B 0460 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.CFRICAL PERMITNOA-10460 BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL. SOOO I IL7;0 4 6 0
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�2 0 ,C2 C!f r- 3 - ?
OWNEI('S NAME: PHUNIi:
C3Olt NAME: LIC No
J r' r-, N/C CON)'ROLa
ARCHITECTIENGINEER: LIC NO: ADDRESS: - ❑
f'-"73�LW oak A
CONTACT: PHONE: 6UILDING PERMIT INFO
./� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
LICENSED CONTRACTORS DECLARATION / QpY ELECTRIC PERMIT FEE
I hereby aRnn Mat 1 am licensed under pmvi,hem,of Chapar 9(commencing JOE DESCRIPTION
Q0.Z with Seaton70fhP.fUiviaiaa 3oDEc Business and Proressions Cmla,and mylirens is RESIDENTIAL:
WOO_ PERMIT ISSUANC17
F 11.11 rnrre and hltixl. � S} /�' ❑SFDWI. ❑KITCHEN REMODEL
�U F Liccnsc CEass ' Lic.p
6 U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F a al Dal, Conimdor
F- ARCHFELTS DECtAkAl ION 0MUL9'1-UNIT ❑STRUCTURAL
Z n��- PANLLS MODIFICATION
I undemmnJ my pions shall be useA as public records
OZ-� UPT020DAMPS ElIN'l PRIOR ❑CHIMNEY REPAIR
E=�F"W Licensed Probe.+sinnaI 201-1000AMPS IMPROVEM1iNH L]SWIMMING POOLS
qW2 OWNER-BUILDER DECLARATION OVER["AMPS C PAID REMODEUREPAIR QDEMOLI'FION
r�t4 a I hereby affirm that I um exempt from the Contractor's License Law for the
iWyxS O y U following rcu.an.(Sermon]EUI 5,Business send Prnl'essions Cmlc:Any city or comny SIGNS ELECTRICAL C OTHER
W 3¢y which requires n permit to enn.trum, her,improve.demolish,or repair any stmchim (�
prior to its issuance.also requires the applicom for such permit to file a signed smrtment SPECIAL CIRCUI FMISC.
} that he is l mcenwd pursuant the provisions of the Continuou's License law(Chance9
a�0 (conunmming with Section 7")or Div lslnn3 ofmc Bloinecsand Professions Code)or TEM It M ITER OR POLE INST. COMMERCIAL:
m d Qoa 'hal he ms mtnnpi therefrom end the basis for the alleged eamnption.Any violation of C NI7W BLDG/ADDITION C DEM01.1'TION
X^so Section 7031.5 hyany applicant fora formsubjects lhedpplicantm a civil pc unity of POWER DEVICES CTENANT ❑FOOD S17RVICE
W oat more than rive handreddollers Cl IMPROVEMENT
F_ 1,as owner of the property.or my employees with wages as their.cole compensation, SWIMM LNG POOL ELISM RIG
f.. will torah( Sea.7044,Business COTHER
^ and Professions Code:The Contactors Licenm law docs not apply to an owner of OUTLHIS.-SW l I'CHES-171X'I'URES cvo
pmpcny who builds or initiatives thereon,and who does such work himself or through ,,-
his own employees,provided that such improvements are not intended act offered for NEW NES IDENTIAL ELEC R FT. -
rule.ILhawevm:'lie huildingorimprovenmmiswddwithinone yenrof completion,the p, .FT FI. RP EA (� {/tiQ'FI'.
r-builder will have the burden of proving that he did not huild or improve for pury I 1 �� 11 yI
poi of sale.L TOTAL: r I II
r7 1.as owner of the prvatery,am exclusively contracting with licensed cadmmors to I h1AY 0 3 199 PERMIT ISSUANCE !� !I
nmsuuc(
be project(Sea.7044,Business send ProrotalooCoda:),
s TTe CamG
i-an. - - -
do.,,.,wLaw loo(apply In wr
annaol'praIndictorPerry.1 hdsor i,npiamm
roic,h .and QTY. PLUMBING PERMIT - FEE I�I,
who contracts for such projects with a contrail licensed pursuanuo the Connectors
License law. f�
[:JIamexemp(under Sec. ason B.R&PCfmthiarc
Owner DoneALI'HR-DRAIN&VENT-WATER(EN f{fw
WORKER'S ltyoCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
R
1 hereby urm penalty of under Deperjury one of the insumfog declarations:r' Co
❑ I hev,provide far by a tion 3,7 01)of the La t r Code,]or for Workerance of a DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
ration,as provided for by I,circa.
