S 2763APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERb11T
BUILDING . ELEc TRICAL
PLUMBING -MECHANICAL
BUILDING PROJF.C'I' MEN'11FIC\TION
PERMIT NO.
S 2763
BUILDINGADORESS:
�� s 59pDVI5 :bR,
❑ADDITION
SANITARY
NO.
APPLICATION SUBMI PIAL DAH'.
2- f �9 9
O ER'S AMh: p `I P7R: e
'V
1, C///V , -
CONTRACTOR'S NAME. LIC NO.
U W�
NIC
❑
CONTROLp
r ARCHITELT/ENGINIiER: LIC NO:
1
ADDRESS:
EL C No - M.v
CON FAC I': PHONE
C
- 16 � %,Obi
I'
E:1 Consultant Fees Paid by Applicant (Initial)
❑OTHER
BUILDING PERMIT INFO
131,106
❑
ELECT' MECH
Rl PLUM ❑
LICENSED CONTHALH)RS DF.CLARA ION QTY ELECTRIC PERMIT
I hereby nffmt mut I am licensed under pm, Won, of Chapter 9lcommerami,
with Section 700n of Division 3 of the Business and Professions Code, and my license is
u nil 6rcc and uffecy PERMIT ISSUANCE
License J1116 Clas, C' C . Lie. # 3 3 w
One Cnntrxcul.N/Q/( < Aa T -Elf APPLIANCES -RESIDEN'T'IAL,
ARCD I I:CI"S DECLARATION PANELS
1 understand my plans shall be used as public records
QYf� OWNER -BUILDER DECLARATION
z tY Q 1 hereby infirm that I am cre npl nom the Contractor's Liecow, Law for the
OWE LLH following reason (Section 7031.5. Bmireae and Professions Code: Any city or effort,
0 y which nyulrcs a peront In eonstecL altar, intpmvc, rcmnlidl, oiT repair any nrticturc
fo" priorm it, is em., ulm atriums theapplicme fn orehpanni,,, Ne usigneJ sm¢mmal
2ga that he is licensed proomm to the provisions of the Contractor's License Law (Chapter Y
t�r'•�00 (commencing with Section 7000) of Division 3 of the Business and Prfffcs%ime, Cale) or
d X e g, that he is exempt therefrom and the basis for the alleged exemption. Any violation of
w Section 7031.5 by any applicant for a permit thjec, the applicant et a civil penalty of
n more than Five hundred dollae, ($5V)).
_ ❑ I, as owner of (lie property, or my employees with wages or, their nom compenpnron.
F- wJl du the work, unJ thu.awmurc learnt 11111adroroll,ecd for sure (Sec. 7044, Bueineen
W3 and Pro1',,,00a, Code: 'rhe Count..Turs Liao Law dere or ,pply man owner n1'
property who hui Ids or improves thereon, and who does such w(ck himself or through
his awn employees, provided mut such improvementsarc ran intended or off ereJ fits
sale. If, however.lhe building or improvement is sold within one year of completion, the
mer -builder will her the burden of proving that he did nor build or improve for pun,
pose of sale.).
1, os owom of the proTerty, am uxclnvively contacting with licensed corral to
construct the perfect (Sec. 9044, Bususalit] Proosoon, Cale) I lie Convaemrx Li
close
re
ds
mencon
Lawdoesfor such
apply man with
a cofpraterty one
sedpafingvr he Clantra and QTY.
Loho icense laws for such projects wbh h amronur(s)lieenseJ punuam m ma Contmcbn's
C] I am exempt under Sec. . B & P C for this reason
Owner Dam
WOIt KIiRS COh1PiiNSAIIUN DECLARAI'IUN
1 herby of o r under penalty of perjury one of the following Jeclurstion.
�[-IlInternal will11 inminaCeniticawof Consent mself-snaprefor WorkersCongwn-
sntion, as provided bur by Section 3701 of the Labor Code, far the perliamanec of the
work for which this permit is issued.
El 1 have and will maintain Worker's Compensation Insurance, as required by Section
rm
3700 of the labor Code, for the performance (if the work bewitch his permit is issued.
My Workers Clu pie tion Insurance f, r and Policy n der
Carrier: -STA G'OMprte Policy He: -1a d/ %y
CHWFIIVCATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
IT his mctionnml not fecmnple,A] it It, permit is fortune huratd dollars(SIWI
for less.)
