S 0634 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECrRICAI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL $J 063'4
BUILDIN0 1'ROJHCTII)VNTIFICAT'ION' '- -P
- HUILDING ADDRPSS: 'SANI'I'ARYNO, API'I.ICATIONSUI3M1'ITAI.i)xrr.
n S 85 :
PgF -
CL P1.60
OWNER'S NAME; PIIONF.: CON�RACI ON'S NAME: LIC No:
l •�
C- '% f10_ p� I N/C CON TROL#
•AItCHIT'ECT/IiNGINIAiR: LIC NO: AODRIiSS. / L21-90 Dr'✓� ❑
CONTACT': PHONE: t -.' - -'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDC, ELECT PLUMB MECH
❑ ❑ ❑
LICINSED CONTRACTORS DICLARATIONQTy,' f ,,;ELECTRIC PFRhI1T.. ,r i, FEEL, -
nterenrarrrothtl 1 :d I p Klaiber 9 astnm , J r..L- t ;r JOB DBSCRI ION
'0Z with Senn.70(c).dD' ision 3 of Ne Bos eaand Prumv,ons Cedcandmy license is RESIDENTIAL full farce and affect PERMIT ISSUANCI.
�WLicemc Class Lia.k ❑SFDWL [I KITCHEN REMODEL
I- U APPLIANCES-RESIDENTIAL ❑ADD]'T'ION ❑PLUMBING Rfl.Pi PF
al G Dam Camm�ur
an ARCHITECT'S DECLARATION ❑MUU['I-UNIT ❑S'1'RUCI'URAL
,. in PANELS - - MODIFICATION
Z p nn I understand my plans shall be used as public records
oz-, - UP10 2WAMPS El INTERIOR ❑CHIMNEY REPAIR
�at,I-
ai Licensed Proles,minel 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IfNgIAMPS [I BATH RIIMODHURIH'AIR ❑DIiMDLI'1'ION
hmaso.iSect(hoe 11. exempt font the Contractor's e:Any c ty o for my
C.pmU [IBATIIt IR El 1FM —
X W following recon.armilnt ]const&Business and Pn de o demolish,
Code:Any oily or untmr SIGNS EL[CI'RICAL
W 3 LL N which requires n pemtil In construct,alcor,improve.Aemnlish,nr repair any stmewreta
1�"�� prior In ifs lssuance.also requires lbs applicant fimsuch permit In file aligned namonvot SPECIAL CIRCUIT'/MISE
Mat he is licensed pounammthe pr..vision,oftheCommclne,LibrenseLave(Chapter 9
_df (ntmmamcir,with Section nla) f Division 3 ofum Business and Pntfesaim,Calc COMMERCIAL
gwl pt )or TEMP.MII'fER OR IY)LE INST.
".K that he it exempt tberefrom and the mail
jun for the cts the eximinnor.
to Any violationsaty of ❑NEW BLDC/ADDI'T'ION ❑UIiM01.1'1'[ON
^m
Section]011.5 by any applicant lmru permit subjects applicant(o.civil Penalty of POWER DEVICES ❑T17NANT ❑FOODSERVICE
Zy sol more than Five hundred dollars($500). IMPROVEMENT
6n FJ Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
W 'o will do the work.and the structure is not'm(emded proffered for uric(See.]1144,Ht,,wess [I OTHER
W,3 eo and Professions Code:The Conlnemr's License Law does not apply m an aware of OUTLETS-SWITCHES-FIX'I'URBS
Pmpeny who builds or improves thereon,and who does such work himself or tough
his own employees,provided that such improvements are not Intended or oRemil for NEW RESIDENTIAL.ELECTR SQ IT
sale,If,however the building or improvement is sold within one year ofcompletion.the SQ.FT.PLOOIt AREA EISQ.IT.
caner-builder will huvo the harder of proving the ho did not build err improve for poo- - L�
passe of>•ele.).
