S 2860 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RACAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
13UILD[NG PROJECT IDEN,r1F'ICA'I'[ON S 286n
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI19'AL DA'1'li
O 1(o n ISS C-r , y-6g 9
OWNEN'S NAME: PIIONIi: NTRACTpR'S NAXf In LIC NO:
? 11 NIC CONTROLp
\�ARCHHI (ENGINEER LICNO: ADD INS: ElI ' ' 7Y a ji, duel
CONI'AC'C PHONE: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB N
t uw� S3'�lS ❑ ❑ It- Cl
L�Ohal
ED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT hEE
I hereby nmrlion licensed coder provision.of Chapter 1)Rnmmenc ng JOB DESCRIPTION
�ti'Z wan sectionnundEicision 3af me Bmsines and Is fission,crate.mainly license i. RESIDENTIAL:
HBO in full intermit effect. PERMITISSUANCE
W I, ❑SFD\41, ❑KITCHEN REMODIiL
aUL,U License Class 1.ic.p APPLIANCES-RESIDENTIAL ❑ADD[TION 0WH)MBING HE PIPE
ZZW Ilam Cmymman'
F7q ARCHITECTS DECLARATION I'ANBIS ❑MULTI-UNIT 0Sl'RUCIT)RN,
Z p In Z 1 undaaand my pinn—faill heedus public records 'MODIFICATION
UI'T(I2(NIAMPS
El INTERIOR El CHIMNEY REPAIR
W Licensed '-!—tonal 201-I01b AMPS - IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER HHo AMPS Q BATH REMODEIJREPAIR ❑DEMOL[I'[ON
a I III alio that I mut exempt tram the Contractor's License Law fur the
Xd O iLU Mimi reason.(Section 7031,5.Business and Professions Code:Any city or cnumy SIGNS ELECTRICAL ❑(OTHER
LL13 LL y which require.a permit m construct,alter,improve,demolish,or repair any suuewn ,FjXl,Q
F•�0a prior hr its issuance,also¢quire%the applicant for such permit to rile a signed statement SPECIAL CIRCU IT/MISC (,r
o) 'bar he is li...odpunuannothe pmoinmrof the Contractor's Licence Law(Chapter 9
W (commencing with Section 7000)of 3 oche Business and Pm&xpion.Coda or TIiMP ME'I'FR OR POLE[NS1 COMMERCIAL:
6 a e ty That be k exempt therefrom and the basis lin the alleged exemption.Any violation of ❑NEW BLDG/ADDITION Q DEMOLITION
X m W Sectio 911.315 by any applicant fora pvmtit subjects the applicant nr a civil penalty of POWER DEVICES
m—y TeunNr QFoonsERVICE
0
t crate Inun live hundred 111(b500).
❑ Luc owner of the pmpenYar mY emplOyeac with wages ate their colt en.Temation, SWIMMING,POOL FILECI'RIC V, IM OVIiMENT
p. will do the work,and the structure is not intended Occidental for sale(Sec.9Du.Business HIiR
3 w and 1'rofe.sinns Code:The Cn draents Uri Law docs nm apply m sI'owner of OUTLETS-SW ITCHES-FIXTURES
property who build%or improves thereon,and who does such work him.e[f or through
his Own enployers,provided that such hnp....vOr,are not intended or offered for NEW RES1UEN'p1A1,IiLEC'fR SQ FI'.
sale.If.however the building or improvement is sold within one year of completion,the SQ.PL FLOOR AREA b/SQ.IT
ovener-builder will M1me the hurden Ofproving dun he did not build or improve for mr-
Lmxe"'u r,
Q %as rwncr al the property,am exeluavely contracting with licenced enntmaws to TOTAL
onamet the project(Sec 901J.Business and Pndo.into Corey The Commcmr'n Li-
QTY PLUMBING PERMITFEE
who contracts for such projects with a contracmgs)license!pursuant n the Commmo/s
Licence Law. PERMIT ISSUANCE S
Q 1 am exempt under Sec. .B&P C for this reason
Ow'ner Dam ALTER-DRAIN&VENT-WA'T'ER(EA) VALUATION
.
