99110089 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I
CITY OF CUPERTINO BUILDING.BEEcTR[C ale, PHRMt I NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENGHFICATION
BUILDING ADD NUS SANITARY No. A LICAfl)NSUBMITTALDATI
OWZERN N*r. PHONE TORS NAME N/C CONTROL#
AM C?zT U,
IMF ENC AD[RNSS
Agl'.1illb /� INEEt
czl� P4
V, 6w
CON I ACI: PHnNE BU
PLUMB MECH
�OM�r*\&qo Consultant Fees Paid by Applicant(Initial) BLDG _ELECT
ls� o, 2, D F-1
LICENSED CONN RACTl\5 DECLARATION QTYJ ELF FEE JOB DESCRIPTION
I hereby affirm that I cons license Up"I Is I In,0 Chapter 9 bmarrolouiu, E��
M=Z with Section 7000)m Dim....3.fdhcB.om,,.m do1iM1J�rdF.dxnyIkcroci, RES10hpol I IAL
WOF PERNUT ISSUANCE
I= to fall PF,c and effect.72, C]SFDWL [I KITCHEN REMODEL
X-i- Lic.# []ADDITION [I PLUMBING RE.PIPE
�_u E,).ccnLWq, APPLIANCES-RESIDENTIAL
h-z at — C.."m
rARCD1T1(7I1D17CLA ION C]MUUThUNFF 0 STRUCTURAL
PANELS
zo,�K I ome,,00aml my Bloci te,.,Fdoo,adlir record., MODIFICATION
OZ- UP TO 200 AMPS [:1 INTERIOR 0 CHIMNEY REPAIR
4 t:a
W Joro'.1 lor"Ifir"i rol 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
s4 OWNER-BUILDER DECLARATION OVER WOAMPS ()LITI
0 BATH REMODELIREPAIR E)DEM ON
< I lumby oiffi...o that I a,,,F,coula It cen, row(or he
X 0 W followi,no-o. ri, o"non, SIGNS E=RICAL (TETER
U It
which require%a pennon to consure,aller.uapso)vc.diconclish.-t r Y came
'c
en
c
oc
R
of
us
u
in
nod
an'so'
on
hon
LA
Contract"
TT-,'dD,C ithe I G
e -m recer
It....... q A"A�T
Foe ''in ,".
.a n 'ead r
other oupsovo dran
p,i... its i...arcs..],I sc,lince,he applicant f..molopeorno,fac.6,rordwoo nen, SPECIAL CIRCUIT/MISC
on
that he is licensed pursuant tode ponvi6mooffhe Contowtva's License Low(Chup 9
of vivo', I,Erne Has radilocconficum,Cock) FEMP.METER OR POLE REST COMMERCIAL
0 (commencing with Section 7")1 f Division 3 of doc Business a
.so . Fo
��2= that he is exempt therefrom and the basis for the alleged exemption,Any violation a C3 NEW BLDGIADDITION El DE:MOLrrI0N
X POWER DEVICES OTENANT 0 17001)SERVICE
�=E Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of
Fall core hall five mendrod delta,,SSo0) IMPROVEMENT
0 1.as owner of the property,or my employees with wages as doir vote compencoxar, SWIMM ING POOL ELECI R IC EI OT14E
will do[tic work.and the structure is uni intended or affevrl for sale(See.7=.B.,,,�cnrc�sv
W otod Pod...on,,Code The Counnuon's Liven,c Uor,does oil apply I.T,cw,,�cnrc�sv LETS-SWI ICHES-FIXTURES
Pp
property I I...Itf,I, ar,loso,,inemn,and ol does ouch Zoak bym�cll...frous'lo \T J
his own co,ployeto, re,ided that...Ii no,wo,enneon,tire ran intended or onous!I NI7%\USIDENTIAI_HLECI it SQ IT
sun, L h,-cv,,. he bmlcho,u,im,roven',,on i,,,,Id widur o.s,,,ar.f canpletionAn, SQ.FT FLOOR AREA VSQ.
