S 1690 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY'CIF CUPERTINO BUILDING-ELECIRICah rr: IT NO
BUILDING DIVISIONAPPLICATION/PERMIT rI,uNlBwr..MIECI IANICAL J 1690
" HU11.5I1G PROJECT IDEN'1'It'ICA'1'ION. 4,
BUILDING ADDRESS: SAN]TARY NO. APPLICATION SUBMITTAL DATE
4o 5 F,ds C"-e-K Q-D
W ! 'S NAMI!: /pw'��l Q 11(INI!: CUNTHAClOk6'S N(py,M�E:. ,v� LIC NO:
(eJ c &OCA So 737-22 uy IOh rN{,• MC CON IROI,«
4W ICI MFC DHNGINEHR: LIC NO, DNI!SS: ❑
19
(sxarnrr: PHONE:. •. y' BUILDING PERMIT'INFO'
❑ CBneullant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONIRAC lOHS UI CI ARnII(N QbYICIiCTR ICI LRMIT, r FEE ED 11
]n a b> s that 1 o f aw d v f chapter 9(ri lime " s - �'! JOB DESCRIPTION
WOO � M11 ISSUANC- - - -EM+W llulllmw uvA
- RESIDENTIALWZ ' r 4 " ElSFWL :
[I KITCHEN REMODEL
6 oe I c APPLIANCES—RIS I DEN I'IA I, ❑ADDITION ElIICUMIING RI31111H
Villa.ljIIaLL Cnnl cl
F,nARCHITECTS DEC ION PANELS ❑MUCfI-l1NIT [I5'IRUCfI1RA1,
Z O r Z I nnJerrumd my plana shall Ins uxul os,amb,red do MODIPICRI'[ON
OZ`=Q Up 10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
h
W Lo'co'ed professional 201-I aff)AMPS IMPROVEMENT E]SWIMMING POOIS
0.
OWN17R-BUILDER DECLARATION
IY `e ]hereby round tbm I nm exempt from For Cnnuo lar's I,Icensc Law Gm Oa OVER boost AMPS ❑HallREMODEVKEPAIR DI?MOLITION
0.x 00.0 fnllov am mrun.(Seen..]0315.1{nimess and 1'rmfir,amtn Cade:Any ci y I t ❑CH 1117R
y or county SIGNS I!LE('lRICAI.
W 3 0.y
onwhichmyuires u penult In construct,ober.nnpn've,demolM1h,ar rePmr any xlmdurc
,� n pr'o t 'I. y -0 ppli rl "ii suchsigned:mrmcm, SPECIAL CIRCUITIMISC.
y
} thnth I Ip m I top of be C I t License l (Comer 1)
�0 (conc tgwlh Sul t.7000olD vvitn 3 of l be it ,'nessild PTMC' 'Cde)rr TEMP.M EI'ER OR POLF I NST. COMMERCIAL II'IDN
oen
0. Ma Ill.,he is cxempl IhereW
fmm and Ibe basis for e allcacd exemption Any violation of C1 NEW IILDG)ADD ❑DEMOLITION
W Section 71191.5 by any applicant for a permit subjects tire applican(Im a civil wooly of POWER DFVICHS
min than live hundred dnllvn(SSIXq. ❑TENANT. FOOD SERVICE
Z p., a o ore IMPROVEMENT
< QLas owner mf thepmpeny,vnnyanpinyeeswithwages aslhctrmdc c0nnpennbtion, SWIMMING,POOL ELIIC'I'RIC
O ']]Ido 1114 work,and lincluanae is notl rendedorollomJ fi ole(See.JOW,Footless ❑OFF IER -
L 3 m and]'mfension Gyle:The Cournme r'.e License law does not apply to on owner of OC Hd7l S-SW I'TCIIFS-F]X'1'1l RI!S
Ne pen,who huilds lir I ties Iberoam,mu]who dv,,I.,It work hnnsulf or tlimaith
his own employee,provided Thal such improvements are not amended or varied far NEW RESIDENTIAL FLECIII SQ IT.
sale.fl.however.the building or lmpmvcmrnl i—old wuloid* tolOunugellnn,t11c S@I .11a0(skA $/SQ.FT.
own
cr-huilder will hove the harden of pmving that he did nm Mlild or improve far par- 1
pose u-wa.). /I11►►��
❑s as owner o the prulmrI ant aneo,v aid contracting with: Thelicensed enntractaII m JUL 14 MRST
tnaaathe project[Ser.]M4,,act of T city
who,
The Commaar, rad
I. J pplyt r1 1 tY h h Its lir nprwecn+rct and QTY, PLGMH INC PLItMIT ',, ,.I'I'Fr� . IY
wht l f .uchp jerlsw lM1aumtrecmrtx)pia nseJl ursunnuvthr Cumrmmr's _ �rl�I,�f UI" lrllp•Cf1I lotu
License Law. PI!I1M I'1'ISSUANCE'
El I um exempt under Sec. ,i{&P C for this remora
ALDER-DRAIN&VENT'-WAIF FillVALUATION
Owner Dale
WORKER'S CONIII17NSATION DECLARATION BACK ROW PROTECT.DEVICE
I nothr a1Brm under pmmlly al'pc Jury vmc al the into,ing declauldi ns:
7satital,
l have and will maintain a Comifcate ofConsent m xlf-insure forWorkers Comlwn- DRAINS-FLOOR,H(KF,,ARIA. ONI- I'ORIES '' PF CONSTR UC'IION
as provided for me Section 39(X1 of the Labe[Cite,Tor the performance of the k hieh this permit.,issued FIXTURGS—PER TRAP
'bnhand will maintain Worker's Campo F Ula,w rktoo, ee,h Ieyaired by SectionN1 nft11e Lobar Cade,lonhe pa'H�rmnnco nfdac workpfur7wt�hich�`I�Lis�lWrmil ix issued. GAS—f3A.SYS'1'i!M-i INC.J OUTI. OCG GROUP ANN
Carrier:
ppq smiOn lT r�vvarnmllyky Ntl'6& (ql�r .
