99120072 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTTRIC]. PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUNIRING-MECHANICAL
naw
BUILDING PROJECT IDFNTIPLCS'I'ION
BUILDING ADDRESS: tiANI'IANY NO. APPLICATION tiUHM1ITAL DA'r
�2-
OWNJ71ZS NAMF, I'1I11NC: CONI RACFOR'S NAME: LIC NO
NIC
CON T"tUl.q
AS
RCIII'IELT/ENGINEER: LIC NO: ADURE55'. ❑
CONTACT: PHONE: - HU ILDING PERMIT INFO
❑ Cr nsultant Fees Paid by Applicant(Initial) BLDG CLECT PI,U�M MECH
❑ ElJ ❑
LICENSEI CON'IBACTOR'S DECLARATION QFY, ELECTRIC PERMIT FEE
1 hereby.nim,(bar 1 on Bedoed Linder provision%of Chapter v amnnntcmdag JOB DESCRIPTION
Qzz with Section 7000)nl'Do,.lan 3 it it,[Lustre,and i'mfcsxl..ns Gine, ran,license is RPSIDENTIAI;
tat Q PERMIT ISSUANCE
�1_ in li If limrcc and cffccj� c/ .� � ❑sPLAvi. E:1 KITCHEN REMODPI,
U Licc
C,do
Lic.p,.]JD APPLIANCES-RESIDENTIAL -]ADDITION E3 PLUMBING RE-PIPE
Fzbe num Contaie
ARCfIITIiCi.SDECLARATION PANELS ❑MULT6UNIT ❑S'I'RUCI'URAI.
[O)H Z I understand my plans shall be used as Public records MODIFICATION
Ztn- UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
oz—o
F�FW Licenced Pmfe..iunal 2(11-I00(IAMPS IMPROVEMENT 0SWIMMING POOLS
W Y J UWNIiH-BNLUIiR DECLARAI"ION OVER HWAMP5 ❑IiAI'lI NIiMOUI?IJREPAIR C DIiMGI.I'iIDN
C Q I hereby affnn that I um except from the Commnor'.,License Law far the
O,U fidlnwing reason.(Senian]11.11.5.Business and professions Code Any city or county SIGNS ELECI'RICA], ❑(TETTER
taI 3 W i- which requires a permit um construct.nine,Improve,Jmm,Bsh.or repair any SWewrc
F,i ool11 prinrmits issuance also rcyuirestM applicum for such permit...file do,nedsntcmem SPECIAL CIRCUIT/MISC.
� } Nal he is licensed pursuant In he provi.ion.wftbe Cnntrecmr'n Lian.c law(Chapter) COMMERCIAL
WK00 (commencing with Section]INgpaf Division 3ofrhe p1moc,sond Pmfesion.Calc)or 'IFMP.METER OR IDLE INST.
daxo ca, that he is exempt thcrefrm and the basis for the alleged exemption.Any violation of ❑III 'BLDG/ADDITION DIA:AfOl.11'ION
WimSection VH3L5byany applicant forapenna subjectathcapplicatn macivil peri of POWER DEVICES ANr C1 FOOD SERVICE
not more an Five hundred dollars($3001. IMPROVEMENT
N
�Z6 []1.as nwncrofthe property,or myemployees with wages as Neirsole compensation, SWIMMING POOL I?LECfRIG
P. ❑OTIIIiN
will do the work,andthemmemm is am immrdedoraeered forsale(Sri.70c,,1,Business
{�i13m and 11nfa.iom Gal,The Conran.....'.License taw Joe,not apply n.an—act of OUTLETS-SWI'ICIIES-PIX'1'URES
pngw 1,who,hui d,o unpruvc.0nocon,and whit dna such wank to nsmlf Lir through
his awn employers,provided iha,such improvanenla mentor intended ar offered for NEW RESIDENTIAL.Hhi!COR SO PI'.
Sp.Irl'.FLUOR AREA $/SQ.PI'.
