S0025 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL"ING-ELECTRICAL FERMI'I NO
BUILDING DIVISION APPLICATION/lIERMITPLUMRING-MECIIANICAI. -WW
BUILDING PRO1FlCT IDE:N1'IFICAI'IOM1' (.
BUILDING ADDRIiSS: :.SAN)L\RY NO. APPLICAI ION SUBMI ITAL DATE
D N. ocF6 peso ,2
OWNERS NAME: PHONE. CO TRACTOR'S NAM F,: LIC NO,
�A �jnN� N/C COVIR01.
11'ECT/ENGINEER: QrJ LIC NO: ESSLTI U ❑
9 /71a u R
CONTACT: PHONE: f1Nd31'() QA 9, 89 dU11.DING PERMIT INFO
104"ApRa /J,���C' �k 31,01 04.1/A� ❑ Cnnsullanl Fees Paid br Apphcanl(Initial) 11 ELX PLUMB MFCH
LICENSED CONTRACIOR'S DECLARATION ✓,_ QTY ELECTRIC PERMIT ° E -•�A\I
0 1 hereby arrrm mal I am licensed ander provision,of chapter 9(commencing JOB DESCRIPTION
O with Section700(hof Division3oflhe ltusinessand Profe.sslonsCWc,andaylicense is I'
F full force andeRect. PERMIT ISSUANCE ❑SFDWL ❑KITCHENREMODEL
CwF nn
aUU can Class Lie0 APPLIANC DENTIA ❑ADDITION [I PLUMBING RE-PIPE
p..Z nal Date Contra r Te
mQe A CHITELTS UIiCWI ATION O.BIJ4Tttu \� ❑AfU1.TI-0NIT ❑STkUCTURAI.
O Z rte'F.DZ 1 understand my plans shall he used as public recsmH N p 2W A MODIFICATION
❑INTfiRIOR ❑CHIh1NEY REPAIR
GYL� Licensed Pmformal 201-I 1P )VEMENT I]SWIMMING POOLS
N f-�
OWNER-BUILDER DECLARATION OVER 1000 AMS ATI.REMODEUREPAIR ❑DEMOLITION
C C C G 1 hereby affnn that 1 am cae.npl from the Comracmr's License Law for the
X 3 a U following reason.(Section]1131.5,Business and Professions Code:Any city or cuonly
SIGNS EhECfRI'AL OTHER
CoA which regu.rr:s a fiction a construct,alter,improve,defrokoh,or repair any ctruemre
F�Oa priorwitsivnincrem...eequires the applicant for such permit In file a signed statement WECIALCIRCUITIMISC O
F. AID
ad that he' licensed pursuant theP :uf theContractor's 1 1 (Chapter to
w�Qp�O Hnmtt g th5 do ](XMB ID r n\ fN H . e: nJP fie - .Ced)lir ThMP METER OR ST COMMERCIA;
d d cr� Shatec io b Ih refit J N t I. N alleged J nal Any -e i n of TIiNANEW B 'll 8 DL1Af®U SERVICE
IO
W;.
Section 703 lS by any applicant lora pernu.mh)pcts theapplicant in acivil penalty of POWER DEVICES ��LL{I
�r`A' nal more than five hundred Jollm,1551X11. IMPRO
SQ ❑ I,asowncrodthe property,or my cn.ployec.,with wages us their snlecnmpenxalinn, SWIMMING POOL ELECT RIC
L., will do the work,and the structwe is notmendcdonmlured f'urmlc(Sec.]1D4,Business ❑OTI+(1` 1. L,
Wim and Po,IOoion,Cndc:'I he Colioeer'I License Law dues not apply at an ownerof UTLMS-SWITCHES-FIXTURES V 1 �Ur�H'F1'INO
property who hands of improves there....,and who docs such work hmu.df..,Iboa,li
his own employees,provided than such Improvunenls are not nended or nlTcred Ino NEW RESIDEN'1'[A],RLP,CTR SQ IT.
sale If,h..weventho building or mpmvcnent is slid within ono year al'mmplctlan,the SQPI'.FLOOR nRCn S/SQ.1'I'
. .
(two
ter-hailder will have the burden of proving that lie did Into ould or improve fat put-
too,
ut- �� 6-69pu,oriole).
