31219 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN LY -
CITYOFCUPERTINO' { . BUILDING,-E RICAL PERMITNO
BUILDING DIVISION - PERMIT APPLICATION/ PIAMBING. I HANICAI. 31219
BUILDING i'RfIJECT )RNTIFICA'I'ION
BUILDINGADDRES
S r SANI'1'ARV NO. APPLICATION SUBMI'1'1'AL DATE
C . e.
Iss, OWN2gS NAME: `- _w PHONE:" - COM'RACfORS NAME: LIC NU:
`/�4wi•V, ib�\Y`lKF- I' N/C CONTROL
IIGHITEGT/IiNGINEER: ., LIC NO. . ADDRESS., �L
CONTACT: PHONE: I BUILDING PERMIT INFO
Consultant Fees Paid by Iicant(Initial) I ELECTPLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby firm man l licensed under provisions f Chapter 9(commencing
' ' "r
❑z00 Date—l ]Illllp ofD snm Sof the Lin
nia WProfess nnC d duty l¢en•le - RESIDENTIAL
y z w
Fly_ in full force and effect. - PERMIT ISSUANCE.
QK cenx Clac LIc.M ❑SFDWL' ❑KITCHEN REMODEL
ntmcwr APPLIANCES TIAL - El ADDITION C3 PLUMBING RE-PIPE
ARCHITEC'PS DECLARATION � -EIMf1IM-UNIT., � ❑S"aRUCTURAL'
PANELS
tnQ�
FyOZ lunderxtandm 1 hll he used blit ranNs
Z O yj Y p ons s a as public � � �MODIFICATION
,oz— UPTONXIAIvi E3 INTERIOR El CHIMNEY REPAIR
OWNERTUII:fil'R DECLARATION j Licenxd Rmfcesinnal 2011000AMPS IMPROVEMENT
I 1 hereby affirm that 1 am eumpt from hM1e Conhrucior's License Lew for the OVER 1000 AMPS El BATH REMODEIJREPAIR El DEMOLITION
aqS O L O Tenant 1.....a. Sano.7031.5,Bminess and Pmfessinm Cede:Any city vremomy SIGNS f:1.F,Cl'RICAL ❑OTHER'
sFu�! O which requires upennit m ronstma,after,improve,demnli.h,or repair any soucmte
ry m Ill I t ': 1intonestit Ilf II Ip II fl 6 I:rl trtl $PECIAI,C RCUITI SC
?5� }
put he licensed pt the univimicals,ofo Crucial License L (Chapter,
_
W CO
(commencing as im Section700a ofD 7 ofth Business andPmfe Code)or TEl ill OR LEI LOMMERCIAL'
IL o C that he is exempt therefrom and the k.. o tit g conniption,Any violation of
' fII J I �NF:W BLDG/ADDff10N I1FNfOLIT10N
$sur ](F.11 sly y ill h[ p r uhlcxxtI applicant cvlpamlty of D[i CD. `f, OTENANT+ LCY/t0_0'DSERVICh
ry —� X more than five hundred dmllas($500). °' I IMPROVEMI'NT.
TSG ❑ I,as owner of the prop,y.or my empldyms wiW wages av their sole mmpchmtion, SWIM NG POOL ELF.
1. stipulate work,orchestration is nm intended oreffered burials Sce.JDtq,Business ❑OTHER
no land Prefessinos Cade:The Commema's Licrmac low does not apply to on owner of OUTLC -S III!S-FIX.NRES -
IE property who builds or improves thereon,end why does such weak fol if or through, "
his awn empioyeev,provided that such improvements are not incia l nr offered Lm NEW RES115EWIM.ELECTR SQ FT.'
sale.IL however.the building or improvement issold within,,.yemil comphoun.the SQ.FL FLOOR AREA ESQ.Ff.
owner-hrifiderwll have the buden ofproving thttidid not buld or improve for par-
pose C 1 ), -
[]I,a of the property, exclusively< ntclnb with licensed t t m 'IY)TAL: ��^ y
common,rhe ppiject(Sec.]0a4 Business d Profession.,Coi*Me Ciforpramek l
sc Lail llovstaPPlyta a w1mial ,,,Perry Is,Thai II.son imp n d QTY PLUMBING PERMIT FEE �//
On b I:f chp I h.wiN a umtm t r(s)licensed pu matt an the Contractors � Y2�
Liven.low Ts PERMIT ISSUANCE
l am axe yonder Sec. ,B•&PCfimthrs a
it ALTER-DRAIN&VENT WATT?R(EA) ^ -
O r Dt ,Lryo AhUATION
W ERS COMPENSATION DECLARATION BACK FL OW PROTECT DEVICE w p
MnI It, by ff under pcndnioimp fCol fed flit ng l C
1t, d '11 ' was CeroLxncoft . n Ide ref W k "C pen DRAINS FLOOR,ROOF AREA,COND. TYPE CONSTRUCTION
nolo 'p tl d far by Section T]I,p of the labor Code,for Ban varlonormaccol the L
wed fortit spermisissued PIXTIIRPS-PER TRAP
and
1 have and will maimain.Wo nirfor Compensation thInsurance,n hif,required by Section
7]1X1 of the Labor Csxle,for the pe'rinmmnce of the woik for which this perinit is ismeJ, GAS-EA.SYSTEM-I INC.q OUTLETS OCCGROUP1 APN
My Warkera C'nmpens:nien Insurance camerPolicy mmtber ere: - ..
