S 2163 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELIiC'I'RICAL Ing IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 216 3
BUILDING PR(IJEM'IDI'1NTIFICA'I'ION
BUILDING ADORES
7 SANITANYN(l. API'LIGTIONSUIIMITTALIIATE
(TWEE :S M[: '✓✓✓/Illy/�+�10,
CONTROI
ARCHITCr/ENGINEEk: LIC NO ❑
CONTACT: PHONE: /n WYWi 1I {' BUILDING PERMI'F INFO
ZX-6,5/0 EIC....Itant Put Paid by Applicant(initial) BLDG OX7 P O p11iCJi
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ((� Y/fpc�l
I hereby amrm that 1 am Been+cd under provioors nfewpler 9(e atntmt1ei"g JOB DESCRIPTION
WOZO with Section 700)of Division 3 ofihe Business. I (al'c.+sinn.+C�Je,antlmy license is PERMITISSUANCE RESIDCNTIJO
F- full force and cR g
aUZU LicenLp
se Lica 0SFDWI. C KITCHEN REMODEL
y6S Dae Cnmmch,r APPLIANCES-RESIDE CADDTTION CI'hI1MBIN0 NE-PII'li
ARCHITECT'S DECIAR (N pANEL.S ❑MULTI-UNIT CSTNUCTURAh
Z O n Z 1 i nderstrad my plans+h til be used as public record. MODIFICATION
O Z..O cme IIP TO 21X1 AMT'S
H�F'IL Lm1"mzesannal 0INTERIOR CCIIIMNEV It131'Ailt
6 .4 201-1000AMPS INIPROV17M F.N'F
,w7az OWNERBUILDERDECLARA'I'[ON El SWIMMING POOLS
(y C W Q 1 hereby affirm duo I an exempt from the Connote,,License I.uw for the OVER IIXXI AMT'S ❑BA'T'H REMODIH/R I DIiM ION
x O 11 U following reason.(Section 903 L5.Bri,iners and Professinns Calle.Any city nr county ❑OTHlilt
W 3 F SIGNS HLECI'RICAL
F.LL,O m which rcyuires a permit m cunswm,eller,improve,demolish.or,•lair any s'Neture
R
Nprior m its issuance,also requires the applicant for.such partner to fl-a signedstatetnem SPECIA I.Cl RCU IT/MISC. ''g�
gnai 11146-is licensed pursuant woe 111,1Lsionsnl the Com.,oa,Llcensc Law lCM1alnro OVI
tD2�pO (commencing with Section 70(khofDivision 3offle Business and Feelessions Code)nr TEMP.MLTER TIN POLE LN. COMMERCIAL:
d C o Y 'hat he is exempt therefrom and the basis for the alleged exemption.Any vialntion of ❑NEW BLD i/ADDITION ❑DEMOLITION
iYCI �4• Sectio 9113 L5 by any applicant fora permit subjects the a"'licam Ina civil penaby of TOWER DEVICES
F„Zy n4arran Imn five hundred dnlmn($100). C'1'ENAN'I' L1 FOOD SERVICE
f=0 C1.as owner of'he pmpert or my employees with wages as theirsole compensation, SWIMMING POOL ELECIR IMPROVENIFNT
ga: will do the work,and the structure is not intinfol or barred for sale(Set.90/4.Business ❑OTHER
W3 and P.nf-esa no,Code:The Coutmaur'11 iernse Lew deal'not apply I.an owner nl' OU'I IAO S-SWII CHES-FIXI URES
progeny who builds or improves thereon,and who does such work himself or through
his own employees.provided that such improvements are not intended or offered for NEW RESIDENTIAL EL EC!R SQ IT.
lute.Ill howeve,the buildingor let an,in sold wiminoneycarofmmpl...... Ila: Sp.Irf.FLOOR AREA S/SQ.FT,
nen-builder will have the burden.rproving mer he did not build or improve for par.
quanLwleJ.
C L as owner of the...puny,am exclusively mnrtnmin, all licensed enntroemn m TUFA L {'
msonet the project(Sec.90N1.Business and Professions Cmc)11n,C.nnnemrt U.
arms,Use does ntuapAy It an owner ol'pmpcny who builds or improves thenon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contracmr(n)licensed moment to the Cnntrac ur:s
Lavirs,Low.