ownor,hould.,will have the Waske.of,alwin,Ehl�action!I.,hard I,improve for pal,
'e'o,at loo). TOTAL:
-1 1.as owner of the property am exclusively contracting with licensed contractors it))
c(ln%tmct the rojost(See 704kol,Business and Prolessino,Cckdc�)File Contractor%Li-
close Law dFv%not apply to an low net of propercy who build%or improves dameon,Iran QTY. PLUNRING PERMIT FEE
whocontracts forsuclopreject,with a conamcluds)licensed punulmitothe Contractor's
Lio..c L vs. PERMIT ISSUANCE
0 1 a.exempt under Sec. —,B&P C fundis reawn
AUTER-DRAIN&V17AWATER BEA) VALGATI.N
Date— — — — 4 , e7
WORKER S COM PENS A]SON DrCLARxrION BACK FLOW PR(AECT DE
I hereby all....code, raAk,offset:.......col'he bdluwro'd�vlaanafion,
n C TYPE
I he,onand ovillumuntid.a Cloulfiern,if C......lot towil-inume,fis,Worker,C......en- DRAINS-FLUOR,ROOR ARHA
,inion.so oMiLd I by S-,i...1 17000 doe Labor Code,I the pelout,-.1.-1- _NND, STORIES CONS I RUCTIO�
w, k fill which his permn is mu,d. FIXTURES-PER TRA fit
an
have and will maintain Worker s Con,coodivin Insurance,us required by Section
)K,')of the Lx1hor Core.for the performance of the osork for which this Wrnmi is olued. GAS-12A.SYSTEM-]]INC.4 OUTLETS OCC.GROUP APN
Elj�l O.N
My Workp� ounce examer and Policy
.ERTEF[CAn 0 GAS-EA.SYSTEM-OVER 4(HA)
EXEMPTION FROM WORK�0�
COMPENSATION INSURANCE GRHASEFINDU�RL WASTE INTERCEPTOR BUILDING DIVISION FEESS
(Dissection need not be completed it the ennot is fmonse hundred obollar%(SIM) GREASETRAP PLANCHECK FEE
,or lc,,)
I cerry that in the FOIlormanstolune work fur which this peraut is issued,I shall SEWER-SANITARY-STORM EA.200 FT
not employ any coon in any manner sit oo.it)beconne subject to the Workerx Canaan. ENERGY FEE
Z sali....Lmv,ofCioldunnia.Date WAI Ell HEADER W/VFN DHIJT�FR GRADING FEE
Z 2 A,Froa,�,
I DO APPLICANT If,aftv,redon,fluk Com,ftatoof ExcrEam,III bit G
o) NOE CF r -111 WATIM�e_WTN CILS FEE
Wc,)oc ninto or he Worker,Com,sm,noun he Lute,Code,oilum
foub"do e opl, all such i....I,,., his permit hall be ch,cursed re,ulled. WATER SERVICE
W-U01 I IP C
CONSTRUCTION LENDING AGENCY I N
Z) z Houthylaffiran,haaffierem.o... M le Ri
U 0 and/. I 0.n., accept
Pthe work for which this Permit is issued(Sec.3097.Ch.C.) I
U I.odcA No. FebPUIIbIUIII full COI&Rpling—d—duft ns. TOTP\
Lendcr',Add.x, ."aBLDING 'A
I colony that I have mad this application and state that the above information k \\ \\\
fzv IC FEE'
U Z building conwoiction.and hereby authorrie reprosontalives of this Vfi;�i \ -
0 couffect.I agree to comply with all city and county onlinarces and stale laws relating to QTY.
city to enter upon the ol
ansive.uncolored pro,my for oullorel on parpow, PH or o�
a roclogn-EcridCay (RnAthiltv days �H cu!
ue1,liliv,.jmlmrut......1,and o,,,cocs 11hill,troy 11,any w y else
WOa,oc to .,c,inalen ily laid kv,tu.... 'he City of C-Penual ala,1�111
in....�,,loorolc ofdoe jurmai-I"fill'I'loon
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR finff,UNIT(T(/10.(X&4) Ad
NOURCEREGU
AIR HANDLING UNIT(OVER
IV 4�� I PD.000 CO"
Sip"ofAiSheancisCusiffactor - ExTusigretweu I FE-E
HAllARDOUS mxTERIAUS DISCLOSURE 44 - ZL
Will the applicant or future Wilding occupoolvoure or handle hurcandous material HEATING UNIT ffo I 0E),000 B I ED
as thfined by the C.,nom M.rici,ad Code Chapter 9A2.add the Hoolth and Safety __ -W�7=_a
Cod".Nest 25532( P .1Affa LQ6---
F-I No PAID
VE NTILATION FAN(S[1,61.17 R EMD) _D�lx Rocs,qo#
Will de,r,hcara or mure hadifirg occu,not use equipmenn c" nd: BOILER-COMP(311POR 00,00011FIJ)
Igo , ;,i�yob,
cloll h,,.Iliou,at,comommul"'ed,fined h,,ho Bay A.A, Quit y0ana,enuou DGAI,
I
D11ni'v, Cl No BOII�ER-COMP(OVER 101).ax)BE U)
I have mad file monadjous tilacrials on,mrimucal,under Chapter 6,95 of the Call- — AIR CONDITIONER ISSUANCE DATE
firmin Health&Safety Code.Smtiory 25505,25533 and 2552kL 1 understand that if the NEW RESIDENTIAL MECH. SQ,pr.
Wilding does not c th,It .,he,it is my Froproxibilit y to notify the occuptint — tl ?
u
blue,, e prortoissomccofaConfi t of ley.
1 6, TOTAL: ISSUED BY.
0 cr r atilhorilrestait v I
P
OFFICE