Cartiee
Policy No.: 'GAS-GA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPGON FROM WORKERS'
COMPENSATION INSURANCE. ` GREASEANDUSTRI,WASTE INTERCEPTOR
(Unk,ec0onncednotheunnplmW[Rhe tis for nnc hundrtN dollvre($11X,1 ' BUILDING DIVISION FEES
or less.) p:m,l GREASI!TRAP, l - -
PLANCBECK;TE
PLA
I nitrify that in the perfonnancemfthe work far which this permit is issaid,[,hall SEWER-SANITARY-STORM EA.2(10 Pf.
` not employ..,person in any mammy so us to became,subject mthe Walk,,,Content- ENERGY FEE
Oz Applianwxof Califomin.Dme v _ • - WATER I(RATER W/VINN I/ELECTR- ''
z Applicant " - GRADING PEE I"
y NOTICE TO APPLICANT:IL after making this CetriEcate of Ekentption,you should WATER SYSTEM/IRPATING'
f~ become subjeed to the Warker's Compensation provisions of the Labor Code,you hnq SOILS FEE
n'�.t li,nhwiN comply wiN'euch provirinnx nnhlr permit shall ho deemed revoked. WATER SERVICE
as Q
.:) z CONSTRUCT ION LENDING AGENCY, NEW RES IDENTIAL PLMB. SQ.FIT PAID
U O Thereby affirm thauhere is uconswminn lending agency for the performanceof H, Dam RaeiptN
the work for which Irk permit is issurd(Sec.LM)],Civ.C.) I.
LL.U Lender's Name TOl' L: '
IandcOAddress - 'TOTAL:
1 certify that,1 have mad Nit application and state that the above information is NUILDII
m rnrrex.Ingree n.ronyhly wbn all city and rnttmy vmmvnce.and xwm lows i'emdngm QTV. MECHANICAL PERMIT FEE
Uz building contraction.and hereby millnucc representatives ofhhis city fainter upon the SEISMIC FET: - t
i have-memioned property for impaction puryproo.
(We)agree to save,indemnify and kap harmless the City of Common against PBRMI'['[SSUANCE ELECTRIC FEE
liubilihiesjudginems,coals and expxaes whichomy in anyway amnia again void CityALT'it OR ADD1'0 M ECH. PLUMBING THE
in consequence mine granting of tho permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MF.CIIAN[CAL FEF.
SOURCE REGULATIONS.
• AIR HANDLING UNIT(OVERI(f(briI CFM, GGNS'I'I1HGT'IGN TAX `
Signature of Applicant/Contrector Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF,
HAZARDOUS MATERIAL S DISCLOSURE -
Will thetipplicunor future hnlldingacenpunt`toresor handle hmuNous mmerivI HEATING UNIT(A)HANDB RTU)
as defined by the Criticism Municipal Code,Clmpwr 9.12,land Ne Health and Safcty
Code.Section 25531(a)? HEATING UNIT(OVER Ifli BTU) -
❑Ye. E]No
- VENTILATION FAN(SINGLE RESID) PAID
r
Will the aan future trading
occupantuse , devices
-
Dam Recein#
emith ad itwmmn rotadefinedbyAoAirQomIiyMdmgfmsnr BOILER 100,0( B
Distrix? +
_ TOTAL:
❑Ycx : EjW, BOILER-COMP(OVER IIXI,000 BTU) ,
µ,
I have read Nc hawdous mamrials p AIR CONDITIONII ,
rcquimmen�undcr Ctia¢r 695 of Ne Culi ISSUANCE DATE
fomia Health&Safety Code,Section 25505,M533 and 25534.1 understand Nat if the NEW RESIDENTIAL.MECH. SQ.FT
.handing does nm cmaemly have a tenni,that'it is illy rcspmsihiliry to nntily the occupant. ,
of the fir,mr, of,which most bi mer livor rnik....one of.Cenificme of flecupars"
Owner or notarized agent Date _ TOTAL: ISSUED BY:
OFFICE