El I,as owner of the Pnge,,L a.n exewsively contrasting with reposed ci mracan,to `.
constrict the project(Fee.LNq,Budnpss and Professinns Gxm:vmc Ccu ramors Li-
nwLaw does nolapply b,an owner of prupcny who builds in improves thereon.and QTY. PLUMBING PE FEE
who commons ha such plocets with a cnnumon,hottest)pato..le the Clinometer',
License I.aw. PERMIT ISSUANCE
I am exempt under See .B&P C for this reason
ALTER-DRAIN&VENT-W C iA VALUATION
Owner Dale /,�,y�
WORKER COMPENSATION DECLARATION HACK FLOW PROTECT DEVICIi
fIs hereby affirm under penalty of Perjury one of the following Jeclialiooe
I haveand will maintain uCcnilicate ofCnnsenun elf-inmm for Wicker's Cmaism- DRAINS-FLOOR.ROOF.AREA,CONDSTORIES 'TYPE CONST RUCTION
scion,as Provided for by Seclinn 3]1X1 of rhe Labor CWe,for the performance of the
work far which Nis permit is issued. IXTURES-PER TRAP
Fl 1 have and will maintain Worker's Compensation Insurance,as required by Section
gl
3Woflhe Llnr Code.far the performance oflhe work for which Nis pemnil is lssoed. GAS-EA.SYSTEM-1 INC.d OUTLETS OCC.GROUP APN
hfy Worker pensotinn{}�1 comer nnJ Policy r j GAS-EA.SYSTEM-OVER a(EA) Z3
1 Cares �I�
COMPENSATION
.SURA
/ CERI'IFlCATE OI�F%EMPTION PROM WORKERS' GREASFIINDUSTRL wASTF..INTERCEPTOR
COh1PENSATION INSURANCE: 1 IN )IV ON PEES
fThissection need not he complacd if the permit is flrone hundred dollars(SIM) GREASETRAP PLANCHECK
or Icss.)
Ioy any print he anymannce rill the work lm mbjML to the it Wisers'Coooted. pen-,hall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as m become suhlecl m the Worker.Compen- IiN1iHGY T
Z salion laws of California.Date WATER HEATER WNENGUELEMR �• GRADING PEE
z C) Applicant \
NOTICE TO APPLICANT:IL deter making this Certificate of lixcreption,you should WATER SYSTEM BEATING SOILS hili
h � becomeevbjen In Ne Workers ComPemalia.p....momaf the Lobar Cede,you must
1y+ 7 forthwith comply wnhsuch Provisions or this permit shall be deemed revoked WATER SERVICE'
WQ
GONSI'RUCL[ON LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.19'. PAID
1 herchy.aftinn that there is a camlmetion lading agency far the perfammnce of D Be, p
Qr wo
the
r- he for whi,h,hi,I)em.il is issued(See 319].Clv.C.1 Leader's Name TOTA h:
U Lcnda,AJdres, \1 I�
0. I total,that I have read Ibex x Plieminn nnA w;uc.hat the uMwc information i, BUILDING h;.
it N7 coni l nsnc m comply with all oil nnJ cnnnty..Ninunccs;mJ sue l:ow.a Mating In QTY MECHANICAL PERMIT FEE SIiISMIC f
U G huilding conamctian.'Ind l.crchynal price relncmntwlves..I'this cifymcuital Ponme
above-mcnuaned properly for hopes i.n Pmpowa. PERMIT ISSUANCE ELP.C'I'R l-I
(Wes)ngrce n.save.indamni nal keep hat.nluss the City of Culemno against
liahillilu,.,ladgmenoa.....swideep u s ducl,nwy ill any way upemcagain,I sail City ITER OR ADD TO MtCCH. I'LUMISI . E
nncqucnce nl flc grandny of t Is Pcnaii.
APPLICANT IINDFItSI'ANOS NO WI1,11 COMPI fi'If ALI,NUN-VOIN'i' AIR HANDLING Clot I(TO 11,110K)C1tM) MECIIANICAI FHE
SOURCE RIzGUI.ATIUNS,
9 AIR HANDLING UNIT(OVER IB,INNI CPM) CUNS'IAl1CI )N PAN
Signemmnf AppluaaV Dal EXHAUST HOOD(W/DUCT) HOUSING MI' ' ON FEE
/ARD( J MATERIAISDISCLOSURE
Willhenfiplicama,finm - ulldithicen,na totem handle boanlommewriel HEATING UNIT(TO 100.000 BTU)
as defined by the Calsomm..Man 'pal Cola Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW.(XX)BTU)
Coda Section 25532(,)^
❑Yes ❑N VENTILATION FAN(SINGLE RESID) PAID .
Dae Itccnpt
1 Will the applicant lir future huilding uwcupanl use equipment or devices which BOILER-COMPI3HP OR 1 W,1XN1 B'RD
m.un,,mene,air eentmmbear,as defined by the Buy Area Air Quality M....enter, TOTAL:
deft BOILER-COMP(OVER L00.000 BTU)
E3 Yet ❑N.. .n
I have mad the lianrdous m ledah requ:teamms under Chapter 695 of the Cali- AIRCONDITIONER ISSUA ISrD
femi,Heald&Sofcly Geta Serf ns 255115,25533 and 255N.1 undcnm:d Nal if Ne NEW RESIDENTIAL MECH. SQ,FI'.
buiWingdocrancurrentlyhvvca mon.lbait ism sibility b.notify the occupant
ofthert musics lits which in t of smmme ofa Cenibcm of 'cu cy. /
Owner or aulhorbW fear TOTAL: ISSURE BY: /
OFFICE