S 0662 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - Cv
P1il 11'No.
BUILDING DIVISION PPIACATION/PERMIT PLUMBING-MECHANICAL
IIUILDING PROJECT IDEM'IFICATION 0662
RUCILIl1�DDRE55: /"�/ SANITARY NO. APPLICATION SIIPMITTAL DgI'E
I
OWN. O It'SN LIC
5 NIG CON'fHOL
RCI IITECTrtiNGINEI : LIC NO: A pR • V ❑
Q PHONE: �iV[ BUILDING PERMIT INFO
jh� (� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICEN ED CONTRACTOR'S CLARATIUN QTY ELECTRIC PERMIT FEE
C
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION oc with Section 9000)of Division 3 ofthe But rasa and PoI Code,. my doe no, PERMIT ISSUANCE RESIDENTIAL:
n full force and eB•
QUU License Cla Lica x ❑SFDWI. OKITCHEN RIiMODEL
hCG Dote77` Contramm APPLIANCES—RESIDENTIAL. ❑ADDITION [I PLUMBING REPIPE
RCHITECI"S DECL RATION(n�� PANELS ❑MULTI-UNIT :STRUCTURAL
zcv 4 tum wand ryplana shallnduscd ax gnhlic recnNsy
:Call `` MODIFICATION
UPT0200AMPS
C la¢nscd ProfcssanN ❑IN1FRIOR El CHIMNEY REPAIR
201-IBINIAMPS
IMPROVEMENT 11 OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
( I hereby,(Sen that I tan exenirw[rain he Cnsions Code:
e:Any
Low for the OVER IINNI AMPS ❑HAfll RBMOUI?I/RI!PAIR DEMOLITION
LL13dV following rcann.(Section 7031.5,Rosiness and Professions Cox3c:Any city or county SIGNS F.LEC 111CAL OTHER
q N whicM1 mquircs a permit m cnnamc6 ulmq iniprzive,demolish,or repair any smcwro �T
priorm its is...nce,m...mogi..the applicant hasten permit ,,file a s'gnedshnenicnl SPECIAL CIRCUIT/MISC. r`..It
that is ticeeadl..rsua.Itothcprovisionso'the Comments U'rnwlnw(Chapmr9 b ,
(mmmemcing with Seen..700 of Division 3 ofthe Rrniness and Professions Crxle or
p0 ) TEMP.METER OR POLE[NST. -OMMF.R JA
dp,e that he is exempt therefmm and the basis for the alleged exemgtinn.Any vioeninn of
w,•, Section 7031.5 byany.1deant for.permit subjects the applicant to a civil Penalty of POWER DEVICES ❑NF.N'BLDGIADDITION ❑DEMOLITION
notnuxethan five handled dollars(SSg). ❑TENANT ❑FOODSERVICE
56D1,to,owner alone propeny,or mynalibyeeswith waimsaethelrsole compen.anion. SWIMMING POOL(ITEC URIC IMPRo VEM17NT
FC willduthewark.andthe sommureisnot intended or offered forsnle(Sce.AWL[mims5 0OTHI7R
3 and Professions Cale:The Cn dreunr's License Law does not apply m an awns,of OUD,EIS—SWITCHES—FIXTIIRES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements um not intended or offered for NEW RfSIDEM'IAIL ELECTS SQ
sale.If.however,the bnildingorimpravement is sold withmoreyearmenmgletion.the SQ.Fr.FLOOR AREA $/SQ.Fr
owner-huilder will have the burden of proving that lie did not build or improve for pur-
pose of sale.). -
❑1,us owner of the Progeny,an exclusively contracting with licensed contractors To TOTAL: 1<9
ntlmet the Protech(Sec.70,4,Business and Professions Code:)STe Contractor's Li- - PAID cense Law does not apply too.m tiarofpmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT I FEE PAI D
who contracts Ro such pmjeem with u cootmchx0)Iieealed gainsaid to the Commuters
License Law,
C] at xemPERM)Y ISSUANCE SE
P 29
I vept under Sec. ,13&P C for This rtason
Owner One ALTER—GRAIN&VI7NT—WATER FDA) y VALI3
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICIi a
I hemby.ffinn under pem.lty of pcopay one.1 the following dm /^�l)l l
l.nulnus: Lor V vrCH ONO
I haveund will maiumida Cenificatanf Comattoself-insure Ba Wakers Camped- DRAINS—FLOOR,ROOF,AREA.COND. �1
cation,as provided for by Section 37M of the Labor Code,for the perfner ance of the STORIES TYPECONSTRUCTION
work fix which this permit is isxood. 10X'1'UIt ES—PFR TRAP
❑1 have and will maintain Worker's Compemmtion Imsurna,a.,requircd by Section
J700 of .Wr Cale,fonhe performance nfhhe work for which this pr�tmit is issued. GAS—IiA.SYSTIiM-I INC.JO1ITLFTS
Mynd rk e a n.vuti netts carrier and Poli�}s (ICC.GROUP ANN
Cartier Policy No.'N+w`�`�"Tr Gq5—EA.SVS'1'F.M-OVER4(IiA)
CER I'IPICATF. .XEM""IN FROM WORKERS'
COMP• SATION[NSU NANCG OIt F.ASIAINUUSTRI.WASTE INTERCIiFTOR
(Thissectinn need not he completed Bit.
