S 0826 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUu,DINC-ELECTRICAL PERMIT NO.
PLUM RD `i
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROECT'IDENO'UIApON C0826 O2v
BUILDINGADDRESS: SANT",ANYNI APPL.ICAI ION SUBMITTAL DA[
Z � �3u« �CL �'j S014— Y - 2111
QWNIiR'S NAMIi: 1 1'10X8.15_7,�' CONTRA Y1,)v5lr.CA-J `nom �JLIC NO:
1�kv,Y '/ -{ .Yla��1JW JQ NIC CON'fROl.p
CONT TIiC1'/IiNCINEIiR; I.RPH NO: (646 l L a,' A-° 45201V V -L ❑
GDM'nCT'. PHONE: BUILDING PERMIT INFU
6�os /n(� -/_ `; 1��'1 ❑ ConsultantFeesPaidbyApplicant(Initial) BLDG C1 Me MTiCI
1 WJ 1\�J lJ1lv1tX1 10✓ ❑ ❑ 0
' IC17NS17D CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amort that I am licensed under provisions of Chapter 9(commencing
WOJOB DESCRIPTION
Z will Nation 70gBofDlvision 9ofthe 3,binu eand Profenion,CodeOr
,and my IcseIx PERMIT TSSUANCISSUANCE' RESIDENTIAI,:
W 00 /N ..g
I in full force andpttal l �� l� ❑$PDWI. ❑KI'ICHIiN REh1(IDIIL
aUV License ave 6 s101fr9 p APPLIANCE'S-RESIDENTIAL ❑ADDITION ❑PLUMBING RIi1'll'li
FZW Date Cnntrucmr-
vs 6 a ❑MIIITI"UNIT ❑MOD1171'URAI.
m ARCHITECT$DECLARATION 1'ANEI ti
~coZ T unJersmnd my Plans shall be used e.public recoNs MODIFICATION
OZ—Q UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
W Licensed Pmlessi...I 2111-IRR AMPS IMPROVF,MIiN'IE]SWIMM INC.POOLS
OWNER-BUILDER DECLARATION Contractors
OVER Il00 AMPS ❑BATHRs MAJITHI'AIR DDlih1( .1'I'IOy N�.
q�C I hereby affirm that 1 am exempt Irnm the Commcnors License Law for the t. ZL-.0
x O a U fnllnwing reason.(Section 7031.5,lboine"and 1'ndesvinn.v QNu Any city or county SIGNS IiLEC'I'RICAI, OTHIiR
W 3 W JF shish requires a permit to consrrocr,alter improve,demolish.or repair any structure rl�Q IJ
T_IsW.cg prior itsissuancq also requite the applicant for such permit to file a signed statement SPECIALCIRCUIOMISC.
fly thin he is licensed punuam to he pn,v,s,one of the Contractors Liccnxc Law(Chapters
W�pO (commencing with Section 7")of Division J ofthe Business and l'mfessionv Coda nr TEMP.METER OR 'S' COMMERCIAL:
d Xo tY that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
co oe Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally oI' POW IiH DEVICHS ❑'TENANT ❑FOOD SERVLCH
trot mote than five hundred dollars($510). IMPROVE W iN'f
SSG
E]1.as owner of the property,or my employees with wages as their srlecnml¢nsarinn, SWIMMING POOL ELECTRIC
C^o will on the work.and thestracmre is not imcnded or obered for sale(See.71104,IfuviasX [I OTHER
W m and 1'm(cssioto CNc:The Conowba's Licence Luw does not apply to an owner of WTh1?fS-SWITCHIi$-PIX TURFS
property who builds or improves thereon,and who does such work himself or through
his own entpinyces,provided thin such improvements are not intended o coffered fill N17W RESIDENTIAL EI.E(TR SQ IT.
sale.IL howeveethe huildiiii impmaemem issnld withinoncycar rf completion,the SQ. T• )OR ARI \ $/SQ.FI'.
1
owner-builder will M1ave the huNen of proving thin he did not IviIJ rr improve for par- �t
pow It mc.).
