99100131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fill I I.DING.ELECI'RIGV. Mll'N(
IH1u.BING DIVINRJN APPLICA'1•ION/PERMIT PLUNiBING-MECHAulcnl. SOOOIas�zw
nDIIAING EROJEC'T IDENTIFICA'PIOry
SANT"CART NO APPLICATION SLIIMI'1'1'AL DM
BUILDING ADDRESS:
19 3 kobth def
OWNER'S(AMI?: xJI PH(NI!: CONTRACTORS .G LIC NQ
kK TS'}W IVV NIC CONTROI,a
CHITECDENGINEERI LICrac ADDRESS. ❑
CON'I'nCl': PHONE, BUILDING PERMIT INTO
E:1 Consultant Fees paid by Applicant(Initial) BLDG/ ELECT 1, UMIi MiiCH
IrJJ/ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PIH. JOB DESCRIPTION
I hemby affirm thm
at I am licensed under pro,wo.s of Chapter 9(co ,n...to,
FSBin full force and effect,rvlsinn3 3,31 the lfuuinc,aund l'ndussions Cade,and myliccnsc ix RESIDENTIAL
wnI Section 91(X1)of D I'IERMI'1'ISSUANCIi
Qw. License Clens LEc.x ❑SIIIWL ITCHEN kI!hIQDHI,
Xaa Dam Conomn.r APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS MODI❑MULTI-UNIT MBUCfURAO
F N Z 1 I demtand my pli m,bdl he uncal uu public records CHIMNEY
REPAIR ZO4— UP'To 2(NIAMPS ❑INTERIOR ❑CIiIMNIEY ItHI'Alk
OZ—M
1:.h F y) Licensed Professional 3111-I0CN)AMI'S IMPROVEMENT
RFMODI:I O HEMOL[TIONWINIMINC FOOLS
<y,2a OWNER-BUILDER DECLARATION Cm1'ION OVER 1000ASIPS ATH REMWIEIJREPAIR ❑DEh10LITIUN
C Q 1 hereby office,that I am exempt from the Comreaur's License Law for the ❑OTHER
�a U following remon.(Section](131.5.Business and profession,Code:Any city or county SIGNS ELECTRICAL
3;m y which enquires a per,.,(m vocarmel,alcor,improve,I.molixh,Ur repair any sn elan
prior it)its issuance.also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUI'i'/MISC.
thin he is licensed pursmnl to as,provisions of the Commences License Law(Chapter 9 ::�4 R i
W�C0O (commencing with Section 7dh0)of Division 3 of the Business and Professions Code)or TEM('.METER OR('OLE INST.
d L e y Ih:n Int is exempt Ihembou t and the basis for the alleged exemption,Any violation of � I7W BLI)GMEDITION ❑DE1101,I1'ION
',Y m
Section 90315 by tury applicant fur n penalt subjwls the a ildn"ai 1();'civil penally of IIOW17R DEVICES ❑FOOD SERVICE
not more than live hundred dollars($51X)1. L k - IE
I SZ ❑I,msswneroftheproperty,ormy employees with wages as their sole compensation. SWIMMING POOL ELECTRIC HER
L will do the work.and the structure is not intended or offered far sale(SecJ0Ok Bmimss
a3 m and Profession,Ede The Cmaracu ex Liceme Law(ars not apply m an owner of OUTLETS-SWITCHES-FIXTURES
pn,peny who hu'ddx uT improves thoraco,and whir does such work hbmelf or thmngh NEW RF.SIIJI3N'1'IAh ELECTk Sp Irl'.
his own employees,provided that such in,pocvemuns are not Intended.r offered Ibr SQ,FI'.FLOOR AREA $/S0.E.
sale.IL howcvca the building or improvcmem is sold within one year of rompletion.nhc
owner-builder will have the burden of proving that he did not builds improve for pu.-
�owmcTOTAL:
r of the prnpeny.oro rxchtsivdy e.nauedng with Iiconxcd mmracm.n m
dace the pmjeca bre.9044.Ravines,and Prohb,.innx Code:)'ILe Cnntrae.,rx i,i�
ensc law does not apply to an owner of property who builds..Impreve,thereon.and QTY. PLUMBING PERMIT FEE
whocontractsforsuchpojecns withaenntracmrts)licensed pursuant.the Courtrai
License law. PERMIT ISSUANCE!
�Ian,cmmpn un ,Set. .l)k l'C for this rexam
Al;11:1t-DRAIN&VENT-WAI'1!R(EAI VAI.UNI'ION
oEaEm A4 Date
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT.D17VICE 060
I hereby affirm under pemlry of pc jury one of the following duclarsti...
