S 0340 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PFy ITNO 0340
PII ICATION/PERMIT PLUMBING-MECHANICAL `U
BUILDING OIVImV:x '"-""""-'- BUILDING.PROJECT IDF.N'I IF'ICATION
SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
EE
083 N �� e Ro�
a OWNS 'S AMI": //���{!y PHONE, CONT n R:S NA ; LIC NU. NIC CItN'I'ROI.p
6-; 57e 4q ❑
RCHIFHCT/1!NGINEER: LIC NO ADq� , (1
CONTACT: PHONE: `` C•7 BUII.DING PERMFI'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICRNSEDCONTRAMOR'S DECLARATION QTY, ELECT ERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under poor.l0n,of Chapter 9(commencing
DZZ. xifullotrcc anJdTecDivision3of the BusinmsanJ PmfessinnsCWe.and mylicen.e is / RESIDENTIAL
X0,0-) in PERMIT ISSUANCI! 0SFDW'1 ❑KITCHEN REMODEL
WUV Liccnsc Class Lic.If APPLIANCES-RCSIDEN ❑ADDITION ❑PLUMBING IIiI'll'li
F.6 U Dae Ci mmnor
+n ❑MULTI-UNIT STRUCTURAL
ARCHITECTS DECLARATION PANELS MODIFICATION k
Z O N Z 4 I understand my plan.shall he used an public record, UP TO 201 AMPS
❑INTERIOR ❑CHIMNI!YREI'OL
CZ_p IMPROVEMENT SWIMhfING POOIS
1-`_'F'W hicenuJ Profes<inaal 201-10X)AMPS ❑'
OWNER-BUILDER DECLARATION ❑BATH REMODll PAIR []DEMOLITION
OVER I(HW AMPti ,'
C 0 Q 1 hereby affirm that 11. exempt(sant the COntmam's e;Any
Law for the OTHGR 1
ac a U hick ire massa(Section 7031.5.S,Puniness and Professions Cade:Any can or county ' SIGNS ELECTRICAL
ac
2� — a -
W 3 LL N which requires n permit to pares the
applialter.cant
improve.for such
h pedemnna to file
repair ed twment
rmic
0� psi t ( e.al Gey :tit ppI tf : �reamu is Lure(Chapter
SI'4CIAI.CIRCUIT/MISC.
Stay Nath .I . dpurs a tit p is
fare uOh,mmctor,License Law(Chapter9 COMMERCIAL:
�a0� R b job Seel ]tNq) fDivi,d T Ith Business and Professions CtWd or TEMP MESrCR OR IroLE INST.
cd aX e C that he is exempt(hcrel'ntm and the besis fur the alleged exanpeon.Any vbintion ill C1 NEW I11.DG/ADDITI(IN ❑DEMOLITION - x
V, an,
Second 7031.5 by any applicant for a pemtit mbjeers the applicant a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
tet more than five hundred dollar,O501L IMPROVEMENT
SSDphmmwner ill Nc rmpeny.or mY cmFlnyecs with wogs n..their nolo cnmrcn..nfion, SWIMMING POOL ELECT RIC
rill Jo the work,and the structure is not intended or offered frnsale(Sec.]614.Business ❑OTlllik
F OUTLETS-SWITCHES-FI%TURES
L 3 m and Professions whom les or
improves Contactors License Law drtcx nm apply m an owner h
his o ny who bniW.or dedm thcram,vol who docs n,,itno watk d d or of through NEW RESIDENT AI.ELEC,R SQ IT.
his own employees,provided that such improvemems an,not intended or offered for SQ. L R SISQ.PI'.
sale.If,however,the building or imrrovcmem is sold within one year 0f Co
the
rvhuilJcr will M1uve the burden ill moving that he did nut build or improve liar Iur-
[-ILosowne ,RH'AL: • JUL 25 RECD
Los owner of the progeny,um eadmively contracting with licensed ountmasn m
tmuuc(the es not
apply
weer al and P.dusx builds
of impro traCommasrx Li- FEE
scl.awd«.tet apply to an owner ill prnpeny who builds or intpnrvc%thereon,and QTY. PLU M BIND PERMIT
%hoconvacu touch projects with a coearellr(s)licensed pursuant RNe Contmnors CIIY Ur k,UrCHIINU P
Liccnsc Law. PERMIT ISSUANCE.
E)1 am exempt under Sec. .H&1'C fill tills reason
ALTER-DRAIN&VF.NP-WATER(EA) VALUATION
Owner Date
WORKER'S COM I'ENSATION DECLARATION HACK FLOW PR(TECI',DEVICE
I hereby aMan under penalty of perjury one of the fallowing dcclarnion.o:
I have and will maintain a Cmifican of Consent to Latif-insure for Worker's Compete DRAINS-FLOOR.ROOF.AREA,COND. STORIES 'TYPE C(1NSTRUCI'ION
lion,ax provided for by Scow 3]01 of the 1 mbar Cole,for the performance of the
for which this perms is issued FIXTURES-PER'PRAP
I 1 vc and will maintain Workers Compensation Insurance.as required by Section GAS-FLA.SYSTEM-1 INC.4 OUTLETS GCC.GROUP APN
4. .]01 of(M1e Labor Cudc,for the Fcrfnrmaace of the work fur which this pmmit is ass.
