S 1513 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EURcrnICAL PLBAII'I'NO. 1513 1 3
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-ME&ANICAL V\
BUILDING PROJIECP DYWFIFICA'l RIN
BUILDING ADDRESS: SANITARY NO. AI'1'LICATION SUIIMI'I'I'AI.DATE
r r' t, �l g
OWNER'S NAME: /1 PHONE: �ON DAC�ORS NAME:/J LIC NO.
(T U I/O 4 N l 1 9 3 � ' NIC CONTROL p
ARCIU ECHENGI .BR: LIC NO: ADDRES : ❑
G
CONTACT: PHONE: ISUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEL• ❑ )C ❑
1 hereby arfatn hw I arta licensed ander grovi lona of chapter o(cnmmemmrg JOB DESCRIPTION
won with Section]IXXgnfMvisloa3ofthe Bmi.essa.d Professions Cde,eadmy license is RF I .NTIAL,
m00 ser PE0.M1'1'ISSUANCE
I Iy F L ease r Cl... effect. 70 9 .�', ❑$FOWL ❑KITCHIiN REMOUEI.
aUU License lms 6 Li
N q Dam Comoumc Tin Vie'-- APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
Q 3
ARCIBrECT'S DECLARATION ❑MULTNUNIT El STRUCTURAL
PANELS MODIPICA'1'ION
Z O , I nndcrswnJ my plans.ab:Jl Ito used as politic rennds
OZQ UP T021NIAMPS C1 INTERIOR El CHIMNEY RIiI'Ah
ate^,LLI Licensed Professional 201-1000AMPS MPROVEMENT SWIMMING POOLS
cad ad C C Q 1 hereby affirm Oat I amexempt the Contractors License Law for the OVER INXIAMP$ TH REMODL'UREPAIR DEMOLITION
X3 d(� fallowing reaum.(Section 7031.5,Bt ainess and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER
W p.�" which reyulres u permit m amarum,alma improve,Jcmnikh,or mPair any swewm
F-Vl fofnn Prior to taei"masee,also ro"n'sv the applicant forxuch genal,,,dile a signedsmmm'm SPECIA I.Cl RCU I DO ISC.
that he is Reenact Is...man un he psoI,mmaof the Commons License Low(Chapter 9
Ia+1�aOC (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)Or TEMP.METIER OR POLE INST. COMMERCIAL
a a c C hat he is exempt herefmm mrd he basis for he alleged!exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^y
Section 10115 by anyapplicam for a permit subjects the applicant nr a civil Penalty of POWER DEVICEsi EITTNANT ❑FOOD SERVICE
1„ amt mere a ban five hundred dnius, 5500). IMPROVEMENT
50 ❑1,as owner of he progeny,or any employees wife wages as heir sole compensation, SWIMMING POOL ELECTRIC
IF-� will do the work,and the suucture is not intended or ollired for sale IS
7I44,Business ❑OTHfilt
S4 m and Professions Cale:The CallraclOra License Law Joins not apply ns un owner of OUTLETS-$WITGHIS-FIX'I'ORE
66 property who builds or improves hereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELEC'R SQ PI'.
sale.If.however.the building or improvement is sold within one year of rollaction,the SQ.F7.FLOOR AREA LSQ.IT.
owner-hu ildcr will have he lumen of proving that he did not build or improve for put- PA p
P's'.III sale,). TOTAL: 0
El 1,as owner of the Property,um exclusively comraaing with licensed coarse....w
constmm he project(Sec.7014,Business and Professions Code:)The Connector's Li-
mrse sew docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE 14 /)dryLQ
who contracts for such pot with a contractors)licensed pursuant o he Conuacrols
License Law. PERMITISSUANCE
❑I am l.al,a nn ter Sec. .It&P C to,his reason L(Ir
4:W0 Ft
ALTER-DRAIN&VENT'-WA'fBR(EA) TON
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following Declarations:
❑Ibave and will maintains Cenificamof Consenun ulf-insure for Workers Compen- DRAINS-FLOOR,RODE,AREA,GOND. STORIES TYPE CONSTRUCTION
as pnrvWcJ fur by Section 3](NI of the I,h Code,for the perfommnce of he
work for which(his Permit is aid. FIXTURFS-PER'I'RAP
Ll I have and will maintain Worker's Compensation loo ronce,as required by Section
37W of he labor Cad,for he nrkmence of the work for which his Permit issued. GAS-CA.SYSTEM-I I NC.4()O'f LETS FICC.GROUP AI'N
My Worle S �ppensati Insvmrl�e a rundl'nlicynumher arG.,
Cartier. S,/A 1/ ✓wd Tei'nlicy Nu.:�1f-4 / o6ii S GAS-PA.SYS'18h1-0VEH4(IiA)
CERTIFICATE OF CXEMPI ION FROM WORKERS' GREASIYI NDUSTRI,WAS'1'IE I NTERCEMDR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Tlaisxccalonneedmn hcon.pleled it the pernaia lx Gnome hundreA dullum($1(NB GREASE 114Ap
nr
less) PfANC11ECK PGL
I certify that,.the performance ofthe work for which this permit is ixsud,Ideal SEWER-SANITARY-STORM F.A.20010..
