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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -RLE(A RICAL
BUILDING DIVISION APPLICATIONIPRRMPr PLUMBING - MECHANICAL
BUILDING PROJF,CI' IDITsITIF'ICSDON
1'13l`J U`No. 3260
BUTLINNGADDIF
"7967 P� kuz, Orioc), CZ t1 o , OA • q�/`/
SANITARY NO.
APPLICATION SUIIMITT'AL DATE
2-/z- C'
OWNERti NAM�� to ark �}}, jJjl��� �J�
IF f(LIICC�NO:
/�l Nl
COWI'):AC)OR'S NAMIi: A,`f3 Nfj��!]'
p'[�
N/C
CONTHOL41
ARCHITECT' GINEER:
A�I�IV
ar��elu,�ied
CONTAC'ry I1i0NE.
BUILDING PERMIT INFO
/
cC 1 ���/��/ _nv i,l/
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECII
❑ P YCJ ❑
LICENSED CONTRACTOR'S DECLARATION
I herehyatom. In.t 1 ant Rcenaedander,ow"am.f Chapter 9 (commencing
QTY ELECTRIC PERMIT
JOB DESCRIPTION
PERMI'I'ISSUANCP.
gE3
wilhSco m9100) ofDivision 3ollheBussinessnnd PrfessionsCode,andnry license is
forma(�cy/pr,�/J 7
ESIDENTIAL'infull
SFDWL ❑KITCHIiN REMODEL
APPLIANCES -RESIDENTIAL
License Clyy�Lic.X
Dae $ Conwmor
ADDITION ❑PLUMBING RE -PIPE
EI MULTI Ll STRUCTURAL
MODIFICATION
❑INTERIOR ❑ CHIMN17Y REPAIR
IMPROVEMENT ❑SWIMMING POOLS
ARCHITECT'S DECLARATION
I mak, and my plans shall be used as public records
PANELS
UPT0200AMPS
Licemcd Pod ,"sioltit
201-1bDAMPS
OWNER -BUILDER DECLARATION
1 herehy union that 1 am exempt from the Contra nor's License Law for the
following reason l Seciian 7031.5. Reline, and Professions Cade: Any city or county
❑BATH REhfODEI/REPAIR C1 DEMOLITION
00HER
OVER 1003 AMPS
SIGNS ELECOUCAL
whhh requir.s o pond to cor"mat, aha. Improve, dum.lisb, ,,r repair any swelnre
SPECIALCIRCUrrIMISC. C
priorto its ,crane,ulsoria,wresthe applicant(orsucb Permit o rile aligned statement
that he is licensed pursuamfto the provost.., of the Contractor" License law (Chapter 9
(v amending with Wel ion]010)nf Division 3.f tb. Buri nes. and Professions QMr)arMP,
Inn he is exempt themhom and the has,. for the allegal esempni.n. Any violation nT
METER 1111 POLH INS'I'.
COMMERCIAL'
❑ NEW BLDGIADDI'I [ON ❑ DEMOLITION
Section]031.5 by any applicant torn permit subjects the applicant macivil penalty of
POWER DF.VICIS
ElTHISANT ❑ FWD SERVICE
an'moa than Eve hundred dol Iris (5500).
cotnlc Business
❑ Lo the work, adlo. propeey, amyemptended.,.nnfli dins Inside
will do the work, anJ the swnure is not intended nnsBbrtd far sole (Sea 7I44, Business
IMPROVEMENT
❑ DrHER
SWIMMING I'[R)1. 13
OUTLETS -SWITCHES -PIXY _
and Rofessi ow Cole: The Contractor's License Iaw does not apply man owner of
NEW RESIDEN'1'I AL ELIiC'IR
property who builds en impmves there,., and who docs such work himself or through
his awn employees, provided that such improvements are tern intended .r offered far
sole. IL hoveventhe huildingur improvemem is sold withinone yeurefeampletion,theSQ.
FT. FLOOR ARG
f/SQ. Fr.
owner builder will have the Wallis of proving that he did not build m improve for per
I,.1 roxaer of the property, an emi.sivtly contracting with licensed contractors In
TOT
consumer the project (Sec. 7054. Business and Profess ns C.dea The Conwero/s LI-
nse law docs not apply,, nnnwnerof property who builds,,, ana,mvs there.n.Ind
QTY. PLUMBING PER FEEwho
contracts forsuch projata with a comracmr(s) licensed pra,matm pm Contractors Conctor's
PERMIT ISSUANCE
License law.
❑ IamesenptunderSec. ,B&PCfurthistnaom
Owner Date
ALTER - DRAIN & VENT'- WATER (HA)
VALUATION
WORKERS g COMPEIJS9TION I31iCLARAl10N
BACK FLOW PROTECT DEVICE
I heraffirmehy arm under penalty of perjury one nT the following declamtinnr.