1,as owner of the prnpery,am exclusively contracting with licensed etmlmemrs to TOTAL: I
constmcithepe ject(Scc.7014,Business and professions CNet,The Cortmemr's Li- ApR 21
censelaw dtwsnmupplyma,lostan,l property who btilJx orintpmves thereon,and QI'Y. PLUMBING PERMIT FEF. 1'�
who contracts for such projects with a contentious)licensed pursuant the Contractor's
Licen.ue Law. PERMIT ISSUANCE
❑ I ten exempt ands,Scc, .B&P C for bonbon
ALI ER-DRAIN&VIiNf-WATER(EA) 1:1AI ION
Owner Dam
WORK17R'S COMPENSATION DECLARATION BACK FLOW I'ROI'ECT.DEVICE
I hereby afros'under'bally of peoury mile of the fnllnwing decamlians '
.J T have and will maintain a CeniGcate of Consenuoself-insure for Workers Cooper- DRAINS-FLOOR,BOOK AREA.GOND. STORIES '1"YPI?CONSlRl1C1101
satiun,as provided for by Section 3701 of the Labor Code,for the perfornunce of the
.,,,it far which this Permit is is sed. FIX'I'TIRES-PIiR'fRAP -
1 have and will maintain Workers Compensation Insurance,as require)by Section
37(10afthe Lama,CNo.for the perfnmtuncc of the work for which Ibis pemtit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLEI:S OC.C.GROUP APN
My Wnrtrr'xLompc,su_linrty rams ca r
policy NicY+.my.r�rs
Cartier. _ _ LY�� me Policy No.:--LLia(ooln[oga GAS-LA SYSTEM"OVERiWA)
CERTIPICAI'H Oil EXEMPTION FROM WORKERS' GRIiASIIINDUSTRh WASTE INTERCIiPTOR
COMPENSATION INSURANCE If111LDINC,DIVISION FEES
(This sectionnminotbecompleted if the permit is forone hunJtcddollars 151011 GREASETRAI'
nr less.l YLANCHIiCK N]i
I eerily Un in file pvilicimace al'the work for which this permit is lssued.l shall SEW12R-SANITARY-STORM EA.21X1 IT.
not employ any person in any manners as to become subject to the workers'Compes- ENERGY FEE
.smion Laws of California.Date WATT:R HE A[ER WNEWAILECTR
Z Applicant GRADING FEE
NOTICE TO APPLICANT If.efix,making this Ccnifcate of Excmptinn,you should WATIiR SYS]EM?RRATING
I--t becons,subject to the Worker's Compensation provisions of the LrMr CNq you must SOIIS Plili
forthwith comply will such pbol,inn,a,this permit shall be demnedrevnkcd. WSJ 1:11 SERVICE
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAR) Dam ei a
U O I hereby aBrnnhat there is a construction lentim,agency for the penialambee mf
dte work for which this permit is issued(-Scc?097,Civ.C.)
TOTAL:
Lender's Name
0 {U Lender's Address TfII'A L:
} a 1 ccnily that 1 hast read this application and state that the abue milmoation is IR111.DING Plili
F' tn cost.l agree to comply with all city and county ordinances and state laws relating To QTY. MECHANICAL PERMIT FET; SlilShflC Pli1;
U Z baildag con,mati n,not ht,hy mIr,f,cmg..cmmivwnf his city u,cine,upon the p--,,//��
above romaimod prnpeny for impectinn purpnms. PERMIT ISSUANCE 3 J V ELECTRIC FEE
(We)agfec to nave,indemnify and keep harmless the City of Canton.againo
luhilitics,juJgmenu,ma,and expense,which may inany soy accmcagaino,eid City ALTER OR ADD TU MHCIL PLUMBING 121113
in cnnsquence of the granting of this pr mil.
APPICAF
TUNDERSTANDS AND WILL COMPLY WITH ALL N N-POI T AIR HANDLING UNIT(TO 10.11(0 CFM) MECHANICAL ITE
SOLI CE EGULATION&
AIR HANDLING UNIT(OVER 10,(XX)CIl11) CONSTRUCTION TAX
'igm fAPPlinun/CnntmuuITatm EXHAUSTHOOD(WIDUC) HOUSING MITIGATION FEE
HAZARI -- __S�LOSUBii 0
Jl the applicant or fmurt building mcupam start or handle hazuNm m
oaterial 111iA1'ING UNI'I'(TO 100.00()N'I U) 2
ns deed by the Cupcnino Municipal CNc.Chapter 9.12 and rhe Hcnhh and S:dMy
Code.
Section 255321u77 IIIiA'I'ING UNIT(OVER 100,0110 BI's)
p Ycs ❑No VENTILATION FAN(SINGLE REST UI PAID Date Receipt If
Will the applicant or future building occupant use equipment or devices whichtlOILER-COMP(?III'OR IIM],INXI li'1'U)
-rat hamrJous air camami...is a,defined by the Bay Area Air Quality Management Uf h:
Dioriet7 BOILER-COMP(OV R 100.010BTU)
❑Ya ❑No
AIR CONDI'ITONER
I have :Wthc hmarinus mmetals requimmenrx under Chapter A.9 rftheC li- ISSUANCE DATE
or
Iia Hcallh Satety CNc,Sections 2.5.105.25533 and 25534.1 undcm dhad, the NEW RFSIDT:NI'IAl.MECI L SQ.FI'.Ii theI � ��
hit ing Joes tcuremly havcmm�anl.Ihnt it is my resrymsibility lr a, nt `aIl
bovole a Ce 1 , 'cu
Ow authorized agent Uma - '[Q'AL: ISSUED fly:
OFFICE