not employ any person in any manner so as to become subject o the Workers'Compen- ENERGY ITC
,2$ satin.laws of Colvarria.Date WATER HEATER WIVENTIELECfR
0 Applicant GRADING RBE
L5NOTICH TO APPLICANT:If,nfYcr making chis Curaificmc of Exempainn,you should malliedhWATER gY$'fEM/1'Ris'I'ING SOILS PEE
a Lw became allied to e Wmkcr'x Cnmf h
penesion provisions oe Lubar Code,e,yon mu
W forthwith comply with such provisions or dis permh shall be deemed revoked. WATER S17RVICE
Z)z CONSa,m,l aT10N LENDING.AGENCY NEW RESIDIEN'IAI.PLA1H. SU.Ff. PAID Date eceipt p
VO work
rmhonhereiesued(Sec.30lending agency far the performanceof
r+ thewak l is which this Permit In issued(See.3f19],Civ.CJ
�' F'•' Lender's Nunn IDEAL
C) L) Lender's Address TUTAL:
�•o a BUILDING '
1 certify that I have mad this application and state that he above information IS si
correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
Ll z buildi....mmactma,ond hembyaumne,rePresentetives admix city to enmh
rupon e SEISMIC FEE
above-mentioned gnmety for inspection Purposes. PERMIT ISSUANCE
(We)agree to save,indennlfy and keep harmless the Cay of Culnnino against
liabilitina.jndgments,aDafs and ulxnscs which nuay in any way anrua isamstsaid City ALTORORADDTOMECH,
In nsegn ).the%rami.g ni"AIN
bis pemtit. ;'COMBING PEI;
APPLE,"Ons"P 'T'U 'DNRSTA NOS AND WILL COMPLY WITH AI. NON-POINT AIR HANDLING UNIT(10 10.0111 CFM)
50I3RC RCGU AT :gam— MECHANICAL P.E
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIOJ TAX
Sig, u," t irant/C nr Datta P.XHAUS'f IIOOD(WIUUCI'I HOUSINGMIT iATION PCG
BOGUS MATERIALS DISCLOSURIi
mpplicam or Nmre building occupant store nr handle hazardous material HEATING UNIT(TO 100.000 BT U)
as def d by the Capetian Municipal Cale.Chapter 9.12,and the Health and Safety
CW.Iii Semon 255J2m)? HEATING UNIT(OVER 100.010 BTU)
[J Yes ❑No VENTILATION PAN(SINGLE RBSID) PAID
. Will the applicam or Goatee building omcpum use equiptned or devices which Ume Recciga p
ILER-COMP(JfIP OR 100,000 BTU)
emit huzatmhs it emimminams as defined by he Ila,Area Air Quality Management BOTq
Disaw" BOILER-COMP(OVER IOB,W)O BTU)
❑Yes Fl No
I hive mild he hamNou.s materials tequimmenrc under Chapter ts95 of the Cali- AIR CONDITIONER ISSUA14Cf.DATE
Toms.14,61h&Safety Club,Sum as,25505,255)3 and 25534.1.ndcaamd that if the NEW RESIDENTIAL MECII, SQ.Fr.
building Joe,nomutetly hove sacnom,that it lanky responsibilitymnmily the ncapant
of the requirements which area he all prior m issuance of a Certificate of Occupancy.
Owner ormthmizeJ ager Date TOTAL: ISSUED BY:�
OFFICE