S 1351 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-HLECIRICAL Pl fT No
BUILDING DIVISION APPLICATION/PERMITPLUMBING.NIECIIANICAL 1351
BUILDING PROJECTIDENTIFICATION
-
NUILDINGAUURHSS: SANITARY NO. APPLICATION SUBMITTAL DAIE
/ L/V �P/Y`^W_\ �(, y �IArQU 1 '•'O �,LR-- I.JLII� �I l
AL
OWNF.k'S NAME,: PHONE C kACfOkIi
'S NAM : LIC NO: 6�ll// (/
71'Vly { C NlC CONTROLp
• ARCHITECT/ENGIN ,�/t LIC NO: At) 'SS1 11 I Vs J ❑
QL i
CONTACT: O !.c'L Hal PHONE: O BUILDINGPERMIT'INFO
Ro -
1A 7ak-15/is ❑ Consultant Fees Paid by Applicant(Initial) BLDG HLECI PLUMB MECH
A 1 ZU fW. ❑ ❑ ❑
LICEN. :D CONT ACTOR'S DECLARATION Q'TY. ELECTRIC PERMIT FEE
QzzII...chyatom,matlatnticanxcduude-.tmvlslons of Cmmmn 9 mnittmeneiltg - JOB DESCRIPTION
gooIh Seeinn 701F),d Divlsion3ofNa Busin"ited P"flessions Cala and mylicensoix RESIDENTIAL:
ad Op wt PERMII'ISSUANCB
goo
n fell force nod cn c /'C�eoT� GicPDWL [D KITCHEN RF.MODIiI.
aFZW License Cla. — Lic.p�- y„y APPLIANCES—RPSIUF.NTIAL (❑_ADDITION ❑PLUMBING RE-PIPE
NQ Wh Datc Contractor {NNNA+A T�--
ARCIiI'I'F.CP,DECLA A'GON ❑MULTI-UNIT ❑STRUCfURAI.
�'1P.20 A/' PANELS MODIFICATION
Z O.z I undcol:md my plows shall he used nc Public records Y
024- UP1020OAMPS ❑INTERIORIIMNEY BE'AIR
flns
~eW Liceed Pml'e,naml 201 ]TRAMPSIMPROVEMENT SWIMMING POOLS
C 2� OWNI;H HUILUER DECLARATION OVER HSOAMPS LJ BATH REMODIE REPAIR ❑DEMOLITION
6'd'sc 1 load,affirm that I am exempt from the Contractors Licen.e Law for the '11 In
xL�d a U fallowing reason(Sccdon 7031.5,Business and Professions Cele Any city ur county SIGNS ELOC1'RICAL Ell OTHER �n� I I Tau r.
W a W N which requio s a permit to construct,aint,inTrove,demolish,m repair my structure /LdOS I , E
X01 prior I.to k1locialot.oi the applicant bh Permitt file usigned statement SPECIALCIRCUI'PMISC.
IM1mI Ipum II til 1 rvt.m. fill C t- 'I L (Clapter9
� CQ (e,mmeucing with Scot too700(lpd Ulvisma 3 at the lltsness and Proles.aro Cado)or 'TEMP ME'IP.R OR POLE INS E COMMERCIAL;
6 Ci o that be is exempt monefmm and the basic for We alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
OU^ Section 7031,5 by any 1PPli13m for a permit subjecBthe upphearm o a civil pcnaltyaf POWER DEVICES ❑TENANT El FOOD SERVICES
FZN not more than five hundred dollars($500). OTHER[IMPROVEMENT
G Las owner nRhe propcny.or my employees with wages as their sole compensation, SWIMMING IY)OL ELE IC
� will do the work.Coal,
'[he tnra lc nm mmndcd o.,,,oones lost
reply Wkm Business ❑OTHER
LY m and Prnfacians Gde:'Thd Cuntrnmor's Licence Luw Anes not apply loam owner of OOTLE'I'S-SWI TG :S-PIX'I'lIRHS
a' r property who hailds ar improves 0orom,and who docs ouch work himself or thz..ugh
his awn employees,provided that such improvements an not intended or offered for NEW RESIDIi IAL ELEC)'R SQ FT.
sale.If.however the building or improvement is sold within ane year ofmnipletion.the SQ.FL FLOOR AREA $/SQ.lel'.
owner-builder will have the burden of proving that he did not,mild or improve for pur-
pose of WIC.).
