B 0465 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO �q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S0001f,(
0 4 6 5
BUILDING PROJECT IDF.NTIFICAI'1ON j9
BUILDING ADDRESS: SANI'D\RY N(1. APPLICAI'I(1N SUIIM ITTAL DA'I
O P—r o6evltTi tlovrt' ( V ✓l is� -3 -Q
(WNIiN'S NAp1E:rN, / D-.8vy-zqa C{} 'NACTOR'. NQA,M`li:, LIC NO:
T++ Q� C1�NIIIA _dCL��O NIC CON'IROL0
\RCHITECT/I: m�lX LIC NO: 9;)ZNLSS: C � � / ❑ Z Z
CON'I'AC1': // PHONE. [( 4/� BU1LDIN PERMITINPO
�nl-I>���•JV/ ,10�-VbY-Z?c �Cnnsultant Fees Paid by Applican((Initial) _9:k— ELIXII ELECT PLUMB MECH
(W c+ !( � ❑ ❑ ❑
LICENSI?DCONTRACTOR:SDECLARAI'ION QTY. ELFCTRIC PERMIT TEF
I hereaffirm
by flet 1 ant licensed under pmvi.iamot mom
chapter 9 mcmcing JOB DESCRIPTION
QaZ whb Section7BXBo1 Disk I...Sof hellnsina,ruall'rofesai...11 Code,mrdmy license In RESIDENTIAL:
W Q O r PERMIT ISSUANCE
CSF in full farce and effect. �SLJI ❑SIDWh ❑KITCHEN REMODEL
GUU Licenses CP CLic md 6 f APPLIANCE S-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPIT
1-Zm Date Cotnrm -
mQc. ARCHITECTS DECLARATION ❑MULT6IINIT ❑STRUCTURAL
Z O H Z I undenmal my plan.shall M used as public records I'ANEIS Af0O1FICATION
OZ=O UPT02MAMPS ❑INTIiRIOH ❑Cl IIMNEY REPAIR
F4 t:W Licensed Pnfesonsual 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Ck F,-1 OWNER-BUILDER DECLARATION OVER IMI AMPS
C1 HAI'II REMODEIIREPAIR [I DEMOLITION
CC I hereby aBim nt
no that I aexempt from the Corachtrs License Law for the
7gq,X5Oy0F allowing mason.(Section 90313,Busimessund Professions CnJe:Anycityoremmay SIGNS ELECTRICAL ❑(MIER
Ia13 W N which requires a pcmtit to constnut.alter.improve,Jenmlish or repair any smachim
F'LLO� prior mit,I.....ee,ahs rolimm,the.,imant for.ocInfernal ,,file asir,rd statement SPECIAL CIRCUIT/MISC.
E�} that he is licensed p....a,to he Pmvnion .fdre Conmteorx License Law(Chapter 9 COMMERCIAL
�ftp0 (commencing with ScctlonT000).f Divhion3man,Businessland Professions Code).. TEMP.METER OR POLE INST.
L e that he is exempt refmm and the basis tor'the alleged exemption.Any violation of [1 NIiW DLDG/ADDITION DIiA10LITION
C. tba
Xen� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑P(XID SERVICH
W h
Fnot mom than live hundred doliam 1$510).
=6 Las mvner of the n.nrm to aswith wu¢s ns thcir.nle cum tion, SWIMMING POOL ELECT RIC OTHER IMPROVEMENT
0 ❑ the
Y Yemp Y b penin ❑OTfiliH
N will Jothcwors andthe sh cture Commulo-Licens Lawdos rede all..Scc.1. a r-el as,a
.r1
U.1 3 m and Professions CnJe The Convucntr's License taw J«.all apply to on mvner of OUTLETS-SWI'I CIIT:S-PI%'FURLSJXO-� l_J
propcny,who builds or improve,theram,and who docs such work hint.sclf or through L/
his awn amployees,W,,i&J that such improvements arc not ialendeJ or offered Ln NEW RESIDENTIAL ELECT R SQ Flt
udcALhowcvm.Ihchui1ding nr imnpravemcmt isxulA within enc year of eamplelinn,the SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of paving that he did not build or improve for par,
pa-n1 n
If was.).
