94070076 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL GRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJBC'T IDRN'nricAriON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
_ a tm Seven ' r; �e aq-qR
"W'NERS ZYL
PHONE: )N�kfkC'I^OYR'S AML: (S ^ 1 l '7bj N/C CO,YIROLn
CHITECTIENGINEER: LIC NO: gUDRbbESS:^ > Y V ❑
CONTACT: PHONE: 1/O V BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑ ram
LICENSED CONTRACTORS DECLARATION QTY (ELECTRIC PERMIT FEE
1 hereby a1Rrm than Tam licensed under pro.isinn,of chapter 9(emnmencmg JOB DESCRIPTION
OaZ with Seclion 7000)of Div lxian Sol he lbomess and Proreesiom'Code.and my license is RESIDENTIAL'
QW O O PERMIT ISSUANCE
H leer,force cl..nJ i]Q '-1 ZQ` ❑SFDwL ❑KITCHEN REMODEL
QUV License Clas A Lic.X I APPLIANCES-RfSIDFMIAL OADDITION 0PLUMBING RE-PIPE
y Q a Dum $� 'ES DEtor
• - HCIII"T'ECI'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z C)vz IUMerewnd my plans shallMused us public rtcoMs PANELS MODUMCATION
UP TO 2 W AMPS
UZ=� [I INTERIOR ❑SWCHIMNEY MINGP OL
tal Licensed!Professional 101-IIgq AMI'ti IMPROVEMENT 0$WIMhfINGPWLS
¢' '� OWNER-BUILDER DECLARATION
Y 0W< ytn p _ OVER I(XX)AMIM1 ❑BATH REMODBf1REPAIR (]DEMOLITION
W m 1 bmen arm,mm I.m e.a:n I Irntn me cnm,amn.'.Licerae Law tali me
❑1X13 uta.bU- following reason.(Section]1131.5.Business and Professions Cndc:Any city or county SIGNS ELECTRICAL ED OTHER
m which requires a permit n)construct,alter,improve,demolish,or repair any suucture _
prior to its issuance,also requires the applicant for such pconatto file a signed statement SPECIAL CIRCUITIMISC.
..Ihe is li¢meJ pursuanno the pmvirions nOM1e Cnnnuc7or'n License Luw(Chup¢r Y s
Ii1CC0 (<nmmencingwith Seetion]IIt1U)of Division Sof the Perinea ant Pmfexsinna Gde)nr "TEMP.M1fEII711OR POLE INS'T. COMMERCIAL:
o.�'yd e y that he is exempt therefrom ant the busie for the allege)exemption.Any via]mion of ❑
NEW BLDG/ADDITION ❑1700DEMOLITION
SERVI
u2�y
Section 7031.5 by any applieamfor aPermit subjects the applicant macivil pewpy of POWER DEVICES ❑TENANT ❑FOODSERVICE
nt moreInns❑l hundreddollars,empl.
f:�YisavoSWIMMING fool.BL[C'I'ItIC IMPROVEMENT
=Q ❑ Lothea rk.mal themary.m o, empinyeeuwithwagesarlhcir.ee. 0,14.Bsiiess
W t:.0 will dothework.endtheae Cornsns',LisdedLaw
o,.IScc..an Business OGTHER
W and Pmfosiom Cole:The Contmaors License Law does not apply s lf owner of OUI'Lfil'S-SWITCHES-FIXTURES
his own whooyeIdse,m imprdvt a Thereon,i and who does such work himself or through
Ha own employee+,pnrviJnl that such impnrvemenls are nal intended nr offered for NIIW RESIDENT'IAL f?LECTR SQ FT.
sale.If,however,the building or imm
proveent is.sold within one year ofcompletlnn.In, SU FT FLOOR AREA ESQ.Pf.
owner-builder will have the burden of proving that he did not Mild or impmve for par. 1
ose ol'sale.) 1 r�
1,as owner of the properly,am eaclnrively contracting ncting with licensed conuacut
pTOTAL:
ttmalmn the prv,w(See.])W,Business and Professim:s Cole:)The Cancer, Li- L D
cense Law does not apply to an owner of prop,ny who builds or improves thereon,and QTY. PI,UA161NG PERMIT 11F.EE It
who caramels for such projects with a contractor(%)licensed pursuant to the Contractors L 9 1999
I,iccnso Law.
