S 1647 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER`L-1IT NO
BUILDING DIVISI PLICATIONYPE MIT PLUMBING.MECHANICAL �J 1647
IIUII.DING PROdti(Tf l[)EN'1'I I0CA1'ION
UILDINGADDRIi$S: SANITARY NO, API'LICATON SUBMI'1')'AL DATE
WOL-F + DrA
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WNEIVS NAME: PHONE: CONT 'S. ICA LIC NO:
N/C C(1 I'ROLp
WHO LCUENO1NEER: LIC NO: )DH t S: �� ❑
CwrACD 111IONE: BUILDING PERMFr INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LF. PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT 17EE
I hereby affirm that I am licensed under provisions of Chapter 9(a ntimanciag JOB DESCRIPTION
D0Z with Seation TXXpafDivixian 3oflhe nosiness and Professions Cole,and my license is RESIDENTIAL:
�00_ ast, LL PERMIT ISSUANCE
OGUF^ in
(r Ch ss Lia.X • ❑SFDWL ❑KITCHEN REMODEL
6 U ici_ APPLIANCES-RLSLDIiN'1'IAI. ❑ADDITION ❑PLUMBING RE.PIPE
N 6 6 Da¢ Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p N UP TO NXl AMPS Z I understand my plans shall be used as records PANELS MODIFICATION
OZ�O
n �IR ❑CHIMNEY REPAIR
mcmat lmfcnso°1 IMPROVEMENT- 5
E3 SWIMMING POOIS
DECLARATIONaq the
OWNrnR-exempt?R mmeCA )EU EPAIR
DEQ=OLITION
IL' Q I hereby affirm than or
I exempt Tll<mr.4 License Law(or Ne OVER 1000 AMPS O BATH RECGs�V R
a5�OaU following reason.(Section]f131.5.Business and Profesxirn,Code:Any airy or county SIGNS ELECTRICAL ❑OTHER s
LL13 LL vfi which requires a permit to construct,alter,improve,demolish,or repair any,acture
priorm as issuance,also requires the applicant forsuch pennitmEleasigmad statement SPECIAL CIRCUI VMISC.
y matheia licensed punvtlllnlmlha pr(1Vl,lollx nfthe Contruemr,License Ltw(Chapten9
GO (commencing with Sectinn]fNXO mf Division 3 ofthe Buxinanamtd Prnfcsxinm Coxic),r TEMP.MCI'HR OR POLE INST COMMERCIAL:
6 6 ca� that he is exempt therefrom and the basis lir the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
SectionTatL.5 by any applicant a permit subjects the applicant m a civil penury or POWER DEVICES
=y ❑TENANT ❑FOOD SERVICE
FZQrat more than frvc hundred Jnllars(SSW). OTHER IMPROVEMENT
❑Ins nwncrnf the proplro.nr mYempinycen woffere Iasiale(Sn.7044,x of men, SWIMMING POOL ELF.C'1'RIC
will do me.ime,aide the omunamnnls Licandt La.del li not all,
wmaleat ❑OTHER
WLL 3 m and enyProf%niob Coda.The oyes th)mon License Luw docs not app)y s if owner nl OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves thereon,and who dreg such work himself on through
his own employers,pntvidal that such racm 4d w arc not intended or offered for NEW RESIDENTIAL CLEC'R SQ FT.
sale.IL howevee the builJingorimprovement isenid within one year of nnnpletion,the SQ.FT.FLUOR AREA SISQ.FT.