'f(ITAL:
1.usownerofthe pee 70,1 .Bexdtsively and commctin%with:fiBes-caotmcwnm 3'n OpO 5F
construct the es not (Sec,nano Business and property
Ish i bui da I), op Contractors Li
nsclawensfor apply toun with
ofpmpery who licensed
namotmaaflemon.md QTY. PLUMBING PERMIT FEE
woo contracts for web projens whh a nmuacmrt.)licensed Punuam m fle Cnmmchds
Liccrosc law. PERMIT ISSUANCE
1 am exempt under Sae. ,Ii&PC for this m.arn
ALTER-DRAIN&VENT'-WATER TEA) VALUATION
Owner Date
WORKER'I COMPENSATION DECLARATION BACK FLOW PROD; I'.DEVICE o0 V
I hareby."am under pcmlty of perjury one of the following declarnimm: 5
I have and will maintain a Cerificale of Comorto self-insure far Worker's Coupon m DRAINS-FLOOR.RCOR AREA,COND. STORIES 'TYPE CONSTRUCT 10
tion,as provided for by Sermon 3700 of the Labor Colic.for the Performance of the 2
•for which this pcmtit is iawcd. FIXTURES-PER T)IAP n
[s'J
'ham
and will nuinloin Workds Compensation hourame,as raptured by Section
311)Id the Ltl+nr CtIde,for the Perforaramofre work for which this Permit is issued. GAS-EA SYSTE 11 '.40V LTS OCC.GROUP •� oN�
My Worker': 'omperysatit �� ccmrier and Policy nuJ1 - LO�/t
Gtrricr. p Policy No.:I; L `kq r•4' GAS-F.A.SYSTE IVI7R {F.A)g/ t246
CER I'U9CAN DI°IiXEMPOCN PROM WORKERSi a I `a
COMI'I?NSAITON INSURANCE BUILDING AS lNl'GNCF:PI'OR BUILDING DIV ISI(( IIBi
(Thissectimaxed not be completed i(flepem+il is fonmu hundred dollars($Its)) GREASETRAP
PLANCIIIiCK IBi13
orle.+E
I Ly inthe performance o workwhich permit slshall SEWER-SANITA Y SO
ENERGY EEE
nm employ any person in anytrnnrwastmbecause subn to the Wrkcto'Com,sn-
Z anion Laws of Califnmia.Date WATER HEATER WNW]aTECTR GRADING FT z
Z O Applicant t -
NUNCE TO APPLICAN'P 11,after making this Ccnificne i(17-orption,you should WATER SYSTENIT RP.ATING
h became subject to the Wider'.Compensation provisions of the Lalnrt Code,You"lust SOILS FEE
CX �y finbwihcauT,wish suehprovisions or his perm it Shull he deemedrevoked. WATER SERVICE
Q
z CONEI'RGCHON LENDING AGENCY NEW RESIDENT IAL I'LMIL SQ. PAID
I hereby affirm that is a comminution lending agency for the performance of Una RecciplM
O the work for which this permit is issued(See3119].Co,Cd
T(IIAL:
O U
Loafer's Name TOTAL:
Lsarad is Address I G LEE
0. 1 cenify that I have rad this application and state that the above Information is it
Fm to cnneet.I agree to comply with an city and county ordinances and state laws relating to QTY MFCHANICAL PERMIT FrE Hs 1r.Ia;r�
U 7Z huildingcon.ametion.and hereby anhorve representatives of thiseity to enter upon fl,
uMrvhnmemiaed pro,r,far l now"am pugxt.cs. PE MI'I ISSUANCE 17 : DUCPI11I
(We)ago-m sivaI"dun nify:tad keep han..Ir,'be City of Calcium'slain'(
Iiabilities,judgmenu.eco,...tad expenw,mchmaY in airy way ueenmagaimt mid City ALTER OR ADO'I(I M HCH. T.UMINNG FEE
in co.utogi nee m the grinning of this permn
APPLICANT UM)IiRS'IANDS AND LL COMI'I,Y N'1'I'H ALL NON-POINT AIR HANDLING UNIT(TO 10.(00 CFM) 'GILANICAL FEE
SOURC EGULATIONS.
AIR HANDLING UNI'I'lOVIiR IBIMXI CFM) CONsI'RULTION TAX
Signal i V]ommcmr Dam EXHAUST HOOD OVIDUCD DOUSING AT'I IGATION FEE
IIA9,ARDOUS MATERIALS DISCLOSURE
Will the spplimmt or it building occupant store or handle bacmdotas material IIEATING UNIT(1'0 100,00 111 U)
os dclimmd by be Ctgmninn Municipal Gal,Chapmr 1).12,and he Health load Safety HEATING UNIT(OVER 100,000 BTU)
CnJe,Senior 2553200'!
❑Yes Nn V17WILAI]ON I AN(SINGLE RESIU) PAID
Uma Recaid 0
Will the.,,I,cam nr fmure building occupant lou equipment or devices which BOILER-COMP 011P OR 100.00X1 BTU)
.it ham mous air ronwminams as defined by the Bay Arca Air Quality Maamem geT A.
)Teruo'!
BOILER-COMP(OVER 100,00 BTU)
Yes Nn
AIR CONDITIONER ISSUANCE DAT'B
I havefmdflc hroulm
amnmrla6requirement.order Chapter 6.95ofthe Cull-
0tmia llealth&S.1'ety Cmlc,Satioms25505,25533 255311 undemm�d(hal if the NEW RESIDEN'HAL MECII. SQ,Ir1'.
boildimgdta_sna ty luomm tcnmlt 1Lsrymcihi li(y to noafy flmoaupma
of the m,aim.n Xw 10 mus be totpria col'"Cvnifieum of(kcal+uncy. _
rrW int N Dam TOTAL: ISSUED IIY:
OwnermauNo
OFFICE