I]Ihnv, ImA wi111nninwin nCcrtiOcatc nl'Cnnscnun self -insure for Wnrkars Gtmf,a.
Code, for the perfmance of the
motion. as provided ln by Section 3]00 of the LaMn m
DRAINS- PLOOIt, ROOK. AREA, CONT.
STORIES
TYPE CONSTRUCTION
far which this Permit is stood.
FIXTURES -PER MAP
krk
have and will maintain Waken" Ca n smsmion last ... mce, m required by Section
]lip of the Labor Code, far the performance or work for which this permit is ward.
OAS - HA. SYSTEM.I INC. 4 OUTLET S
OCC. GROUP
1Z
My Worker's Evans n lnsumecc carter and Policy nun cr�n� n' -y
C.arrier:�_I au, Na: ((��/ XT
0,07z
Q�
0155,
GAS -EA SYSTI3M-OVERJ(EA)
CERT IFICAI H OF EXEMPTION FROM W OIt KIiRS'
COMI'17NSNI'ION INSURANCE
GREASIJINDUSTRL WASTE 191'EBCEPTOR
BUILDING DIVISION FEES
(This section tad not be ran"lemd iffle permit is furore hundred dollars (SI )
or Ics..)
GREASETRAP
SEWER-SANDIABY- S-1 ORM EA. 21X1 FT.
Loy any permhat in the perhanwnce nlin, work as,,xainr which this pee Wadimued,rpen-
not employ any person in any manner so u, ro become xuM1jem Bur the Worker' Camper-
F EE
WATER BEATER WNENTdil.ECrR
satiate laws of California. Date
Applicant
GRADING FEE
-Se
NOTICE 10 APPLICANT: IL abl, making this Certificate of Esemptiun. you should
become subject to the Works/s C ... uNnmtinn provisions of the labor Code, you most
WATER SYSTEMITREATING
WATER SERVICE
forthwith comply with such provisions m this permit, hall bedcancd rcvalost.
CONSTRUCTION LENDING AGENCY
IherebyalBrm ohm there is a construction lending agency for the perhumancc of
PAID
Doc X
NEW RESIDENTIAL. PLMIL SQ, FII
the work for which This Perrot is Issued (Sea 3097, Civ. CJ
Lender's Name
TOTAL'
Leaders Address
TOTAL
BUILDING PER
I certify that I have .it this application and nmmu that the above infnoradam is
QTY. MECI IANICAL PERM PP 17EE
SEISMIC HE O
corral. l agrammntply with all eityead counryordlnniccs umd Xwte lows wanting to
building rore0uerion, and hereby authorize representatives .f this city to enter upon the
PE-RMI'T ISSUANCE.
ELECT RIC FP.:
above-manimad propcny for impauion purposes.
(Wo) agree h, e, savind.nmiry and keep ba aales the City of Calmrtin..gaimst
PLUMBI 'EE
liabilities, judgmenu, costs and expenses which may in any way accrue against said City
in nn,eyue .f the granting of this permit
APPLICA r INDERSTANDS ANWll.l 'IMPLY WI If ALL ND -POINT'
SOURCE 07G AglONS.
DAIR
ALTER OR ADD TO MECII.
AIH HANDLING IINITIT010,(IgICPM)
MECII CA .I>IiH
HANDLING UNIT(OVIiR 11,0110CIM)
CONS ION TAX
nVComernr hale
. Ignatu c pplsant
HAZARDOUSMATERIALS DISCLOSURE
EXHAUST HOOD MMULT)
HOUSE ' MITIGATION PER
HEATING 1101'( (TO 100.000 BTU)
us ¢
mudal
W 1l the appheard mfuture building acupam nom or hnnJlc hazardbromide.
as defined! by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Coda Seem, 25532607
❑Ycs
11EATING UNIT (OVER 100.000 BTU)
PAID
Doe Haeipt X
VENTILATION PAN (SINGLE RESID)
Will the applicant or furore building occupant use equipment or devices which
,not har.nNeus an confrommoolsnv dented by the Buy Area Air Quality Manage. so,
BOILER- COME(3HP OR 100,000 BTU)
TOTAL:
BOILER I00,WKB'TU)p
District?
Yes
p
AIR CONDITIONER
I have read the hazmd,u, Inwerial yuiremcros undo Chapter p.95 of the GJi-
fornix Health & Safety Cade, Sento' SDS, 25533 and 25534. 1 undersr that Vthe
buHh n •x of curcntly havetet to do it is my pnnsibility no. ,lify t m
ISSl1ANCE DATE
NEW RESIDENTIAL MECH. SQ. FI'.
tel the lircn el . w i h mst l n. 11' Cenilicale
w ry )uc
Q.
ISSUED BY:
O L:
OFFICE