S 0616 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 0 - BUILDING-ELECT RICA], PIITN(1
HUILDING DIVISION APPLICATIONWERMIT PLUMBING-MECHANICAL J 0616
BUILDING PROJE(:1'IDF,N'I'IEICAI'ION . t_ I
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
qv .
Ave I
OW iN:S E: - PHONE CON'ILI
'RACIOR'SNAME: C No
a ue NIC C'OMIItOI.%
XfARCHITECOHNGINEER. /Fk MC NO'. ADDRESS: ❑ .
CONTACT. - _ PHONE: }r.,r BU ILDINC PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 1'.1.FC'r PLUMB MI?CII
l?" ❑ ❑ ElLICI NSPDCON9RACTORS DECI ARAFION QTY(it i r CLECJRICPI EMIT° s. ' 1 I PLL'" f 1 JOB DESCRIPTION
I hereby afforded 1 am I d do p f Ch Pt 9(a nm g -
rn—,b%Z with Section]mHBofIT an 9afflmB s u _nlPoh,s,s -C I dray licenses - RESIDENTIAL'
�F PERMIT ISSUANCI.
❑SP
infrllfsmetndoRect DWh ❑KITCIIP1J REMODEL
UF- it
Class I
Cl
License a . .R
Q U APPLIANCES—RCSIDEM'IAL ❑ADDITION [:1 PLUMBING RL'
IiPIP
I-•7aW Dam Contractor ❑
.� 0. - ❑MIJL'fl-UNIT STRUCfURAI.
ARCIII'ITCI'S DECLARATION
E,ptn PANELS - MODIFICATION
O ZI undersand my plans shall be itself as public records UP TO 200 AMPS
[I INTERIOR [I CHIMNEY REPAIR
W Licensed Note s.vior.I 201-1000AMPS IMPROVI:MIiNT SWIMMING POOLS
YEJ OWNI;R-BUILDERDECLARA'I'ION OVER IM)AMPS ❑BAI'HREMODHIJ EPAIR ❑DEMOLITION
rya,C4 cd Q I botchy affirm that I and exempt from the Contractor's License Law for the
x 3 LL U following rea.vnn.ISection 7031.5.Bdvinens and I'rofes.vions Cod:Any oily ar county SIGNS ELIC RICAI. ❑OI'IIER _
4whichs re9 .i,to construct.atm improve,d h 1 pa; m
, tntcre '
0
fq. r/s� prior to itsissuance,also mquiresthe ppl t lot suchpermit t file a signed statement SPECIALCIRCUI'T/MISC:
wnypthat he licensed purstt II p em . t'tl Contractor 1 1 (Chapter9
�y0 (c americans with Section701hof Dolour 3af the Badness and profession,Castle, TEMP.METER OR POLE INST COMMERCIAL'
that he iv exenlpt therefrom and the basis Lame alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLIT10N
Seclinn]OII SM1y any npplivum faro permit mhjeasthc applicvnuoa civil penalty nl 'POWIiR UIiVICES ❑117NANT ❑FOOD SERVICE
F. not more than five hundred dollim 050) IMPROVEMENT
O ❑I,as owner of the propeny.or my entpioycex with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTIIER
all do the work,eel the,"clre is bol imtndM.e.flumd f m talc N..IlN4,Biroucen _
W 3 and I'rofesstons Cade:The Commumil,Liver.law does no,apply man owner of OUTLETS—SWITCHES—FIX'fURES
property who mildso,improves thereon,and who does ouch wed himself m mumm
hid own mnployee.v parvldM that such imp r...aten,,an,,not inrendee or offered for NI?W BESIDIiNTIAh I?LECTR $Q Ery.
sale.If,howevea the building or improvement is sold within one year of completion.[lie SQ.PI'.FL 0 AVb SISQ.PI'.
ser-builder will have the hnnlen of proving that he did not build or improve for pur- P MNM �f
u l 'I l IO r^
a:I fah property, exclusively contracting 6 thThelicensed Contractors
counselorsI SEP 1 9 ,err CI
constructneprotect, to
Business ei r..' .Cuba:)Tn v, t m n,an - - .
I s' r sr,/,
c La s tpl IYt fl Itudy h till: 1 eII e d QTY-r* t - j.PLUMBING PERMIT . .il f, iPF..r
who tmAfar such p )tic:withunm ctur(s)licnersed famonallI th Cnalurrites
License Lo PLRMM ISSUANCE.
