99070082 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ( !v X oa�z
CITv OF'CUPERTINO BIALDING-Ed'ECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONI(PRRMIT PLUMB NG-MECHANICAL.
BUII,DIN(;PROJF,CT IDD-N'I'IF'ICATION
B�.DIQNG AI)I)NFSS: /c ` / r SANITARY NO. APPLICATION
/,S.(U/FBMIT-1'AL DATE
WNER:S NAME: G PHONE: CONTRACT'OR'S NAMIi: �� LIC NO: `�
Aid `-A-lici d l C)� It J / NIC ROL x
Cl I ITECTIIiNG I NE ER: l' LICN): O ADDRESS. ❑
CONTACT:
PHONE. UILDING PERMIT'INFO
S �� ❑ Consultant Fees Paid by Applicant(Initial) BLDDG6
G B ELECT PLUMB MECH
40,Oft -
d VV LJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby offrm that I am licensed under pmvi,ians of Chapter 9(commencing JOB DESCRIPTION
WOOD0C, with Sen1oo7(XX)falf DI...I011 Sof the Bu.irr,,.r l Profcssions Coe..and my lice...is RESIDENTIAL:
full PERMIT ISSl1ANCE
FW in Class e.Bret. ❑SFUWL ❑KITCHEN REMODEL
QUV License Class Lic.x APPLIANCES-RESIDENTIAL ❑ADDHTON E3 PLUMBING RE-PIPE
vFi Q L Dole Contractor
NtCHITEM'S DECLARATION [I MULTI-UNIT El STRUCTURAL
~,,llZ I understand my plaits%hall W used as public record. PANELS MODIFICATION
OZ
UPT0200ANC MPS [I INTERIOR ❑CHIMNEY REPAIR
17:E'u: Licensed Prufusional 201-IOOOAMPS IMPROVEMENT ❑SWIMMING POOLS
�e cS�..I OWNER BUII,UI?R DECLARATION OVER 1000AMPS ❑HATH REMODELIREPAIR ❑D M L 1 N
,C W Q' 1 herchy uftirm Utm 1 am exempt from the Comraaar'a 1,c...Law!ter the
X3 a F followin.......(SOccian]0315,Business ane Profession,CWe:Any city ter county SIGNS ELECTRICAL ❑ .HETR
W 4I� which requires a permit to consumer.alter,improve,demolish,or repair any structure �r^L
F'LLOQ prinno hs ismanec,alsn requires theapploant formch permit fileasigned Muterant SPECIAL CIRCUITIMISC, l � n�
y�Y, redo he is lier"Ipurxmnnr ,,the pmvlsaonsaftheConuuenr's Licence l,aw(Chapter 9
e('O (nnnmcncing with Sectian]IXl(B of Division3af the Business ane Prolession,CWe)nr TEMP METER OR POLEINS'r. COMMERCIAL:
a a c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
�w
Swint 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
~=Qnot ire(him Eva hand...dollars($500) IMPROVEMENT
ner ofrue propeny,nr my employees with walct—rheirsole compensation, SWIMMING NAIL ELEC'T'RIC
S F.O willdothe work.andthe structureisnot intended or offered fursulc(Sce.]Ou.Business ❑OTHER
a 3 w and Professions CWe:The Contractor's License Law does not apply to an owner of OU I'LETS-SWITCHES-IIXTURF_S —.- --
property who huiWs or vnprove,Hereon,and who does such work himselrnr through _•
his own employees,provided that such improvements are not intended m rlicred to, NEW RESIDENTIAL ELEC'I'R SO FT —_
mlc.If.hawevim the building or impmvcmemis told variation,ycarrfcomp101f.c.the SQ T.
urI:Wt1L�k� S
r-builder will have the hurden of fluvia,that he did not build ter Improve I.par. t L'! D
p . ofsulu).
