S 0976 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL. P 'T'"° 0 9 7 6
BUII,DING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL.
BUILDING PROJFXTIDENT'IF'ICATION
BU11.1)INO-3cl.S'.S� / /��� /O / SANITARY NO. APPLICATION SUBMITTAL DAFT
OW : 'S NAME (!^`(,P_Hj(/ONG go* CO Rn�fOR'S NAME: �f �� / LIC NO:
1 Y✓L J11�� F FYfv� -,15-1-3 14! Q.:.CC-�"`JO)ti ^—""'aG�l' .S3"'1 NIC coNTROLa
•ARCIRTECr/F.NGINEER: LIC NO: AD'R'I`5'. S L ❑
4� r yZinr,
CONI'AC'E PHONE: BUILDING PIiRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRACTORS DECLARATIONt
QTY ELECTRIC PERMIT FEE
L hereby arrm,that L am licensed under pnlvixi.lnx of maple.v(r..mmemlag JOB DESCRIPTION
WOO with Section]lIW)af Uivininn3 nfthe❑nsinexs anA Pndrssionx Crvle,and mylieens,is RESIDENTIAL:
4100 PERMIT ISSUANCE
HUF` in fullfarce and affect. `.k,C '^' D$PDWL KITCHEN RF:MODEL.
vt U Lsrnw Class Tick a+a APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING REPIPE
N 6 6 Dme ,1� Air Cnmmc m
ARCHITECTS DECLARATION 0 ❑MULTI-UNIT ❑STRUCTURAL.
p.,D m PANELS
w Z unJerannJ Iny plans Shull be nwA as public nxords CHIMNEY
TION
REP
ZOZ4`O 1 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
5I:4I Lievowd Professional I 201-1"AMPS 1PROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATIONS OVER IIXO AMPS k1ATH REMODEVREPAIR El DEMOLITION
IY W 6 I hereby uhctn but I ren exempt from,he Contractors Lhams,Low for the
F O L U following mama.(Scctinn 7031.5,13.11maa and 1 olfir"ions Code:Any city or county SIGNS PJ.CCI'R ICAL ❑OTHER
3
usl- which requires a permit to convbec,,alter,improve,demolish,or repair any structure
F'LLOQ prior to its issuance.also requires the applicant for such permit toile a signed statement SPECIAL CIRCU ITIMISC.
E Y_ ma,he is licensed pursuant to the previsions of the Contractor's License law(Chapter 9
H (cnmmencingwith Section7")i)fDivision3afthe Buslnessaml Pmfensionscodc)mr TENIRMETERORPOLEINS'I'. COMMF,RCIAL:
d q o C soul he is exempt therefrom and the husix for the alleged exemplinn.Any violmmr of ❑NRW BLDG/ADDITION ❑DEMOLITION
W m Secllna 90315 by any applicant far a Ilctmltnubjea,the applicant It,acivil penallyof POWER DEVICES 0ENANT ❑FOOD SIiRVICE
not more than five hundred dollars(85111).
F Z Y
❑
Sat La<owner of the pmpecty,or my employees with rages as their sole compensation. SWIMMING FOOL ELECTRIC IMPROVEMENT
SL will do the work,and the accurate is not intended or offered for%ale(SecJUW,Business ❑OTHER
Wm and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpmy who Wilds or improve,mere...,and who Jucx such work b""self or through
his own employees,provided that such improvements an not intended or offered bar NEW RESIDENTIAL ELECI'R SQ FT
sale.IL hoai the building or improvement is sold within one year ofcmmpletion.the PT.FLOAAhE VSQ.FE
owner,builiker will have the burden of proving that he did not build or improve for per- Ab
pose of, ). /1 7
F1 1,as owner Om property,am exclusively contracting with licmrsed eonaracnns w IOTA I.: Y/ i
construct the project(Sec.'l0ad,Holmes,and PitCode:)*1 he Contractor's Li- V
acre law does not apply to an owner of property who milds or improves thereon,and QTY. PLUMBING PERMIT FEE h b
who contracts for such pojects with a contmmor(s)licenwd pursuant m the Contme al
License law. PERMIT ISSUANCE ♦�//N
E] 1 an,exam,antler Sea. Ii N PC for this rean
.:n
Owner Date ACfER-DRAIN&VP,N'I'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE C'/1<l
I hereby affirm under penalty of perjury one of the following declarations: @000
�OlhatT and will nmimain aCenifiamr dCnnscnl In self-i^sur a for Worker's Cempen- DRAINS-FLOOR,ROOF,AREA.COND.