PAID
I,as owner of the property,am exclusively contracting with licensed convenors to TOTAL:
eme wen the project(S .704L Budr,ol d P f: C ale) he Contract Li-
cense
- --,r ���
A
c n L des otapply l fp pent h builds or improves thereon and QTl ',i J PLUMBING PERMIT-/ s `s �lr..1FFIf'-' 4
wht Ivu ' oul w'Nue coart Is) pursuanno the Com lull r^s1 (G
Lc reLaPERMIT ISSUANCE r.��,
❑ l an exempt under Sec B&P C for this mason up
I.I' hl _
ALIT?R-GRAIN&VENT(rwxl 3R(II A)
Owner Data � YVV
ORKERS COMPENSATION DECLARATION BACKMJF.,FLOW PROB H., G-
I hi affWirm under pcnally of perjmy one ofine following decl.rations: '
I have and will maintain a Cenifcale ofComem to self-insure for Workers Cooper- 6RAINS-1'1.001CROOP,ARPv1, STORIES TYPE CONSTRUCTION
.mica,as provided Iia by Sbdian 3700.1 IIs Labor Code,for the ,fur-o-of Thu
work for which this permit is issued. FIXTURIS-PER TRAP
❑1 have and will maintain Worker's Contpensution Insurance,as required by Section
3]OBof(he lalm,Cale.for be performance of the work f which this P�ern�it is is•�ue/dI.') GAS-BA.SVS'fHM-I INC.401ffLE'IS OCC.OROIJI' APN
My Worker Co. e.,I mance carrier and Poicy licy napyberaq:15J7-/Y GAS-EA.SYSTEM-OVER 4(IIA)
StgT N��&OMMPENS'ATIONIINSURANC[ORKERS' ��7 BUILDING[)(VISION IPHS
GR17ASOINDUS TRL WASTE INTERCEPTOR
(Thissmtinn ncW not he coupletWil'the permit is En one hundred doll ars IS 100) GRIiASETRAP f
,I,less.) PLANCIIIiCK THE
I cendythal inthe,edomwnccnfthe work lorwhlchlhis#rush is Issued,Is hill SHWFR-SANUARY-STORMEA.200FI'.
b -
not employ any person in any manner so as to butane subject to(lie Workers'Compen- ENERGY FEE
ZZ saftin laws of California.Date WA'I'F,R H FKIER WNENITMLECfR
O Applicant ( - GRADING FEE
Iti pJ NOTICE TO APPLICANT:If,afar making this Certificate of E.unalo m,you should WA'ITR SYS MIATREAUNG
F �+ become subjen(r the Worker's Contpensntinn prow.ionsof ire latae Cade,you moa( - SOILS FEE
Wforthwith comply evilhsnch provisions an this .it shall be deemed revoked. WATER SERVICE
CONSTRUCT ION LENDING AGENCY NI?W RESIDENTIAL PLMB.- SQ.PT. PAID
Thereby affirm that hem is a construction lending agency for he performance of Date Re, 1p(a
'he work for which this permit is issued(See.319],Co.C.)
O ULender's Name _ AL:
Lenard.AddessA
yt1 ( fBUILDING FEE
0. I cenify that l have read this app) t d tat that theb f n( n I.
(A enmel l agree mcomply with alloy ad county ordinances and state law,reli gl Q7Y1• s ' MECIIANICI PERMIT .1 s YEE
L Z budding construction and hereby e(hmvc reprevrWt offs city it)enter upon the n _ SEISMIC IT.F.
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agreh m save,indemnify and keep harmless the City of Capemino against ELECfI11C FEE
liabilities,ludgmems,costs and expenus which nsuy in any way accrue aguinvt raid City. ALI'ERORADD'IOMIiCH.
in consequence of the granting of this p ninh.to
FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LI,NONE INT AIR HANDLING UNIT fD)II Bi,CFM)
MIiCHANICAI.IE
SOURCE Rf: UI TIONS '
AIR HANDLING UNIT(OVER 10,M)CFMI CONSIRUCfIO TAX
Signator of pplicand t actor ,
D r EXHAUST HOOD(W/DUCT) HOUSING MITIG 'ON THE
H 9 DOLS MAI ERIALSDISCLOSII I
Willlheapplic fume building rccupunl store ar handIT le havard material HEATING UNTO 100.0")BTU)
as defined by the Cupenmo Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Seelion 25532(a)] HEATING UNIT(OVER 100,00(BTIJ) -
❑Yce F1 No PAID -
VIiN'TILAITON PAN(SINGLE RESID) Dale Re cipt a
Will the applicant or future building occupant use equipment or devices which
car(h:tzmdon,air con ourem s u,defined by the Bay Area Air Quality Management BOILER-COMPLIHP OR 1X1,00(113 TOFAL:
Disvin] I
[3 Yes ❑No B(IILER-COM P(OVER 100.000 IITU)
I have read the hvallous order s), AIR CONDITIONER ISSUANCE DATF.
requimnntons under Chapter h95 of the Cali-
brain Health&Safmy Cole,Sections 2.5505,25533 sad 25534.1 understand Thal it the NEW RESIDENi'[A],MECH, SQ.FT.
building does not currently haven count,that it is my retporeibilb,to nollI y the occupant
ofihe vgeimment-s which must he stet prior m ill....rf a Ceniftcam of Occupancy.
Owner or authorized agent Date '1'OI'AL: ISSUED BY:
OFFICE