WORKER:SCOM naltyoiNSAHON DECLARATION BACK PLOW PROTECT'.DEVICE
I hereby ndwaffirm under penalty of perjuryaneofthefollow ingorair declaration,
QIhave and will forforetion 3700r,1 CeIabOT d0..forthe Worker'sce of
UNAINS-FLOOR,ROOF,AREA.COND. S'IORHIS TYPE CONSTIt GO]ON
ration, r pI n h hi 4th by Manion 39tX1 of the Lvhnr G,Je,for the performance of the s
1 forty hick thispermit Iciorker Fix'fUHES-PER TRAP
Q I neve and will mninmin Workels Cman,of.inn Insurance as required by Station
My of tau LC Celc.lorthe lerlornulnreoonl Poh Albrwnich this permit is issued. GAS-IiA.SYSTP,M-I INC..OUTLETS (ICC GROUP 3y MESS
My Work Cu ct 'liy ut ncc cq♦i�rvnd PUGcy����gg
Cmiar: V 'odr,lxh,� 5r 3%g/ G..- ?A.SYSTP - VER4( ��O1J
CERTIIICATEOFEXFP 'TION FROM WORKERS' 1 J
COMPENSADON INSURANCE G /INTI 'Ili IN CE
(This section need not nennnpII il'tbe permit is for enc hundred dollar,IS I so BUILDING DIVISION RHS
Or Ices.) G °TRAP PLANCfIIiCK IPf3
1oenify Person
nrhe anymanner a nsawork Bo wldch Th is permit i+irs vl,d.atall
nntentploy any penon in any mannermmmnecnma wbjm to Workers Civilian SI -R-S MTA Y $ NM ._ ENERGY FEE
O � cation Laws of California.D:nr W ,R HEATER WNENT/IiLF.CB s ✓
z O Applicant GRADING FET!
NOTICE TO APPILTCANFE If,after nmkin this Certificate of Exemption.
g pion. , unarm, T�l;YS'PP.WI'REATING
a > Fachme cuatif to the Workers COmpensahis erall ons of the cal Cove, an must SOIhS FGF
S Q
forthwith nnnply with inch provixinm ur this pemtit shall be damned rcvnkeA. / NATER SERVICE e-30
CONSTRUCTION LIiNU1NC AGENCY NFiW RESIDENTIAL PLMB. SQ.FE PAID
V O IM1ercwhich mthatlseI learn (Ser.onlendre.agency fm the perfnmsancc of - °�:� Receipt is
� H the wank for which thix permit it issued(Ser.3097,Crv.C)
OU lender's Name TOTAL:
Lendef,Address TOTAL:I
.(~ y I crnify that 1 have real This application and ante Nat the.Mwr infnm.atiov is BUILIN i E
V) correct.I agree to comply with all city and county ordinances and slate laws relaingm QTY MECHANICAL PERMIT FEE
U z building construnion.tmd hereby canonize acprncnmtives ofthis city to cnterulum the SEISMIC q .
aMwo mentioned property for riparian purpoxs. PERh11'I'ISSUANCE(We)agree Or save,indenmify and keep harmless the City of Cuferlino ballot ELEC I FEE
Iiahilitic,,ridgments.co.is and experove whichmvy in any way same...inasadd City ALTER OR ADD TO MECH.
in quance of the g0A11g1;SI
it. PLUMBING
II'YLICAN'1'U ERILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,01X1 CFM)SOI/RC1 ST NL r
ANICAEF,
L .VR HANDLING UNIT(OVER 10.000 CIM) COCONS'fRUQIlON TAX
Sigrandou of Ap ''am/Conn or Ilam EXHAUST HOOD(W/DUCf) FIOUSINC MITIGA'T'ION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building reclaim store or handle bvwrdou.material HENTENG UNIT(TO 100.000 BTI!)
as deiced by the Ctl eoino Municipal Cade Chnptcr 9.12,and the Hculth vnd Sale,y
Code.See tion 25532(.)? HEATING UNIT(OVER 100010 BTI!)
Q yes PAID
VENTILATION FAN(SINGLE RF,SID) Dae Recti I B
Will the applicant in its a builddefined by the n use equipment nr devices which P
emit nvuNous air contaminants as defined by the Hay Area Air Quality hlan:gcmcnl BOILER-COMP CHIP OR 100.000 BTU)
Uivricq 'Ah:
Qyes `q'No BOILER-COlP(OVER Ioo,ourilU1f)
I have mad the humNous materials rnli inmcros under Chvpmr 6.95 of 0a Call. AIR CONDITIONER ISSUANCE DATE
mmm Hem11h&Safety C dc.Sec' m 25505,25533 mm 255A.I undenwe!001 if de NEW RESIDENTIAL,MECH. SQ.IT
buildmgdnccnnt a yh, m,thatiti.my rosrxtminiliry tonicity thexcupum
o he nice est rmmi,ssuance of a Certificate of0crapancy.
O o,mo srizcda nae TOTAL: ISSUED BY:
OFFICE