s rion,as provided Gm by S.Iio i 37111 of the Lahot Code,fur Ilea tierfomnanm n the STORIES 'TYPE CONSTRUCHOt
' rk lin which this permit is issued. OfIXTURES-P17R TRAP
XI have and will maintain Workef%Compensation Insurance,as required by Section
W ofthe labor Code,for the performance of the work for which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Wnrk Comps �ly� Ima once tamer and policy nu rp �/
Curier:StaTP�aY✓✓Y� Policy N, : W323 / GAS-EA.SVS'I HNEOVER 4(F/Q
CERTIFICATE OF LXEMP'HON FROM WORKERS'
CCOMPENSATION INSURANCE : GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
ot be completed ifNepermn is fore",hundred doll.($101)
nr less.)(This section need nGREASE,TRAP 1'hANCHECK Plif:
I certify that in lheperfontral ,he work for which this permit nissued,l shell SEWER-SANITARY-STORM EA.2W IT
not employ any person in any manner so as to become subject it)!he Wmku:Compen- ENERGY PEE
ZZ cation laws of California.Data WATER HEATER WNENT/ELRCTR
� Applicant GRADING FEF,
h NOTICE TO APPLICANT:If,af¢r making this Certificate of Earraptmn,you should WATER SYS'TEMOREATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,yon mus, SOILS FEE
Oforthwith comply with such provisie"v or this peril shall be dec mJ revoked WATER SERVICE
I = Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FL PAID
11' U0 IherebY alBrhtit there i..acnr,.cwetinn lendingagency fonhe perforance of Date Real,#
,he work for which this permit is issued(See.RED.Civ.C.) 0
OU Lc.der'a Name %,, TOTAL:
U Lender's Address TOTAL:
(r" y I rectify that l have read his application amt nate that the aNsve infonnaim is BUILDING FEE
Wcorred.Ias=tocomply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
UZ building construction.and hereby authonec representatives ofthi,:city to enter upon he SEISMIC ME
ah:ve canaimedproperly for inc,,.i mpurposes. % PERMITISSUANCE
(We)agree ea satin,ind,mnily and keep hamdds the City of Cupenino^gain, ELECTRIC FEE
habili,ies,judgmems,ro,s and expenses which may in any way arrm,against said City ALTER OR ADD TO MECH.
in ..sequence of the gmnting of this permit. I PLUMBING FEF/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURC- EREQULATIpNSn / //�_�J� AIR HANDLING UNIT(OVER 1(1,(00 CPM) MECHANICAL Jt:CONSTRUCTION [AX
Signature of ApplirmalCurltncmr Data EXHAUST HOOD UVDUCr) HOUSING MITIGATION FE.HAl RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant.store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by,h,Cupeuino Municipal Code,Chapter 9.12,and,be Health and Safely
Cod,Section 2553200? F117ATING UNIT'(OVER I00.0n)BTU)
❑Yes ON. HMD
VENTILATION F'AN(SINGLE RFSIU)
Will the applicant nr future Wildln,overpmnl use egaipmem oT devices which Dme eccipt a
emit buNous air commniramsn,defiaed by,he Indy Area Air Quality Maaugermvd BOILER-COMP(3HPOR 1(0,(XOBTU)
• mDin,tirl;a 'TOTAL:
0 Yes F1No BOILER-COME(OVER IW.f0d BTU)
I have read the hazardous materials is under Char 6.95 of the Cali- AIR CONDITIONER
'squirea p ISSUANCE DATE
fmnia Ilcahhilt-ori Ods,e.tion 25505,25533 and2553q.I to notify
that aft NEW RESIDI?N'IIAI.MY'CII. SQ.1.7
M1uilding Joos no,namnlly hove a tenant,the,i,is any responsibility m notify thmxcmuam
of the mquiremmns which most be that prior to isennce of a Certificate of Occupancy.
Owner or authori zed!agent Date 'TOTAL: ISSUED B
OFFICE