owner-huddler will have the burden of proving that he did nun build or improve for par- ❑flA� 1(D AAIB(
pevol"de.L IvA nil 0
1,Its owner Of the property,am exclusively comuacting with licensed contractors to
cataract the project(Sec.7044,Rusmexx sad Profesdom,Cale:,The cntnmctnr'x u-axe CITY Uf GUf'tY{ IN
Law does not apply m an owner of property who builds or improves thenand en, QTY. PLUMBINGPERMIT FEE
who comets for such projects with a mnann,E)licensed purloin,,,the Conmtemr's
License I.nwPERM ITT ISSUANCE
^ ❑ I am exempt under Sec. .If&P C kit this reason
�ti r
ALTER-DRAIN&VENT-WATER IRA) VALUATION
Dae
WOR KIR'S COMPENSA I'ION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury ane of the following declination,
I hove and wi 11 otaintrina Ceriifi<ate of Conxem to rel Fi nm re on Work,xC,,mpen- DRAINS_FLUOR,ROOF.A RHA,COND. STORIES 'TYPE CONS'I'It UCTION
nation,as provided for by Section 3]0)of the Labor Code,for the prominence of the
loo
r which this permit is issued. FIXTURES-PER TRAP
1 have and will multam.Worker',Compensation Incur nce,as regtimad by Station
37 (iilia ilia TThe�yrafporgrmaanncee of the work for which this pewit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET' OCC GROUP APN
MY Wrlli /Ad1 WttlGK.1Y r11)yol cy Nay) n era a: GAS-1?A.SYSTP.M-OVER 4 RA)
CrarierVY�
CERTIFICATE OF EXEMPTION FROM W IRKF,RS'
COMPENSATION INSURANCE GREASPJINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thin section aced not he cropland tOhe permit is forone hundreddoll:m($IW) GREASE'1'RAP ---- - - —
or le".) PLANCHECK FEE
Icenilytbut in theprrformaree ofthe wink far halt this permit i.Y LYmtnl,a shall S17WFit-SANITARY-STORM CA.21X11'1,
no an
cloploy y person in Imy manner sr as it)become subject to the Workeri Comper, ENERGY FEE
Z
satinrt latus of Caliromia.Data WATER HEATER WNENI'/ELECfR
Z 0 Applicant GRADING FEF.
Oil, NUDCR11)APPLICANT:If,ager,making thin Certificar of Exemption,you should WATER SYs'IEM/IREATING
Nissan subject to the Worl,crx Conmeruatiou pmvisirnx of the Labor CBW,you must SOILS IEE
!-T Flo Rrdiwinh mntply with such provisions or this permit drill be dawned revoked. WATER SERVICE
WW Q
UO CONSTRUCf10NLENDINGAGENCY NEW RESIDENTIAL PLMIL SQ.CL PAID ar
I horwhichi fix
isaconama.30lending agency,for the performance of Use Receipt
LL Fthe work for which This penin is issued ISe<.3(197,Civ.C.1
Lender's Name 'TOTAL:
� �
Leader's AAJress '1'(HAL:
0. 1 edify that L have read this application and state that the above inlonnation is BUILDING FEF•
V) comect.l agree mcomply withal)city and county ordinances and star laws relatiagto Q.fY. MECHANICAL PERMIT FEE building consummator,and hereby initiation,represemativea of this city to enter upon the SEISMIC FEE
abuse-memiuoed property for ovate,ino purposes. PERMIT'ISSUANCE
(H'a)agree to save,indenmify and keep harmless the City of Cupcninn against ELECTRIC FEE
Iiuhilitics.jnJgments,casts unJ uxpenxx whichmryhuay wayacemragaimn saidCy ALTER OR ADDTO MECH.
J. nsequenr fthcgruningofthispermir PLUMPINGF r
APPLICAN L ILL roMPLY W"DERSTANDS AND W .L NON-POINT AIR HANDLING UNIT fTO 10.00d CFM)
MECHANI L FTai
SOURCER GI DEISTS.
AIR HANDLING UNIT((1VIIN IU,g)O CFM) CONSTRUC'f10N
ignum AI a ax rr f�I/Due EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION E
HA'r RD US MXIER ALS DISCLOSURE
Will the applicant rto um Molding occupant store of handle hamrJoux material HEATING UNIT(TO 100.001 BTU)
as denied by the Cupcninn Municipal Cole,Chapter 9.12,and the Health anti Safety
_Code,Sartori 25532(a)'! HEATING UNIT(OVER NI,(XXI RTU)
❑Yen PAID
VENTILATION PAN(SINGLE RES ID) Data ReceplX
Will the applicant or future building occupant use equipment of devices which BOILER-COMP(3HP OR I W,00B BTU)
nit harmdor,air amtamiour s an died by the Boy Atria Air Quality Management TOTAL:
❑i,tein: /Ycx BOILER-COMP(OVER 100,0I(i /
El �/yew
I leave read the hasardoux materials requirements under Chapter 6.95 of the Cali- A)R CONDI'1'I ONEISSUANCE DATE
brain Harlin&Safety Calc,Sections 25505,25533 and 25534.)undemmndt that if the NEW RESIDENTIAL MECII. SQ.ET f6-
buildingdas not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which oust be tact prim to issuance of u Certificate of(echo ncy. y/S
Owner ormill zed agent Date TOTAL: ISSUED BY:
OFFICE