My Work'SkyCnptnr'nna ID{tn Xcc turn In it cy'll GAS-I!A.SVSTI:M-OVI!R4(EA)
Carvin:G'MTY �.g�`A
CERTIFICATE OF EXEMPTION FROM WORKERSGREAdJINDGSTRL WASTE INTERCEPTOR
BUILDING DIVISION FE
COMPENSATION INSURANCEES
(Thismnionncco nmbecompleted ifffie rmitisforsrnchuWmddol.am(S10)I GREASE TRAP PLANCHECK FliI!
or les..)
I cosily that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-S'TORMEA.200FK IiNERUYFEE
as employ any person in any manner sr,as m become subject m the Worker"Compeer-
,a section laws of Cali Funds,Doc WATER HEATER W/VENT/F:LECTR GRADING FEIi
Applicant I
1
(�
NOTICE 10 APPLICANT.IL alter making this Centre-a of Exemption,you.h.uld Wp'TIiR SYSTLM?REAPING SOILS FEE ,
f" y become subject to the Workers Compensation previsions I the Labor Code.you mast s
W L fnrthwilhmmply with such pmsislons or this permit shall he deemed revoked. WATER SERVICE
4 ^
CONSTRUCTION LENDING AGENCY NF.WRITS -N'I'IALPLMR, SQ.FL PAID
Da¢ Receipts
Vz Ihorcby affimtthatthcrcls ucondruction lending agency for the performance of
the work for which Nis permit is issued(Sec.3097.Civ,C.) TOTAL:
Q (•" Lender's Name TOTAL:
Lender's Address s BUILDING FEE!
G 1 cendf,Nm 1 have read this application Bill date that the u.nrvc inl'.nnati.l is
en eumcr.l a gree to comply with all city and county ordinances and nate laws minting to QTY. MECHANICAL PERMIT FEE SEISMICFEE
UZ, building con%ruction.and hereby authentic representatives ofthis city to enter upon the
ry shave-mentioned property for inspection Impose, PF.RMI'I'ISSUANCE ELECTRIC TIRE 17.
(We)agree m save,indemnify and keep Imando s the City of Captain,again,(
liabilities.judgments,coat and expenses which may in any way uccme against said City ALTER OR ADD TO MECH. PLUMBING FEE
-it,cralsequence of(lie granting of this permit.
APPLICANT UNI STANDS AND WILL COMPLY WITH ALL NEIN-POINT AIR HANDLING UNIT(TO 10,000CPM) MECIIANICAL IEE
SOURCE Rf iULAT S.
7 AIR HANDLING UNIT(OVER 10,000CFM) CON$'IRUCTI(1N TA%
Signature of ApPhcunJ tmetar Date EXHAUST HOOD IW/DUCq HOUSING MIIIGA'DON IEE
H RDOUS MATERIALS DISCLOSURE
Wilhhc..plica I r prime building occupant.vorc ar handle hamrJousmmerial HE ATI NG UNIT'(TO IIMrand BTU)
as&rated M1y the Curve am Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Cudc.Section 2553200! PAID
C]Ycx ❑No VHN'I ILATION PAN NI NOLE!RESID) Done Rcacipt® _
Will the applicant or future building occupant use cymipment or devices which 13011-ER-COMP Off OR 100.0X10 BTU) i
mi(hoadlo r,air cnmamin 1,an dcfi ed M1y thc Boy Arca Air Quality Manages cut TOTAL:
District? BOU.E -COMP(OVER 100,0011TU)
❑Yes ON.
Ir AIR CONDITIONER ISSUANCE DATE.
1 have read the k ode.Sections
material. 5,W3 ears under ,1 and oro rl(he Cul l-
fn III Hwlth&Safety GWc.S¢tions 25505.2553]mJ 2553].1 umkrstaal that lathe NEW RESIDfiNI'IAL MECH. SQ.PC
III loos nrn cu n0y huvenfcnunk that it is myrcnpmxIDiliry mnotify the cccuy
of the me (. hi hmus m`i Prior m....save ol':y� cy.
Ow er au(hnri I on, •, Date 'TOTAL: ISSUED BY:
OFFICE
DD
LE
"0
O
P7
m
MZ
Kt
x z
COMA
0 70 m m
CDzti
z <
17"
70^
no
0 4.nA� --
m
�� t-, E; �� Z, C)
--1
0 c m
Z
M
:1D M
S� L r6
0 M
(A
rr,
pw
it�aQ
cc)
czO O = n C)
C=
,j 1*3
D D713'
3 y
PI�I I I I -MTITIT -�Tfl (TTTTl 1-I I I 11111"f l h f1T,
_J .
-� _-
3 KD
>
3 i = •�,;r:'' i it� ili i li - 5 � _
lot 'N
T
_ '• ~
cn
4.
M chi+
�oo�� z E HOME 5TATE RD. %
2 � o� o 1
�iO2NN m J
aanypC
t
0