S 1652 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PET NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 1652
BUILDING PROJECT-IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
22'SNAME
OWNEkAME,A PHONE: C 'E1 AC'1 OIL'S NA E: LIC NO' '�y
1• - �QJGe c�o�b X16 CONTROL#
gRCHITF ;NCINHh:R: I,IC NO: ADDROLS'S: 4' � q�7'
CONTACT: PHONE: ^=�i_•ti BI ILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG El FLT PLUMB MECH
❑ �K ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMI'T FEE-
T hereby.arm that 1 am lounaw node,prnvi..mrs of Chapmr9(enummteing :. LOB DESCRIPTION
nizz 'i'h Seec'n0aul)of D' dnosxand Prober..lom Carla and my license ie RESIDENTIAL:
�WU t v ARCIIITPAT qb PERMIT ISSUANCE'
Ixlon3 nlThc6 _ ❑SFDWI. ❑KITCH17N REMODEL
ulpp a#� APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
I'll force and F u
U
ti tan DECL ❑MULTI-UNI T ❑STRUCTURAL
'S DECLARATION
Fez I understand my plans shell be used its public records PANELS MODIFICATION
O44-0 OP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
2
4ItW Licensed No@ssimml 201-1000AMPS IMPROVEMENT SWIMMING POOLS
_1
OWNER-BUILDER DECLARATION
..I OVER IGO AMPS El BATH RE 0 EL/R IR )I 1
y' 1 hereby affirm that I tan exon,from die Coalracmrs License Law for the
XO y U following eraeon.(Scelon 90315,Business and Pmfesetons Cede:Any city rar countySIGNS ELECTRICAL, ❑OTHER
� WPIm¢"' which tritium,.p 'ain tot t 'It -improve, 1 l,n p any structure -
12 Ito
y.] runtrunto nuomame,tilk.nooroe,h ap,licautf h permitl filon't'nerfooloner, SPECIAL CIRCUIT'/MISC.
b y mm he is licensed pursuant ithe p f the Contractor's License La (Chapter 9
LL1 dC (conneneagwith Seen,,.9000hol Division 3 of the BaxmsaaW Profit..i t:Cnlater TEM P.METER OR POLE INS'I'. COMMERCIAL:
❑ p, C Ilan he Is exempt derefront all the for,far she alleged exemptfne.Any violmlon of L1 NEW BLDG/ADDITION El DEMOLITION
Why Seclion90315byanyapplicemfnr ape nna sub]ectx the nppliwnlmacivil penaltyof POWER DEVICES [j TENANT ❑FOOD SERVICE
22 t me him five hundred dollar.,U500). IMPROVEMENT
Ir'gQ oap1,as owner of the property.or my employees with wages as their sola compereatier, SWIMM ING POOL ELP,OTR IC
"$y�,•ZQ wfl l do Wo work and ihesWdure isneandiehoUrnlTemd for sale(Sce.9044.Bust new ❑O'T'HER
ly a. and Profession,Code:The Cnnmvemr's License I.e.rix,not apply to an owner of WTLB'TS-SWITCHES-PI RIPS
pmpmty who builds or improve.(her..r,and who doe,such work Ili mso f a,through
his own employees,provided that such impmvemmns ire not intended or offered for NGW RIPSIDCNTIAL ECTR Q P'
sale.If,however,the building or improvement ismld within one yenter mnnplelina,the SQ.FE FLOOR AREAar-hul $/SQ'FT.
elder will have the harden of proving that he did not build or improve for par- P A 9 [y'�l
brae of Raley
❑ 1,as owner(if the prolwny,am exclusively contracting with licensed contractors to T(YTA
construct th project(See 96f4 Befirc,andP f:. ns Ciall'I'n C mem. Li-
cense
MAY 13 A1'p
L l t apply to of p p ler n builds p :thren nit QTY. PLUMBING PERMIT ID
FEE AY0
who contracts for such projects wit contractors)lied pursuantt the Contractor s
LiunmLaw. PERMIT ISSUANCE C��Y �L.
