S 1528APPLICAN7TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECfRICAI.
BUILDING DIVISION APPLICATION/PERMPP I'LUMBING-AIECHANICAI.
BUILDING PROJEC'1'IDENTI4'ICA'1'ION
YE�'"'"°15 2 8
BUILDING ADDRESS:
1941 RoSCMAQC L.
SANI'CARY NO.
APPLCAHON SUBMITTAL DATE.
q-1(._qy
NAMw EPHONB:
CONIRACI'O'19h: LIC NO
I Hw
N,
❑
CONI ROI.
ARCHirECTIENGINEER: LIC NO:
A DHESS:
v. 0 305 rv� _ IVA
CON [ACT PHONE:
BUILDING PERMITINFO
! c® 16 `/ /,��
T 7
❑ Consultant Fees Paid by Applicant (Initial)
HL❑DC ELECT PLUMB MOH
LICENSED COM'RACfOR:SIDECLARATION
1 heathy Ofim. the, I am licensed mad, rrhimum of Cha,for, 9 mmnmtneing
QTY. 171,IiCTRIC PERMIT 17171i
JOB DESCRIPTION
will,Section 70o hii,ion30t the Bnxinew cast Pn.fmsions C...L. achy hoots, i,
in full litrec and eisiq. 54361 `
1'IiItMIT ISSUANCE
RESIDENTIAL:
❑SI7WL ❑ KITCHEN RESIDUE],
APPLIANCES -RESIDENTIAL
Liccnbe Cl �--�" I.ic.p •J b
Dani f— or
❑ADDITION ❑ PLUMBING NE-PIPii
`(3 TS DE
ARCHITIiCTS DECLA ATMPANELS
(understand my plain,fall he oral as puhfumsundn V
❑MULTI -UNIT ❑ MOD[FiSTRUCTRAL
srlO
111"1027 AMPS
J11102
CHIMNEY
❑IN'CP.RIOR 0GHIMNEY RETAIN
IMPROVEMENT ❑SWIMMINGPOOLS
Licensed Professional
201-1000AMPS
OWNER.BUILDER DECLARATION
I hereby affirm the, 1 am exempt from the Commerce's License Law fm da;
following tor son. (Sixhion 7131.5, Boniness and Professions Code: Any city or county
❑ RAI IT REMODEI/REPAIR ❑DEMOLIT[ON
❑ OTHER
OVER IIXM]AMPS
SIGNS El ECLR ICA].
which mucous a pennil to cnnelocel, alter, improve, demolish, or mpair any mmaam
,f
SPECIAL CIRCUI'19MISC.
,notion, issuance,e6o tebircesthc applicant forxuchpermit In file a signed,orchmnl
�w
that he is licensed pursuant in the provisions of the Comments Fashion Law (Chapter 9
(commencing with Section ID(1(pnf Division 3 ofthe Bu,ilawmal Professions C:Ne)or
TEMP. MM- 711 OR POLE INS'll
COMMERCIAI: ( 1 t1
Nut he in mwor pt lhomfnsm and the hods for the allcgal exemplino Any violai0n of
❑ NEW BLDCIADDITION ❑ DEMOLITION
Se"i 9031,5 by any applimam foil Pecan subjects the appliwnl to n civil Penalty of
sol more than five hundred dollar, Wish.
,I]1. as owner ofthe property, or my employees with wages as their role compensation,
will Jn the work, and the atmctare is not intended or offered for sale (Sec. 7114, Business
POWER IIEV]CHS
❑'TENANT ❑ FOOD SpRVICE
IMPROVEMENT
OTHER
SWIMMING POOL ELECTRIC
and Professions Codc: "a Coordinators License Law does not apply to on owner of
OUTLETS -SWITCHES -FIXTURES
pmpeny who makk o, improve, thereon, and who dam.weh work himself nr ihmngh
his own em to provided pmvemen
p y, him led Ibm such int is am not year ofd or ploriosl fol'
sale.],.hnwer is sold withinoneyourofcpromi,for the
eve building
NIiW RESIDI?N,,AI. ELP.C'I'R $( IT.
SQ. FL FLOOR AREA
SIS FT.
Q
with
ncrvhuilAer will have the burden of paving that he did not buil) or impmre for pur-
of proem
pose of creJ.
E] 1, a, owner of the prnperty, um exehuively contracting with Iicenmd counselorsto
'TOTAL
crash a,, the protect (Sec ]044, Business and Pml'c,motn Cn I,:)'I'lie Cunwmum', I.,-
- -
nmLewdomnotaEpl, o an owharof pmpeny who builds acanthuses thereon, unJ
QTY. PLUMBING PERMIT PEE
who contracts for such project with a commemr(s) licensed pursuant to the Connector's
License Law.