❑I am exentptald•r se¢ ',B&PCm-his C1IY Cif wetfi HN
IZ
TLLZoT ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Data
W derPCOM of,sarjury lin Dfthe be AI'ION BACK PLOW PRO]ITT DEVICE ,
1 hand w abBnn under penalty of perjory one of the insure for declarations:
o
❑Irhave
asonswill maintainaCeni3700 of 0,Latin,
Code,in,Il,perf...m Cempcn- DRAINS—Iq,(lnR.ROOF,AREA,GOND. STORIES TYPO CONSTRUCTiOf
work f r provides for M1y is issued,
3]n0 of tot Culver Code,for the performmuce of the
work ave.aich this lnatimout,is i,oaed. FI%'NRES—PER'I'RAP
❑I have [,s will mdinuin Nbrker rCoae III h w rk for ce.which
h requires by Section '
37ml of the LuM1nr Cada,fin,hu perfnnnmse nl'Ibe,mrd for which thi.v pnnnit is issued. GAS—EA.SYSTEM-I INC.d OUTLETS OCC CROUP AIN
My Workers Compensation Insurance tamer and Policy number um:
Combat:. Pal icy Nn: GAS—EA.SYSTEM-OVER 4 EEA)
CER1'IFICA'I'EOPEXEMPfION FROM WORKERS' GItIiASFJINDUS'I'kI.WAS,1i IN'11F Cl?PI'OR
COMPENSATION INSURANCE N1111.DIN0 DIVISION I'I?F:$
(This section needoot he completed ifthe pc man is bureau hundrtd dollars(SHE) GRBASETRAP
nr PhANCIIECK PEE
ens.)
I ccnify that in thepe,umrmanwafthe work(drwhichthis Namit is ksuM,I shall SEWER—SANITARY—S'IY)NM HA.200 PI'.
ma employ any pemnn m any manner w,as to tw-mnm suhjccun the Workers'Compen- ENERGY IEE
Zmeion lawx of Cmikurnia Data WRIER II HRIER WIVEN,71fil ETlt CRAVING FEE 0 Applicant l -
NOTICE 90 APPLICANT.If,after making this Certificate(if Exemption,you should WA}£RSYSTEM( REATING
F ;
reissue subject to It.Workers Competxanmr-„ismu,ofm,loth,Code,yea runt sons THE
Wforthwith comply with such Provisions nr this permit shall he decntM revoAM. WATER SERVICE
n
CONSTRUCTION LENDING AGENCY NEW RESIDENT[At,PLMIi, SQ.FT, PAID
U O Iherchy affirm that there issamnwclinn lensing agency 4br the lrtmformuntt of
Done Rmc'atM
the walk for which this permit is issued(Sit.30)].Civ.Cj
OU Lender's Name TOTAL:
U Ic J sAddre. _ TOTAL
Q. 1 ccnify that 1 have read this application moderatethat theboa of rat t m is
- BUILDING FUR
N car ti b t m.1,wimall fly and ty ordinances d,late l .lei t tlm QTY. t MFCHANICA[ PERMIT I FFF
U Z bolding nmmcfon.anihereby..ill A, ,m.,mdti x, fah sty tucntere the 1't• SLiISMiC ELI.
ahovamemioned property far impaction Pm,swas. PERMIT ISSUANCE
(We)came to slave,indemnify unit keep harmlexx the City of Capanino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway uccome,linstood City ALTERORADD'IOMECH
PLUMBING FEE
in consequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL Nr N-POINT AIR HANDLING UNIT(To IB.1Np CFMI MECHANICAL FEE
SOURCERCGUL DNS.
I Air- AIR HANDLING ONI'I(OVI;R 10,000CF6f) CONSTRUCTION TAX
` Signature mfr plical �anlmanr to i?XHAUS'I'HOODIWIDUCD HOUSING SO I'IGATION FEE
H ]ARDOUS MATERIALS DISCLOSURE
Willticopplica torfntumbuildtngcecupaninmrcorhandlehueurdoho,material HHATING UNIT0TO 100100 BTU) -
as deftnM by the Cupt,dinn Municipal Code.Chapter 9.12,and the Health and Suit,,
CMC,Section 255321,0 IIIiATING UNIT(OVER Iq,IIOD B'IU7
❑Yes No V IN'I H.A'1'[ON PAN(SINGLE REST Of PAID I]In¢ Rccti)t4
Will the applicant or future huilding accepted use equipment or devices which
”. ' )OILER—COMP(JHPOk I0BTU
emt wbyteByArcaAuQality Management
TOTAL: �q
Dlnne] U)
❑Yes ❑No BOILER—COMPlOVER10,00013I
'
I have revel the hmanloa,materials requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DA9'E
fumia Health&Safety CM,Sections 25505,23533..it 25534.1 undcomnd that if Ne NEW RESIDENTIAL MIKE. SQ.ET.
huillhng Ar nomnrtemly hav¢atennnt lhat it lvmy msponsihility mnmify Cher
of the marts which must he act prior m issuance of a CaniEcam of tjq nnc
(leen,o, zed agent >m TOTAL: ISSUIiD BY:
OFFICE