Las mineral the prop.ny,am exclusively Contu¢t' g With licensed contractors to TOTN. J U L 019 9
instruct the p[pet(Sec.mW, sit nes and ofc, ons CWe:)The Convenor',Li
se law docs.map roan ncrofpm of a builds or improves thereon and QTY PLUMBING PERMIT FEE i
vbI c tr.ir ror.w roj veto ithaconu or licensed pursuant a the Contractors
Liccme Law FERMI r ISSUANCE
❑ I um exmnpt ,cc .II&P C for this reason Y �b•
ALTER-DRAIN&VENT-WATER([
Date TT��
WORKIiH:SCOMI'IiNSAT10N UECLARAI'[ON BACK FLOW PROTEC'E DEVICE /( /• I
I hereby uffirm under penalty of perjuay one of the following declarations:
I have and will maintain a Cenificate of Connor self-insure for Workch Compen- DRAINS-FLOOR.ROOF.AREA.COND. STORI TYPE CONS'TRUCf1ON
station,as provided for by Section 370X1 of the LaMn Code,for the performance of the
work lin which this permit ix issued, FIXTURES-PER FRAP
O I have and will coalition Worked Compensation Insumnee,as requital by Section
A(Xl ofthelaMnCWe.far the peninmance mf the work fm whichmospcnnitisissocJ. GAS-EA.SYSTEM-]INC..OUTLET'S OCC.GROUT' - 2�r MIN �^
My Worker's Compensation Insurance comer and Policy number art: (� V
Currier: Policy No.: GAS-EA.SYSTEM-GVHR 4(EA)
CERTIFICATR(IF L'XTih1PTION FROM WORKERS ORIiASFIINDUsI'RL WASTE INTERCIi1'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisseawdrused not be cnmplemJif the Mnnit is fnrune nmWred Jollom($1118) GREASETRAP
or less) PLANCHECK IEE
la�niry chat In the pertbrmun,r,A he work he wh,,h this permit is issued,[,hall SEWER-SANITARY-S'I ORM EA.21X1 IT.
But employ any pc,.a in any rnanncno as m becan a subject m the Workers'Camper- ENERGY FEE
OZ scion laws of Califand.,Dam WATER HEATER WNENpffiLECTR GRADING FEE
O Applicant
NOTICE TOAI'PLICAN'I':It,oberankle,mos C°nilicumalExemption,you should WATER SYS'IEM(fREA'TING
fortune abject to the Worker's Compenmcian provisions of me Labor Code,you oast SOILS PTH
forthwith comply with such pm,i,inm or mos permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB, $O.Fi. PAID
I hereby affirm that there is a aouamm
ction lending agency for the perfotance of Dat wtptp
U P the work for which Jail .it i,I...ad Isec.3097.Civ.C.)
LL P TOTAL:
C) U Leader,Name TOTAL:
�a d " readn -
I Address ansa I have read mtm
this rlicuunn unA state row aha about infonnnnn Is BUILDING FEE
Fan nnrect lagrecmcrmply withal[cltyand countyoNmances and sum lawsrelaingn QTY. MECHANICAL PERMIT FEE_
U Z building coramaion.and hereby anchorite representatives of this city to enter upon the SEISMIC FET:
abovo-meminneJ property for inspxctiun purpoxes. PERMIT ISSUANCE,
(We)octet,to save,indmnnily wed k T hI....&x 8m Cary of CupcnaF
lno ir,l ELECTRIC FF.I.
Iiabilincs,ryd,rusno coax.^it nscs which nay in anyway accrue agaiusl said City ALIERORADDTOMECU PLUMBING FEE
I.<o quenc of me bra g0 npermit.
AVP CAN UNDF;RS'AN 'AND WILL COMPLY WITH LL NON-POINT AIR HANDLING UNIT(TO luoraf CFM) MECHANICAL FEE
SO 'L WLATIO S. �� x
AIR HANDLING DNI'1'(OVER 10,(XX)CFM) CONS'1'NI1C'f10N TAX
ignatore of Applicl UContmnor Dae EXHAUST'HOOD(WIDUCID HOUSING MITIGATION FEE
I IAZARDOUS MAI'ERIAI S UISCLUS URE
Will the applicad or future building(wcupamstore or handle hamnlommaterial EARNGUNIT'(TO100,801BTU)
as defined by the Cul,muno Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Section 255320)? HEATING UNIT(OVER 100.0110 BTU)
C3 Yes I}FMt VENTILAI]ON FAN RESIDE PAID
r' Dam Recetpc M
Will the applicant or future building occupant use equipment r devices which BOILER-CONIP(3HPOR 10488(1 BTU)
mit havaNnus aI,conami...1,m reined by the Bay Arca Air Quality Marugcment TOTAL:
Di...let BOILER-COMP(OVER 180.0011 BTU)
❑Yes �✓No
AIR CONDITIONER
I have read the haallouateri
o`s mals requiremts enunder Chapter n.95 of the Cali ISSUANCE DATE
forma Health&Safety Carle,Seer na 25505.25533 unit 255311 undenanJ that if the NEW RP_SIDENTTAL MECH. SO.14.
1, Ifo tori"' cam lyba, wet,chainin ay.......ibil'ny la used,the maupant / �!
man •gaim, aswhieh ma ret Oriunn lrxuanm aracrn)r0 mol/(mc'uranby.
O ler or uwhnrized •ant 7 /Q°ti TOTAL: ISSUED BY:
OFFICE