1 �SJ GAS—LA.SYSTI!hLOVEkJIEAI
Clis: IIICAlE OF
EXEMPTION FROM WORKERS'
COMPIINSATION INSURANCE GREASOINDUS'FRI,WASTE.INT'ERCFPTOR
BUILDING DIV[ Igi115
( ssmiun neral nil he cooplutcdlflhepemtit is formic hundred dollars is 100) GREASE TRAP or It,,.)(I I'LANCIIECK ltiP.
Iccnify mal inlhc patonnand,oD orak for wnodidlis permit is issued,1+11411 SEWFId—SANI'PARY—STORM EA.200 PI'.
not employ'any person in any manner sn as to hecnme.subject ,,Ilse w'odcri Compen- ENERGY FI!E
OZ satin.laws of Cnl,bmla Dam WATHIRIIEAIMR WIVEN'VELFC'1'k OItAUING PI!E
Z Q Applicant
,or, N(Y]ICE'm APPLICANT If,IIIc,making this Cenits.le of L?xamption,ynu'should WALK SYS II!MN RHA'I'INO SAILS PEI:
humme subject ,,the Work,,',Compensation prosions of the Latin,Code you must
W Form,all arnnp], air+arh provision it Ibis permit shall he deemed revoked WA']'IR SERVICE
Z) Q
UO CONSTRUGHONutionLENDING AGENCY NEW RfSIDEN']'IAI.PLM1t B. SR FI', PAID Dale Receipts
1 bar.Hry affirm Thal mit I i.4 to (S,.30 Iuulima Ugamy for the porfortnamc nl
Ibe work for which Inie permit ix issued(Sic.IIF)],Civ.Cd
� F Ixnders Name TOTAL:
V Lender's Addrees ']OTA].
} W i s rify that I have mad this pplicat t and state that the abovef n urn's - BUILDING TELE
.Fat N correct I.,me i ply 'n oil On, ly -1' I rI h Finsen QjY MECHA NICAL FER MIT FFF
U building construction,and herebyuth.ix representativesf tlis octy renter Upon the i SIASMICITE
alxrve-mentioned property for inspection purposes. PERMIP ISSUANCH
460
(We)agtec m save,indmmmify and keep hsmJess the City of Cmpcnim,against
I!LFCI'ItIC PEI!
Iiabilitiea.j.damcnts,cosound expenses whichncyIran,wayaccmcogafntxuid City ALTI!R OR ADD'IUMECII
n+e ceof the granting of this far it. PIAMI{ING PCI:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN]T(TO IC,0RI CFM)
SOUHCF Al ONS. / MECHANICAL FEEG fQ NR HANDLING ON]T(OVER 10,0101 CFM) CONSTRUCTION TAX
mute of ApplismmlGut... r Date EXHAUST HOOD(W/DUC17 HOUSING MITIOA'I'ION ITEHAZARDOUS MAI I!RIAIS DISCLOSURE
Will the aynpliuunt lir future holldingoccomnnl a0rc lir handle hazardius mmxrial HEATING UNIT DO 1111,000 BIG)
as defined by the Cupenino Municipal Code,Chapmr 9.12,and the Health slid Solely
Crile.Se,lion 25532(01; HEXI INC,UNIT(OVER I Niand HT111
❑Vcs ❑Nn VEND ILATION FAN(SINGLE RESID) PAID -
Will the applicant ar future hnildin occupant use equipment lir devices which Du Revel
pp gi p Area
p01LIR-COMP C HII OR I(110dil BT U)
til icl? nus air nmlaminantz as Jd1nuJ ray Inc stay Area Air Quality Management
liavinlTAE:
E]Yost 0 N HOF LER-COM P(OV FH IALM)1{TID
Ihave road the hazardousmaWriab ntpurcments under Chapmr 6.95of We Cali- AIR CON DN ION lilt IlSIJANCE DATE
forma Health&Safely Catlq Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MIiCI I. SQ,it]L
nuilding does tot curcntly hava a tenant,Incl it Ls my resrymsibillty m nntify the WCupant
of the requirements which muss lie and prior m 1....a,,ul a Cenificate of Occupancy.
Owner or umhnrnal agent Dome TOTAL. ISSCEM BY.
— OFFICE —