.ale.If,however.the huildingorimprovement i.sold within ono ycana'cnmpletion,the
ncrhuilJer will have doe harden of proving that he did am build all improve for pur-
pose of sale.). TOTAL:
h as owner of the property.am exclusively contracting with licensed contactors nm
maim the pmjee,(Sec]MW,Business and Profeslons Codcp The Contractor's Li-
cone Law does not apply it,anowner ofproperty who builds orimproved thereon.and QTY. PLUMPING PERMIT FEE
who contracts for such projects with a enntrncmr(vl licensed pursuant m the Contraoors
[Accost,law. t ' 1117RMIT ISSUANCE L
1am exempt under See. ,B A Y C for his rcasnn
ALTIiR-DRAIN kViiMl'-WATER ) VALUAI'IUN
Owner Pan,
WORKERS COMPENSATION DECLARATION BACK FLOW PRUE HC 1'.DIiVICii
1 hereby a1Erm under Penalty of perjury one of the hollowing dalamtionc
I have and will maintain a Cenificate of Consent to self-insure for Workers Crimper. DRAINS-FLOOR.ROOF.AREA.CO ND. S'I( IES 'I'YI'E CONSTRUCDO
union.as provided far by Section 37M of the Labor Code.for the Exams nonce of the '
will'far which Nis permit is issued. FIXTURES-PER TRA('
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ofrhe LaMn Guic,fnnhe performance ofthe work for which thispermit is issued GAS-EA,SYS DR.I.I INC.4 OUTLETS OCC.GROUP /5 MIN
My Wurkcr'x Gmmprnvutiun Inwnmec I 'cr and Policy n n M1
1 `r' I
CllrrmnTVLI kkR Policy Nni A� DLA GAS-CA.SYSTEM OVER4BfA)
CERI'IpICXTF OIt RXF.MP11ON FROM WORKERS' GREASIYINDUS'1' CWASTEINT51CLYT)R
COMPENSATION INSURANCE? I t^ BUILDING DIVISION fIaiS
Obissa'tion need not becompleredifncapcnnd isfinonehundreddollan($100) GREASETRAP I G\ IN-�1� PLANCHECK ItiE
arlccxl
I<enify Nat in the perfnmmnce of Ne work lorwhich this permit is ismeJ,hhall
SEWER-SANTI'A m STORM EA.2 FT ENERGY FEE
not employ,any permit in any manner so as to become su ajen to the Warkerc'Compete
Z ration ELoo,f Coliform..Data WATER HEATER ENI'( GRADING FEE
zO Applicant 1
y NIIIICE TO APPLICANT:IL after making this Ccnificmc A Evem anion,you should WATER SYSTHMO A'I'ING
F' hnvtne subject to rhe Wader'.Compensation ns ol'the Lst, Code,you nnnl SUITS FEE
J mor prol'III
rLinnwnn a,Innlr watt.mtrn pradt.ian.mthi..nennh_d,uu he necmnrn m.akrd. WATER slsRvlcr,
m ❑
0.
CONSTRUCTION LENDING AGENCY NEW RESIDEN'rIM.PLMB. SQ.191 PAID
,z Date Reccipla
U O I hereby affirm that Nem is ion lending agency for the performance of
the work for wM1ich Niz pennir is issued
ueded N(Ser,ec.3097,Co.CJ 'IYTI'AL:
0 F-' Lenders Name 'I OTR-:
;_ W fender.Address BUILDING IEE
M I codify that 1 have read this application and state that the above information is
tnenm
c .l agree umtnply with au city and county ordinance..and.rte laws rdatingm QTY. MECHANICAL PERMIT FEE SEISMIC Phil!
7o
U G building mnswmion.art hereby.dandcotprcsentativel of this Illy of microfilm the
jo,, aaantiored Pmficny for in,pectton popo.o.. PFRMII'ISSUANCB HLECIRIC IIID
(We)agree w.twin,iadetmtify end keen hun lles.Ne Cay of aperrimm ag.iaxt
liabilitic.,judgmcm.,caa.undcxpcn.ac,which may in any way mare again.said Col ACI'ER OR ADD TO MICA. PLUMBING FEE
in mmequcmcc nl the'main,of Thi.permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WE 1'If ALL NON-POINT AIR HANDLING UNIFTO 10,000CF14) MECHANICAL FEE
SOURCE:REGULATIONS,
AIR HANDLING USEOVER IO.fggl CPhp CUNSIltl1CTION TAX
Signature of ApplicanUCnatmnor Dare EXHAUST HOOD(W/DUCT) NOUS INC,MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or I man building occupant oblation handle hmaNaus moerial HEATING UNIT(TO 100,000 BTU)
n,Adincd by the Capaninn Municipal Calc.Chapter 0.12,and the Health and Solely I IEATING ON I'(OVI?It 100.00 BTU)
Code.Section 25532(m)'I
El Ye. E]No VENTILATION PAN(SINGLE BESIDE PAID
Doc Receipt M
Will the applicant or furore building occupant use equipment or devices which BOILER-COMP(3HI'OR 110,000 ET
:mit h.eaNins air contaminants as defined by Ne iiay Area Air Quality Management U) TOTAL:
Uwrict' BOILER-COM('(OVER I W,g10 BTU)
❑Yes 0No
L"
d the l N m: do
y ' t:underChapter fi 95 f the Cal
AIR CONDITIONER ISSUANCIi DA'I'li
fn H Ilaff Stfdy( Sections2.5511525511 at 12559W,I J I' Jrbm I'dm° NEW RESIDIIN'IIAl,MECIL SO FI'. / �
huligJ turnt,hi t nl,that ' Y :pm,hltyt ifYth anoPt 2 V
of the requirements wNch mol b:run prior to sauance at u Cs.l can of Ocumpancg
Owner Lir authomd agent Dam TOTAL: ISSUED BY: s'
OFFICE