-
1117RMU ISSUANCE 5 O
1 am exempt under Sec. . R & PC far Ni.s renam
owner Data
AIA 'ER -DRAIN & VEIN 'I'- WA'I'IR (EA)
VALUATION
BACK FLOW PROTECT. DEVICE
ECLARAI
WORKERthrourSCOM"IiNS
Iofthefollow ION
one of the following tmlamdnm:
I hereby ill nnder penalty lie
mai ncperjury
I]I 1. to and will ma,Imineed 3700of Carthame self-insum Workersmool lie
anlionl pmvo br Stento 37X1 of lite lather Code, for the purl'ormuncc nl' lite
IIRAINS- PLO(IR, ROOF, ARG,COND'
STORIES
TYPE CGNSTRUCTION
t gn mi
work lie which this Permit is minor.orker
FIX, '11RES - P1311'I RAI'
h required by Section
1 love sad will ode. fon Workers Compensation work for which
3703 MLabor Gale. for performance of the work for which this Permit is
OCC. (iROUY
AI'N
CTAS -IiA. SYS 'I'IiM-I INCA OH1'LETS
My Wnrk�r's CoryryQ� ryry-aaty� Ipp��{{�� c��c..��yy and Paliey�np herar:
M,Wo
Carrieel azz". nq/i�U1G ePoliey No.1`rw G'y 1146701
,
GAS -EA. SYS'I'1?M-OVER4(1?A)
ChKI'I IICATE OF EXEMPTION FROM WORKHId S'
COMP17NSATION INSURANCE
GRHASEANDus FRI. WASTE IN' I'ERCF.YTOit
BUILDING DIVISION PEES
(Thissectinn need not becomplmedi[We pemJt is ,anent hundred dnllarr (StINq
or IcxxJ
GREASE "1'RAI'
PLANCf1ECK Plil[
Icertify that in the per(nnnnneeuf the work for which this permit is iswC..open
nm cnlplof any paten In may mooted so ism bcc0nlc,ohpc1 m lice Workers' ColnPClt-
SEWER -SANITARY- S'IORM IA. 20019'.
BNI?RCY PINI
WATER HW PR WIVEN'VELECTR
,anon Lawn of Coifinort Data
Applicam
GRADING PER
NOTICE TO APPLICANT: IL after making this Certificam of Exemption, you should
laconic ,object m the Worker's Confenvahas parkin is of the I.ahor Code, you nest
WATER SYSTENIfTREATING
SOI(S FEE
Gad,all comply will, inch pmvision,or this l'tnnit shall be deenhlrevoked.
WALUR SERVICE
CONSTRUCTION LENDING AGENCY
I heathy aflinn lits there isuntmwaion lending agency Roche perlormanccof
PAID
Date Ruder X
NEW RESIDENTIAL PLM9. SQ, ET.
the work for which mi, permit is irsucd (See. 309. Civ. C.)
Linden's Nana
TOTAL:
Lender's Address
n ,
ptRHUINC-bdE
I certify that I have read his application and sone Nat the olawe infomalion is
correct. l agree at comply with all city and county ominanees and state laws mining to
building aromatic", and hereby edthnrim mpraw havesufffinoty tnenteregmlha
QTY. MECHANICAL PERMIT FEE
SIiISM1 EP
PIRMI'1ISSUANCE
abovo-nmminned mc,hy for impcclkno parpnsas.
(We) agree to sive, laden.... y and keep In:nnlax, the Cily 01' Cupenarn against
]'... F t i
Iiabililiea,judgmems.c... sandexprow, which may many wayacene a,mosimit City
in nntmrmence of the gaming of this' mal.
ALTIiR OR ADO ID MECIL1'LUMl11NG
FEli \ O
J
AIR HANDLING UNIT (TO II JB0 CFM)
APPI ICANT UNDERS ^DS AND WILL COMPLY WITH AL1. NON -POINT
SOU CE REGUL. 1'Ifl 5. 4-/_!6
AIR IIANIILING UNIT (OVER 111,INNI CPM)
CONST RUCI] N L
C(lNS'I'ItUC'I'ION'I'AX
1
Sig a reofApplica UCu tactor . Dam
HAZARDOUS MATERIALS DISCLOSURE
EXDAUSTROOD(W/DUCT)
HOUSING MITIGATION PER
HEATING ON] T(TO 100,001 If l' U)
Will theapplicant or future building mctlparr amt or handle hnallousucamial
a1 definsx] by the Carinthia. Municipal Code, Chapter 1). 12. and the I Icallh and Safely
Cosa, Section 25532(a)'1IIBAI'INC,
UNIT (OVER 100d)(n BTU)
❑Yes �No
Will the applicant or lmuryryry hu"?ding occupant use a deduction- devices which
,mil hamNeun air coaarfZr,`hor Jcli,2 by the 11uy Arca Air Quality Manugclncnl
District'sL��lln.
I] Ye.
PAID
Dale ReecipI
VENTILATION FAN (SINGLE RESID)
BOILh;R-COMP (3HP Oft IBO,INN) BTU)
TOTAL:
BOILER-COMP(OVER IINUNNIB'fU)
AIR CONDITIONER
I have read the hecndnm railroads Terminations under Chapter 6.95 of the Cali-
ISSUANCH DATE
NEW RESIDENT AL MECH. SQ. bit
fomes alth & Safety Colic, Sections 25505, 25533 and 25534. 1 wtderstmed (hal it the
builJl taesnol... cralthrova anl, lltnt it Ls my reef,'nsihilitymnoefy the nnvpunI
ofth ' %P_ttswbitlitmmt l •m I manoiss I C - t f04
ISSUED BY:
TOTAL:
Owns or authori,ed agent ` Data
OFFICE