permit is fnrunc hundred dollars ISI W) BUILDING UI VISION PIiLS
or less) GREASE'1'RAI'
I'L.ANCHECK FEE
I certify that in is perl'nrm.nce nl the xkfn ov vh this permit' issuul,Ishall Sf3WEN—SANITARY—S'roRM IiA.2fN1 PT.
no,empbyv pars in any manner ton a ars'Cnmpcn" ENERGY PIiO
0 ,� nminn L.wa n alit . WATER IIigTIiR WNEN'I'/F:LIiC'I'R
z ""'cant - GRADING FEN,
y NOTICE TO AP in
If,utter taking this Certificen of lixemption,you should Wq'fER SYSTEM/fNIiA'GNG
aHearn subject m the Workers Compensation provisions rf the Lnnor one,you must SOILS PEE
UJ forthwith comgly with such provisinm ur this permit scull be deemed revoked. WATER SERVICI?
4Q
CONSTRUCTION LENDING AGENCY NEW RESIDEN'T'IAL PLMB. SQ.FI', PAH)
V Iherehy ufOnn lhn there isacnnNmninn lentling agency fonhe pedbrmance of Dae Receipt
w F+ the work for which this pcm n is issued(Sec.3107,Civ.C.)
Q lender's Name 'I(yTA L:
Lenders Addre, TOTAL:
I ser ily that 1 have read this application and shim tam the above information is BUILDING FEE
r-t rA correct.I agree m comply with all city Emit co.nty ordources.nd sem Inwx rcltniog n, QTy, MECHANICAL PERMIT FEE
U ,Z building con%lmction,and hereby authorize reprceematives ofhhis city(center upon the SEISMIC FEE
abovementioned property for inspection purposes.
(We)agree to stove,indemnify and keepharmles.the Cit f Capetian n PERMIT ISSUANCE
y o pe gains ELECTRIC PP.P.
liabilities,judgmems,encs and expenses which may in any way uoeroe against said City ALTER OR ADD TO MECH.
in consequenc<af the gaming of Nis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 1'1'0 III,000CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT 10,(X0 CPM) CONSTRUCTION'TAX
Signiturenf A,dicaMCmdramnr Dahe EXHAUST HOOP tW/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION ITE
Will Iec applicant or future building occupant tion,or handle hazardous material I[EATING UNIT'TO HNltgla B'1'(1)
as retired by the Cdgenum MmieiW l Code.Chapter 4.12,and the Health and Safety
Code,Section 35532m)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes Fl No
VENTILATION BAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Reempt X
emit hucudoos air contaminants as defined by life Bay Area A it Quality Management BOILER—COM P(9 H P OR 100AO BTU)
Dinriet? TOTAL:
❑Yes EIN. BOILER—COMITOVER 100,000 BTI!)
I have dobe haznarso materials requirtmenu ander Chance 6.95ofue Cali- AIR CONDITIONER ISSUANCE DATE:
[oars Heal &S fifty RMe,Smtinm 25505,25533 A 25534.I undersimJ that il'tho NIiW RIiYIUP.N'I'IALMECII. 9Q.Pf.
boilJi�,, =Lh.uoxrc
s doaven tenunl.thou Iy arymsiclayto fy thea am
ofth 'mtgriem op,m Uate 'TOTAL: ISSUED By:
OFFICE