lam PERMIT ISSUANCE,
esepl und &aide,See ,li P C for this rcawtn
m 'I
ALTER-DRAIN&VENT W 'R(EA ON
n J
Data
S. WORK17R'S COMPENSATION DECLARATION BACK I'I,ON'PROTECT.DEV(
I nercny arbmn under penalty or perjury m,e tame rau,wmg demnrtnlona
❑(have and will maintain a Certificate of Con.enno sclLinsure for Workers Compen- DRAINS-FLWR.ROOF.AREA,CONI. STORIES 'TYPE CONSTT RUM[ON
cation,as provided for by Section 3](X1 of the Labor Code,for the performance,of the
work lar which this pemat is issued FIXTURES-PER TRAP
k I have and will ntnimain Worker's Compensation Insurance,as required by Section
39110 of the Labor Code,for me Performance ofthe work for which his ,air kosued. GAS-EA.SYSTEM-I INC.d OUTLETS OCC.GROUP �APN��
My Wo 'r'sC Pe nun saranecc d Policy puotber arpp�ll/tO GAS-EA.SYSTEM OVER J(EA)
Cmrier�Palley No
PROM
T,�A V T
GIIRI'IPICA'IL ENSN!&ONINS PROM Wh)RKERS' ONIIASPIINDl15fRL WASTE IN'1'BRCI?('TOR
COMPIiNSAI'ION INSURANCE BUILDING DIVISION FEES
(This section need not hecomm
pleted ifthe Petit is forms,hundred dollan(SIM) GRIASETRAP
tali less., PLANCHECK FEE
I eerily that in the peitermance of the work for which this permit is issued,l shall SIiW17R-SANITARY-STORM EA,20(1 FT.
not employ may Person in any manner so as to become subject In the Workers'Crimper.. ENERGY FET;
Z e.,.an Laws of California.Date WATER HEATER 0.NHITELLECTR
OApplicant GRADING FEE
G WEICH'1'0 APPLICAN'C If,after making this C'adi.,m of lixcmptioa,you should WATER SYS"[UNITREAI'ING
F , been,subject to the Worker's Compensation previsines if the Labor Gde,yea moat SOILS FEE
forthwith comply wiihsuch pownt...no this pemtilidall the deemed invoked WATER SERVICE
Q
a
is
CONST co lLENDING AGENCY NEN'RESIDENTIAL.PLMN. SQ.FT. PAIL)
V Ihcreny affirm that thre ixconaervctinn lending agency tper
onne lbrmmx
uof Dat ReuiptX
D. E" he work[in,which this protan is issued(Sec.3(19],Civ.C.)
TOTAL:
Lsnter's Name
WLender's Address TOTAL:
6. 1 enil'y that 1 h.vc rwd this applicminn and slate than the shove infmrmatian is BUILDING FEE
,o, connect.l agree to comply with all city and county ordinances and stale laws mining t" QTY. MECHANICAL PERMIT FEE
U Z building cunswction.and hereby.mhonxe representatives of this city to enter upon the SEISMICmE
abnvemention d progeny for inspection purposes PERMIT ISSUANCE
(Wc)::gee to save,indcmniIy mW keep hamdms the Chy of CuITnimn against ELECTRIC IT E
Iiotalitics,judgntents.casts and esMnses which may in any way acemc against said City Ail ER OR ADD TO MECH.
m emeaqu,ncemftbegmeartg ofthis cnniI, PLUMBING FEE
APPLICANT UNDERST D. , D WILL COMPI F.MHOsbPOINT AIR HANDLING UNIT(TO 10."CP61) MECHANICAL FEE
SOURCP
NR HANDLINGON[C(OVER IOIXIIICFM) C(INSTRUCIION TAX
Signature of ApplicantiCommeno, �L Dana EXHAUSTHWD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will Iloe.pplicunl ar furore building orunpanl rove or handle moub msnmerinl IIHATING UNH(TO 10.000 BTU)
n defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Carl Section 155321x)? HEATING UNIT(OVER I W.000 BTU)
❑Yes 0N PAID
VENTILATION PAN(SINGLE RESIDE Dare ReceiptX
Will the applicom or furore buildingocenpanl use N tiipmedl or devices which BOILER-C0MP(3HPOR 1W.000BTU)
mit haNm
uous air contaminants defined by the Bay Area Air Quality Management TOTAL:
DisainO RO1LER-COMP(OVER Koh.0(X1 BTU)
❑tees E_]No
I have read the hmalloes mu ted.],requirements uMe,Chaptc,n.93 of the Cali 1 AI R CONDI'1'IONER ISSUANCE DATE
empant fomia Hwlth s9 Safety Gde,Secywn�5505.15513 an Iundemand that if the NEW RESIDENTIAL MT:CH. SQ.Ff. �Z
maedi <lenant mm nrpmdbJbymnmiry etc m,avy.
tanto mmhsuancc ofegtr'itnryje�rg�pancy.
)saner ma diamard agent ((�_'OO�t(r TTDme TOTAL: ISSUED BY:
OFFICE