I cenify the in the pednrmance of the work forwheir thi, permit is issued. (shall
not employ any person in any manner of at, m become subject to the Worker' Compen-
C)anion laws of California. Dae
Z 0 Applicant
h NOTICE TO APPLICAN F. If, of mf maki all this Certificate of 1; linpt inn. you shradd
become subject,, the Worker's Cumpem won pr 1 seam of the Labor Code, y ou must
[ra I orthwah ennpply with such provsame. or loisper l It shill l be deemed revoked.
1
U Z CONSem is acUNLItNOlNG AGENCY j
U.
l.forw which
hi that there isacomaec. constructionlendingagency for the performance of
C) F the der, for which this permit is iz,ueJ (Sec. 31197, Co, C.)
0 U Lender's Name
Address
lender'seeif,t
F V) I tendo Nut buvn read this y road coup and sem ce, me shove te, reation to
UZ lonredImildiL ngrccnecomply withal( &y road cepresntaiivesofthomade lowsrcl,Boge QTY
Z abovengmmnuctionunJ hereby amhmiecrposes,nmtives of this ehy to toms upcm the
aMpvo-memioncJ prnlpny lurimpeniun purposes,
(We) agree m v.a uncertainty and keep harmless the City of Catania against
liabilities,judgments, costs and expenses which may m any way accrue against said City
in consequence mf the granting of this permit.
APPLICANT UNDER STANDS ANI) WILL COSI PLY WI'1'if ALL NON -POINT
SOU RCI? :C ULA'IA)NS `TQ_
.,.,i n [.�C'AY 3-d,;-5,5
IV / HAZARDOUS MA'1'ERIAI S DISCLOSURE
Will the applicum or furore building nlccupam,mre or handle hacvJous maerial
as refined by the Cupcnino Municipal Code, Chapter 9. 12, and the Health and Safety
Code, Section 25532(x)"
E] Yes DNo
Will rte applicant or future building vel me equipmmart or devise, which
mit hazardous air conmmlmams as Jefinad by the Hay Area Air Quality Management
D ont" 1
❑Yes ✓ No
I have trust the hazardous courr e, na,mornems Under Chalet, 695 of the Cali-
ILmir health & Safety Cole, So,, 25505, 25533 and 255.14. 1 nndersmnd that if the
builfi gtllc not an rndy huvc u t nt nmut lay—porromil l ty m unlit y the occupant
regal end which lona be AsllyyGwtR'nsuun....f a Certifentc af(Acumnev.
TEMP. NIETER OR POLE INST.
SWI MMI NO POOL ELECTRIC
OUTLETS - SW 11 Cl IES - FIXTUR Fir
NEW RFS IDEN'I'[AL ELECTR SQ EL
PLUMBING PERMIT'
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER IIIA)
RACK ROW VBUI'EC, DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
FIXTURES - PER T RAP
GAS - EA. SYS 'T'EM-I INC. J OUTLETS
GAS -EA. SYS1'I:M-OVER 4 EEA)
GREASUINDUS'I'BE, WASTE I N FERCEPTOR
GREASE'I RAI'
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER W/VF,NT/ELECTR
WATER SYSI'1;NET R17NE ING
WATER SERVICE.
NEW RESIDENTIAL PLMR. SQ, IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.0h, CEM)
AIR HANDLING UNIT (OVER I0.00) CFM)
EXHAUST HOOD (W/DUCT)
HEATING ON] p ('11) 100.000 BTU)
HEATING UNIT (OVER ]NOW W BTIB
VNN'I ILN1'ION PAN (SINGLE RESIU)
BOILER -COMP (3HP OR 100.000 R'IU)
BOILER - COME (OVER I0100013TU)
AIR CONDIITONER
NEW RESIDEN'IT AL MEECH. SQ, FI'
OFFICE
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI,
❑KITCHEN RI?MODIiI,
❑ADDITION
El PLUMBING RI PIPE
❑MUI:1'1-UNIT
El STRUCTURAL
MODIFICATION
C1 INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑BATH REMODF EPA
DJ1* O (TION
❑OTHER
�•%'r--.
COMMERCIAL
❑NEWBI.DG/ADDITION
❑DEMOLITION
[I TENANT
❑ FOOD SERVICE
I,MPROVENIF.NT
DOTHER
S'T'ORIES
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
DEALING ITE
SOLI S I131i
PAID
It Date Receipt at
BUILDING ypE
FEE
SEISMIC I 'Ji
ELECTRIC N. E
PLUMBING AE
MECHANICAL 193E
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
ISSUANCE
3 2 f-,-9 Y
ISSUED
$lSQ. IT.
I