C l am cxorn,nod-r ,Sec. ,B&PCfoffikoloor 1113RMI'IISSUANCE
Owner
ALTER-DRAIN&VENT'-WA'T'ER(EA)
Dille VALUATION
WORKER'S CO,y,)f AT1 on DECefirlo ia, BACK FLOW PROTECT.DLVICE �X 0 ....�
1 hereby affirm under penaby of pedury one.1 the following Acciamtions: !JJ
C 1have:ad will muintaina Ceni5cmcofCmarbt tosclbinaurc for Worker's Cnmpem DRAINS-FLO()R,ROOF,A1iHA,COND. e
"lion,.v....idled for by Section 391)0 of the Loh.,Cuda,for the perl'1,nnuna of the S'InRII:is '1'YI'i:CONS'fltHCl'ION
for which this keral is issued. FIXTURES-PERTRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3700 If the l.a or Code,ton pofom tceof me work In which gds pemtil is is ucJ. GAS-IA.5YS'HFM-I INC40UTI.H'llti (ICC GROUP AI'N
My War it, -u 1, m ter and l'nlicY
Caniee Policy No.: D GAS-EA.SYSTIi. ER4(E
CIiItTIFICAIli OF S iMVI]ON WORKERS'
COMPENSATION dr INSURANCIi GItEA51%INUUS'I' 51L1 IikCh ON
(This section need not bee.mpleed ifihe Imnni'isforone hurdmidellua($IM) BUILDING DIVISION PEPS
.r lav+] GREASl:'I'kAP -- - -- '-
I'I.ANCI ECK FEE
Ioyanyth4 int he ptoloanyarmaerwiarothoure,rThe work for which ys,top ew.,siamed.jdardnter- SEWER-SANI'1'A -STORMFA.200
not employ any Person in any manner sn as m bse.me subject nl the workers C.mpen' IiN1RGY IIiL
Z smionl...I of Culifnmia.Dam
Q Apllinlnl WATER IIIiATIiR 'NENTIBLECTR GItAU1NC Flili
y NOTICE TO APPLICAN'1:If,Often making oris Cenificm-of Exemption,you should µ•DYER SYSTENf
a ; become subject m'he Worker's Comparomion pmvisinn.+nine,Labor Calc,you must SOILS FEE
W forthwith culnply with such pnrvtsons ar to (diull he dr n ed rev.ked.
i
Q WATERSHRVICH
5Z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
I herebyalimuhatthem is a e.mrructiat landing agency mrthe performance of Date , lPtn
C) 111,-11,k fa which t his punnit is ol-111(Sce.3099,Co.C.)
Lauder,Name V TOTAL:
Lia 1,-nder1/entrees TDTAI:
iI crnify m
ol I have rand his uPFlicminn and evuu Etta We Move inlimnalina Is BUILDING Il?E
Vi carnet.l agree to comply wih all city and county ordinances and state laws rehiring to QTY. MFCI IANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives ofthis city toe'nerup it the SIBSMIC PER
those-namio^ed Property for inspection purposes.
(WOO to save,indemnity and keep hmMts+the Cit I'Cu against PIiRMI'I'ISSIIANCE
gree y p yrs leninn a n4 ELECTRIC 141E r
ince ise,nanc of the
growing
exlcnseswhich may in any way accrue against said Ci'y ALTER OR ADD*10 MECI I.
nICANc Nthe RranANDS this Permit. _ PLUMBING TLE
APPLICANT UNDERSTANDS AND WILL COMPLY W1D{AI N(1N 'OIN'
SCORCH 'UL TIONS. � �� AIR HANDLING UNIT(TO IU,1X111 CPM) MIiC11ANICAL hFE
090
AIR HANDLING UNIT(OVER 1(1,1X%1 CFM) CONSTRUCHONTAX
Stg IApp lcunt/Contracmr "Ulm 1i%HA115'1'1100DIWNUCI)
HA9ARDOUS MATERIAL S DISCLOSUREHOUSING MITIGATION FEE
Will the applicant or I'uwre hailding occupant store or handle htzardarsmaerial HEATING UNIT('I'0100,1X111 BTU)
as defined by the Coleman Munlclpal Code,Cinc ter 9.12,and the I cath and Safety
Code,Section 25592m)Y HEATING UNIT(OVER 100,0X1 BTU)
❑Ye.
VHNTH.AGON IrAN(SINGLE RHSIO) PAID
Will the applicant or future building Occupant u«ryuipmem or devices which Data Receipt H
emit hazardous air contaminann as delinetl by the Bay Area Air Quality Management BOILER-COMP(3HP OR I(B4O00 BTU)
District? TOTAL:
CYes V<— BOILER-COMP(OVER 10gMo]it liI
"Overcall
rand the hazualuas materials requimmems undo,Chapin 6.95 of the Cdi. AIR CONDITIONER
^ ISSUANCE DATE
Torula IIr.JIh&Sufcty Cwlq$anions 25505,25513 and 8534. understand mm if the Nliµ'kESIDEN9IAI.A11iCll. SQ.P1'. ` /
building da mnercntly 1141-4 nnanr.mai'is myrevryntsiM1ihtymnoti thcoe '
nf/he ran remyl1.which runs.M.at Flora issuance of a Culifly
l/ I / f�
gem zintatc TOTAL ISSUED BC
OFFICE