Ian,exempt under Sec. ,B&PCforEisraasm (/Ur Cil l tDi
ALTER-DRAIN&VCN'1'-WATER(5A) VALUATION
Owner Dole
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 media affn'm under petal,of pe jury sant of the following direction
IharonnJ will mvavtoin nCeniOeumot Consenno self-Insure fur Worker's Cnmput- DRAINS-FLOOR,ROOEAREA,COND. S'fORIPS TYPE CONSTRUCTION
. lion,nit provided for by Section 3700 of Labor Coda,for the perlbrmanof the
work forwhichills Iwnniis issued. IHX'NRES-PP.R TRAP
❑ 1 have and will mountain Worker's Compensation
Co Insurance, rl Section
3900 ofthe LaboCnde, nnhe peirmanecoftho work forwhich this required
is
issued, GAS-GA.SYS'I'P.M-I INC.4OUTLETS OCCGROUP APN
My Worker's Compenmtinn Insurance Comer and Policy number are:
Carrier: Policy No GAS-EA.SYSTEM OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUS'I'U.WASTE INTERCEPTOR
BUILDING DIVISION PEES
(Thiacefion need norteeonpleled if lbs permius[m onehundmd dollars($Iq) GREASI.TRAP
or IessJ PLANCI RICK FEE
I unify that inthe part of he .k for which his permit is issued.ishall SEWER-SANITARY-S'1'ORM F.A.200 FT.
relemployanypersonint y manne".sen �l $N t to the Workers'Cannon- ENERGY PEE
nnnnn 7��--a Ration L. ""r
Til Dem �, --t'�Y WATER HEATER W/VBNTI5LBCTR
,.,an
-I&
W Az—�°I GRADING PEE
NOTICE TO PP :IL atter making thio Cenifmrte of Bxemplaon,you should WA'I14R SYSTENU TREATING
F becomerocetto the Worker;Compensation provisions of the Labor COR,you most SOILS FEE
fonhwithemnply with srich provixiom rarthis Penne shall be decmelrevnked. WATER SERVICE,
Q
aa7. z CONSTRUCTIONLENUINGAGENCV NGW RESIUF,NTIAL PLMB. SQ,FL PAID Date Bassein of
1 herby aRtrnt that them is sued(See.30 lending agency For(he pert nnanu of
U O Ix war,for which this pemtil is issued(sea 309],Cie C.)
�' Lender'.Name 'TOTAL:
V
Leaders Address TOTAL
}t 13) BUILDING ITT
1 miry door I lava reap thisapplicationand sacra mm me:move Imsrmwnon ie
E".
laid remI agree n comply with m1 elry and county nNinaneas and state lowsreveling n QTY. MECHANICAL PERMIT tt PEE
U Z building construcam,:md hereby rather relrresetmtives of this city to enter upon the t" SEISMIC PEE
r
t•'r above-menronel punpoo,fa,inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Ca serrom against PERMIT ISSUANCE, ELECTRIC PE
liabilities,judgment,,c...sand espouses which may in any voyamrre a,mure,snid City AUT ER OR ADD TO MECH.
in co secretive of HE running of this pemril. PLUMBING 5
APPLICANT U tST'ANDS AND A' 1.COMP W I"PH ALL NON-POINT AIR HANDLING UNIT(TO Magid CFM) [PAID
CHANI
SOURCE ,C .'TON
AIR HANDLING UNIT(OVER 10,000CFM) NSTRUCT AX
ign r r
r
SA1pli anV. mm�dor Dale EXHAUST 11001) W/DUCT) USING Ad 'ADDS FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building ouupannstore om
,handle hardous material HEAD NG UN I'I'fl'O 100,000 BTU)
as defined by the Cupanino Municipal Code,Chapter 9.12,and the Ihealth and Safety
Code.Section 25532(a)? HEATING UNI',(OVER 100000 BTU)
❑Yes ON. VENTILATION VAN(SINGLP.RES ID)
Will the a r Iicvnl(itfuture belldin at use equipment or devices whim D. Recdptp
unit hazednusou,ournminJnlsas defined by the[my Area Air Quality Management BOILER-COUP QHP OR 100,010 BTU) TOTAL:
�) Disu'ion' ❑Na BOILER-COME(OVER 100,0001ITU)
7 Ya,I have mud the huzardnusntalflal.rc ¢a der Chapter 695of the Cali- AIR CONDI'HONF.R ISSUANCE DATE
yuircmmt p
fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that lithe NEW RESIDENTIAL MUCH. SQ.FT.
buildinglimeerncuahich havaonnant,their ismyresponsibilitymneflytheocca,r
of the relnircmenP which nmsl M mel prior m isuenee of u Cenifenmof Onvpan y.
Owner rar mdm,ized agent Date TOTAL: ISSUED BY.
OFFICE