I htvenndwill 1rin a Cenifcate of Consenttosdf-Insure for Worker's Compen- DRAINS-FLOUR.ROOF,AREA.GDM). STI IEg TYPIi CDNSI'HUCI'IO
7ni n,to provided for by Soil 391X1 of the Lubul Codc,fill the parfonnem.of the
work far which this hermit i.v issued. I4 X'IV RES-I`IER'1'RAP
❑I have and will maintain Worker'aC.mpcnsatiors lnmreme,ax required by Section GAS-EA.SYtiI'IEM-I INC. OIII'hET$
3I00 of the labs Code,for the performance of the work fur which this permit is issued EOCC.GROUP •J AI'N /
MyW'orker's Cmnpcnsai.n lnsurancc comic.and Policy number am: GAS-EA.SYSTEM-OVER4(PA) 3
Carirr. Policy Na: '3
C17 R'I'IFICATE 01'17XLMVI'[ON FROM WOR K IRS GRPASFJIN UUS IRI.WASTE(N'I'ERCEMOR
COMP ENSALON INSURANCE BUILDING DIVISION PEES
(This.,am need ma the completed if the permit is for one hundred dolla,(S I an GREASETRAP PLANCHECK THE
.r l s)
toy any pest in many banner so its
tne sit)mckhm Inch'his.'da,WlEkm"C..Inbdl SIEWIEk-SANI'ITRY-ST ORM IIA.2lN1 Irl'. (ENERGY FLEE
nm employ any person In may nmm�er xn ns b,h.conw,nhjed m,hr WnrAu:Campcm
Z sanies Lawn of California.Date WATER HEAI HE WNEN'Mi1.1iC'I R
ant \ T GRADING FEE
Q Applic
NMI
N
boa,
nhwi
ACE TO APPLICANT.If,after making thea CeniGcate of Exemption.You should WATER SYSTEMUREATING SOILS FEE
,object b,the Worker's C�m Enoninn pnrvi ...m of the Latin, de,ar Coyou must !
th comply with such provisions or,his permit hull be dented revoked. WADER SERVICE!
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ.FL \Rctt
Uutc tpt a',•\
I hereby affirm that there is a cmmumion lending agency far preliminaries,preliminaries,of
mk for which this pmit eris issued(Sec.3099.Co.C.) t
��'� '(TfAI.
ceu Name TOTAL:
r'.v AJdrenv I aiLUING[Tit!
1 comfy that 1 have read this application and state that the above information is
eI l agree no comply with all city and county ordinances and some laws aiming no QTY. MECHANICAL PERMIT FEE , SIDE)
ding conswction,andheaby antboda.rpmemr.ive,, is city ncenter upon the
a
ncntionud propery for impection purpo,cv. PIERMIT ISSUANCE ECfRIC Ilii!
(We)agar m nava,Inden oily and keep bth
mnlens e City ofCupcnino aguinvl
hilinics,judSmennt,costs and expenses which miry in any way accrue against said City AFTER OR ADD*10 MECH 11 FIRE"TE' ✓�✓
conaquence of the granting of this pernit /
PPLICANT UNDERSTANDS AND WILL COMPLY'WITH ALL NON.1'OINT AIR HANDLING UNIT(TO I(LIgO(FM) M: CALPEB
SOURCE!REGULATIONS.
AIR HANDLING UNIT(OVER III,IXNICIM) CONSTRUC'IIUN'1'A%
'came of ApplicanJCommcme ,Au�1 Dene "HAUSTHOOD(WIDUCI') HOUSINGMHEGAf10.S`FEH
HAZARDOUS MATERIALS DISCLOSURE
Will the applimm nr future buildin6 a,ccup:mt snore or handle haemdnun material I HEATING UNIT CITE 100.000 BTU)
u.v Aelincd by the❑gmninu Municipal Coir,C1ba,ba 9.12,and the Health and Safety HEATING UNI'('((EVER hio,oix)aru)
Code.S,oioa 25532(.)1
❑Yes ❑NnVENTI6AI'ION PAN(SINGLE RESIDE PAID
Mae xerdpn x
Wr
Will the applicant or future building mearpol use e,dipmen,of device,which HULLER-COMI'(31HPOR 110,001 BTU)
AIw
,nil ha.ard.un air comus
nluminan defined by the Huy Area Air Quality Management TUI'
District',' BOILER-COMP(OVER I lin(RI I IO U)
C Yen ❑N.
1 have read the hmallom ounum s requirements center Chi 695 of the Cali.
AIR CONDITIONER ISSUANCE DATE,
R,mla licdth R SaRry Code.Somans 25505.25533 and 25534.1 undersnmd ohm if the NEW RESIDENTIAL MECH, SQ.IT
building dcex not 11 mnty have it"'non,thm'n iv my,e,,or,ihif y la notify the oeupant
ofthere ire nown'humthennt 'arm l"came oft Cenilical,of panlnmcy.
At
P,neriaauNorixed.gem ,are
TOTAL ISSUED B)':
OFFICE