn,m,this permit.hall he domed revoked. WATER SERVICE
ILL Q i.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMB. SQ.Ell PAID
Data Rmccipt#
I hereby affmnhor atom k a constmmion handing agency Ionmla
he perfomwof
N the work iia which this iysucit(Sec.31X17,Civ.CO 'ITHAL:
O U Is J b '1(TEAL'.
{IJ IuJ 'AW .. BUILDI FEE
y Icertify that I have read tb appl f and state that the h information is
at, c rut.l agree to comply with all city and county ordnance:and state laws nlatog In QTY : MECHANICAL PERMIT PEE SEISMIC FEE .
U holding conslaramo,and hereby authorize representallves ofthis city(Denier upon the
ahmve-mcntimned Notary for inxpead u l Purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupcnino agaimt -
IiabilitisjuJg^toms.rn,ts and exlwn,es which m.y In any wayaeem,tigainstsmd City ALTER OR ADD:FO MECH. PLUMBING PEE
onsc,macc of me gmr ting of fhi,pcmth.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALJ:FE
SOURCE REGULATIONS.
2 AIR HANDLING UNIT(OVER 10.000 ChM) CONSTRUC'T'ION TAX
Signanin cit A' IirnnUCnnwetor Datel EXHAUST HOOD(W/IIUC'1') HOUSING MITIGATION PIT.
HAZARDOUS MATERIALS DISCLOSURE -'
WIII'he applicant...from building oecupradoe ,,handl,haeonlmus mmcrial HEATING UNIT(TO I OB.(111131 IT
on,d,fned by the Gtperino Municipal Calc.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER W.W11 BTU)
code Saef,n 25532(x)'! _
Yes VENTILATION FAN(S INGLE RE SID) LAID Dom RccciP'p
Will the aPplu,nol or furore building occupant use equipnant or devices which BOILER-COMP(3HP OR�IfNI,(NNI BTU)
hazardous air containment,as deficit by the Be,Arca Air Qualify Management
txnin'! BOILER-COMP OVER 100.000 RTU)
ElYex rr
AIRCONIII'rIONER ISSUANCE DATE
Ih lead the h N : 't ial y'e r' J CI Pt,1.95 fthc Cul' -
form.Hand,&S I"y Carl,Sectim,25505.25533and25530 I DondI that if the NEW RESIDEN'T'IAL MECII. SQ.FI'.
h 'IJ"g d ws nm,,molly h vie tenum,tit t f ro my r.po..bili',to noddy the I....Paul
of the m;uimarwhich met prior to issuance of a Cenreenm rel"Occupancy.
Own authorized agent
Uma TOI'AI-: POSTE11
0FFICE