El 1.as owner of rho property,ton vaciti ively c saftonin,with licmtae.I contractors In T 1;
constrict the pr]cot(Sea 7044,Ilanire,s and professtom Cor,:)ri he Con na,mn U.conow Low does not apply to on owner of properly who builds or improves thereon.andp'I PLUMBING PERMIT FE'
who contacts for such projects with s om ntrucamP.)licensed pursum,Ionic Contacmfn
License law. PERMIT ISSUANCE
❑ lam exempt under Sec. ,B&P C for this reason
Owner DateALTER-DRAIN&VENT-WATER(EA) VILLA)]ON
f
WORKERS COMPENSATION DECLARATION BACKFLOW PROTECT.DEVICE � / 6Sav U/J
1 M1crchy alTinn under penally nfp juryone ul'the following declarations:
�❑l have and will maintain a Cmiftcate of Consem to self-insure for Worker's Compery DRAINS-FLOOR,ROOE AREA.CONT. STORIES TYPE CONSTRUCP'ION
sation,as provided for by Section 37M of the Labor Code,for the perfommnce of the
work for which this permit is issued. FIXTURES-PER TRAP
R 1 have and will maintain Worker's Compenxmion Issuance,as regnirM by Scotian
3700A Are LabmCde,rnrtheperlinamore of the work fnrwbich Itis pennris Vacd. GAS-EA.SYS'1'Food-I INC.4OIG 1.1 OCC.GROUP APN
My Wor9._(:ntgpensal^Encu rand No.:nu aryl,.
Card ee fey.Y_2}1('' ""II++-yea 1'nlie NndA 711 6� y GAS-EA.SYSrFPAhOVER 4(li
CERTIFICATE OP EXEMPTION FROM WORKERS'Et0 III/jo
COMPENSATION INSURANCE GREASFIINDUSTRI.WAST NTRCEPTOR
BUILDING DIVISION FEES
This section need not be completed ifthe permit is fofone hundfeddollars($100) GREASETRAP
to
or lose.) PLANCHF.CK FEE.Ixxnify that in the pmfi,nnnecofthe wink in which this pcnnh is iswed,[shot SEWER-SANI'I'A -STORM PA.200 FT,
no,ompiny any person in any rume
mr a,as Ia beeontn mner,to the Workerk Compen. ENERGY PEI:
OZsation Laws of Califomin.Dom WATER HEATI° WNENT/Id E.C'1'R GRADING PLE
Z O Applicant y
NOTICE*10 APPLICANT.11,after making this Cenificate of Exemption,you should WATER S\" :Mf REATING
a ; become object to the Worker's Compensation provisions of the Lala,Code,yna must So FEE
Ida forthwith comply with such mo,Nmsnr this permit shill be deemedeval WATE :RVICE
�O CONSTRUCTION LENDING AGENCY N RESIDENTIAL PLMB. SQ.P. PAID pan RecciptM
1 herchy affirm that Inc.k a emametian lending agency for Ibo famfnmmnee of
the work for which this permit is issued(See.31197.Civ.C.)
U. H Lenders Name TOTAL:
V Lenders Address TOTAL:
aI certify that I have rend Ihix upcucto,orrtrod state that the above inllnnmtion is BUILDING FE
coned.l agate to comply with all city amleomn,orol anecs and,tnta ww.rdan, ,, QTY, MECHANICAL PERMIT ,Ila FEF.
U Z boldingc...mmctien,and hcrehyrota c rcpmsctwtives ofihis city banter upon the SEISMIC FIEF
aMwe-mentioned property for inspection proposes PERMIT ISSUA if I'.n
(We)agree to save,indenmily and keep harmless the City of CuNnino against ELECTRIC FOR
liabilities,judgments.costs and expenses which may in any way accrue against said City g1.TER OR ADD TO MEC .
In eo
nmquence ofthe granting of this Permit. PLUMBING FEE
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT NRHAN ULINf, IOp00 CFM)
SOURCE REGULATIONS. MECHANICAL IH1H
AIR HANDLING UNIT(OVER I ,I11lC CONSTRUCTION]AS
Signaturenf Applicant/Contionear Date EXHAIISTHOODfW/DUCT) HOUSING NIHIGATIONFEE
IIAYARDOUS MATERIALS DISCLOSURE
Will theupplicome,future bnlldingocca,ma ctorco,handle humtdous material HEATING ON['GO 100,000 IIT
a,defined by the Cupenlnn Maamci,d Coda,Chain,9.12,and Thu I leallh and Safety
Code.Scotian 25532(11)'! 1]HATING UNI T(OVER I(I,/"()it I I)) -
❑Yex }tole VENTILATION PAN(' GLI;RSID) PAID
. Dam Receipt x
Will applicant of building occupant so Ise equipment
;¢ ar devices which BOILER P OR 110.(1(61 RTU)
emit hnnlan,us air contaminants
ntz a us defined by the B -
ay Area Air Quality Management 'TOT
❑Yes No
District! BOILER-C( TOVP.R100,000B.HD
�
AIR CO 1'1'IONER
I Health
read Stiety manhmctiorn 55 5,2553IDnLc under .1 rand h.9nd that Cali- ISSUANCE IJ �
bruin g does&Safety CMe,Sections 25505,25533 and 255]4.1 umkm:md that if the N RL'SLDIiNTIAL MECii. SQ.FT. 1
building Ices notalaRaccurrently have a,Iran,,that it i,my responsibility rits to notify the occupant !/
o[Ne rcyuimmenrx which must he met prior to issuunea of a Cenificme of(kaquncy. orO
Owner or authmimd gens Dxto rOTAU ISSUII BY: t/ 015' A
li
OFFICE