3]00 of the Lubar Code,for the l,artarmuncc of Ne
work for ..,I this permitis coder FIXTUNES-PEk TRAP
1 have and will maintain Workers Compensation Insurance,h required by Section
J]W or the LnM1,r Code.Eire theypRerfom,an{rce aide work far which this permit is issued. GAS-EA.SYSTIiM-1 INC.4OUTLETS OCC.GROUP APN
k C
Imal Policy
C m`ottY+' 1^4AKA 1C Pol ry No,7V!zmqq 1:1
CAS-EA.SYSTEMOVBk 4 HLA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE IM'ERCEPTOR
131111.UING DIVISION FEES
(Thi,scminnneednu be complcuvl ifthe Permit is hunts,lonamcd dollms I$IN)) GRHA.SH TRAP
rrc less) PLANCIIIICK Fllll
Icertify that int he perfmrnanmof We work far which dams permit is issued,I shall SEWER-SANITARY-STORM EA.2W IT. Z Q
not employ any parson in any manner v,as to become subjectto the Workers'Compen- ENERGY FEE
C) amian Laws of Cal`fomma.Dote WATER HEATER WIVENT/IiLCC IR GRA INC PET.
Z O Applicant
y NOTICE TO APPLICANT.If,after making this Certificate of Ea,nrp bat,you should WAHR SYSTEMRREATING
(•-' become subject to the Workers Compenmron provisions of the laboa Cada you must SOIh
Wforthwith comply with such provisions lot his permit shall N,deemed revoked. WXiER SERVICE ;IN
�G NA V A 2 1
z CONSTRUCTION LENDING AGENCY NEW BESIDES I'IALFUME, SQ.FT. PAID Dies `R •iplN�
U O 1hembyaHirm that there is.cnnyauction lumingageacy farthe perfmmuoce of
V. E-' the work for which this permit is issued(Sec.3097.Civ.C)
C Lcnders Nyne TOTAL
U
Lenders Addmsc A
M.
M. 1 reality that 1 have mad this application and state that the above information is 13UII )I
F 3/1 correct.l agree to comply with all city and county national and state laws relying to QTY. MECIIAN ICAL PERM IT FEE
Uz building conymctior,and hereby eahorire mismalnmtives of this city to enter upon the SEISMICFEE
asove-mentionod pmpeny for impu:lia I purposes.
(We)agree 1. .1,indemnify PERMIT ISS UANCH ELHC RIC FE
g y and keep harmless the City of Cupcninn against
Imebilitmes,jvdgmems,caasand expenses which may in day way acemeagainsl said City ALTER OR ADD TO MECH.
in consequence of the g.him,of this permit. PWMBIN [L'
A VPLICANIUNDERS IA NDS AND WILL COMPLY WI'I'II ALL NON-POINT AIR DANDLING UNIT(TO 10,00)CFM)
SOU }I�CULA'1'IONS. MECIIA CA +HI?
ise
AIR HANDLING UNIT(OVER 10.003 CFM) CONSI']IU ON'IAS
Sigortamot AppTandCnnitocmr Date EXHAUST HUOD(W/DUCF) HOUSING TIGAI'ION HE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle formations material HEATI NO UN 11'(TO PRILSOb BTU)
as defined by the CupeNno Municipal Cob,Chapter 9.12,and doe Health and Soucy
Cnde,Section 25532(m] HEATING UNIT(OVER 100,0110 BTU)
Yes [yNo
VENTILATION FAN(SINGLE RE SID) PAID Date Be'.. I#
Will the applicant or(umre building occupant use equipment or devices which BOILER-COhtl'(HIP OR IIp,000 BTU)
mit lasciviousair conmminana as defined by the Bay Arca Air Quo Management T
Distinct
❑Yea 04, BOILER-COUP(OVER 100.000 BTU)
I have read the hamNous materials ra3uircmer entc urWChapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE /s
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RES IDE N'1']AL MECH. SQ.FT. r^ y
huildmng,kit}qlot currently Noun bal(list it is illy responsihilaymnrify'hcarcaponl J
oflimic aR,whichm ham iprlonoissuanceofa Ceni3,ca(eof Occupancy.
Owner or autauthor' dagent Date TOTAL ISSUED BY:
OFFICE