S 1502 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HULLOING-ELECTRICAL PETE No. 1502
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`J
BUILDING PRO.II+CF IDISN'I'IYICAT[ON
BUILDING ADDRESS: :SANHTARY N(l. APPLICATION Sl11fM11TA1,IIA'TF
OWNER'SNAME:
POO NE: (pM'RACI'ORS NAME: LIC NO.
/yl A NIC COO TROha
ARCIII I ECIIIiNGINIAiIt LIC NO: Z ADQRIiSti: ❑
PHONE: BUILD-NG
CONTACT: NG PERMIT INEU
(4iNj 73cc-%S7 g ❑ Ctmsaltant FCes Paid by Applicant(Initial) HLIIG ELECT PLUMB MECH
MA ?ko.,.,\
❑ ❑ ❑
LICENSED CONTRACTOR'S UIiCLARA'I'ION QTY ELECTRIC PERMIT FEE
1 hcrchy infirm mm I urs licensed.,,do, e
ncr pro, r, (continentalehapter, (continental
DESCRII"PION
�CLZ with Stt'tion 91X1111 of UIvlXinnJ of the Nosiness unA Pmrnsionx Code,mW mylirelvw is RESIDENTIAL
w0c, m I'LRMIT ISSUANCE
CWF full forces Icct. DSFEWI, GKI'1'CIIEN REMODEL
U Liron>c Cl�s� Lic.a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMPING RE-PIPE
f-ZW D:nr —Comms
H6a ARCHIIEC'I"S DECLARADON ~'`Ys OMUI:1'1-UNIT ❑STRUCfURA1,
F r�Z I understand ntypla.,shall Mused se Public ac cede PANELS MODIPICA'1'ION
OZvi- UI"T0200 AMPSDINTERIOR GCHIMNIiY REI'Alk
rac .iecnsW Pout...used 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
OWN17R-BUILDER DECLARADON OVER 1000AMPS DRATHRE GDEIJREPAIR DDEMOLITION
C Q 1 hereby alEmt that 1 am exempt front Inc Contractors License Law for Thu
❑OTHIiH
following n'amn.(Semina 703 L.5.13miness and Prof—tar,Cade:Any city or e,umy SIGNS ELECTRICAL
al a ki ae which require,u permit to callamel,alter.lima ,dcmolidi.or mp,i,;,ny amctus,
Q p'i.. I ':" .al, l :th ,la, tf hp tt II .11Isocal SPECIAL CIRCUfUMISC.
�'� thatn n:dseasa ll to p 'won: rd L t t r 1 L ILnapmr9 L:
COMMERCIA
s
W L4cc (atmmenemg wnh Secuon]WB)nf DirisionJaf lM1e Nus ncss unJ Rofes.:ons Cada or TEMP.AIEIER OR POLE INS'I'.
q iaC e W that he is exempt full and the basis for the alleged emmptima Any stunner of ❑NIiW tlLDG/ADDITION ❑UEM0I.ITION
Section 711.315 by aryall,icant fora permit suhjects the uppli,m,oa civil penalty of POWER DEVICES GTENANT GFOOD SERVICE
not more than Eve hundred dollars Siff)) IMPROVEMENT
�F-,=� Dl.as owner of the pmpcnX or my employees with wa&es ns thoinnle compensation, SWIMMING POOL ELECTRIC
will da the work,a.d the,huca re a,.,,,imended ar offered fm sale(sec.]IFU,Bmine.e ❑OTNG
a I'rofusniunx Gule:'fhe Commclurk License huw,Jrws nal apply m Ito owner or (rtf :TS
fLf -SWITCIIIS-FI%TURES
L prolum,who build or impose,patio i,and wee due,such work hin,ch nr through
his own employees,press"Nta
at ch implemented,me nm intended in offered for NI?W RESIDENTIA1.IiI.IiCTR SG I'I'.
Tae.If.however,the building or inmovcmem is,eld within one year oftompletion,the SQ.14.FLOUR AREA EISQIrl'.
.
er-builder will have the horde.of po ing that he did nut build or improve for pur
pw of set,). v TU'1'A L:
0 1,an.owner of me propcny,am exclusively annotating with licensed oamcters in
construct the project(Sea.70 W.Business and Proc siom Ctde:)The Cnnwaor's 1-
rouse apply to an owner of property who build,or improve,thereon.and QTY. PLUMBING I FEE
who cataracts lar such pmjcct,with it canal act...ln)I1,cnWd pmm-ent to the Contractor:, / O
License Law. 1117RMIT ISSUANC-
0 1 am escmpt under Sec. .H&P C for Ihi,ream.
ALTER-DRAIN& li -WATER(EA) VALUA'T'ION
Owner Mute
.
WOR KHR:S COM 1-17NSNI'[ON DECI.ARA'I'ION (SACK FLOW IROI'PC L DEV '
/I hereby affair under penalty or perjury ono of the following dcctatuti...:
L Il base and will meimai it u Cem Ocmaef Consent oself-insure for W'nders Crimper- DRAINS-FLOOR.ROOF.AREA.C STORIIS TYPE CONSTRUCI ION
Taiwan,Ire pmvldo-1 for by Section 371X)of the IaMtr Coda for Inc fork om,:mec of the
work for which this fent is issued. FIXTURES-PER I'RAI'
0 1 have and will maintain Waders Compensation lmurence.as"aped by Section
J]Ilp efthe l,mor Code,for the perfunnovice cflhe Werk for Which his prnat is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
1y WnrAcr'n Gvnpcnxatinn hrs soja nl Policy nnmtrcr arc'
rte t' 1('c.0 1 urnpcc v f�Ilcy No,: /] GAS-EA.SYS'IP.Mit, OVIiR4 IRA)
s�
CERTIFICATE OF EXEMPT(IN FROM WORKERS' GRFASP/INUUSTRL WASTE INTIiRCF.140R x
COML'CNSATION INSURANCE HOILDING SION ITHS
p his union recd not he enntpleted it tnepermit is for alto hundred dollars(E 100) GREAS171'RAP
,it less.)(I PCI:
I cemiy that in the ponfomtance ofthe work for which dais permit is issued.l shall SEWER-SAM'rARY-STORM EA.200 PI'. �J
not employ any pence in any manner no as to become subject to the Workers'Certifier- ENERGY Ss
Z smwN D
ion l.annf California.Date WATER 1117/0 ER WIVEELECfR s
z O APPLcanl GRADI TEE JJs
NOTICE 10 APPLICANT:IL reemerging this CeniLicate of Exemption,You should WAT4:R SYSTEM/u'REAGNG
= SOILS ITL+
>
become subject colo to the Wuch rs Comms or this previsions of the Labodeemed
Colee you mut
FD r hrnnwim comply with such provisions or this ry:rmit shall he deemed rm'okcd. W'A'TER SERVICE
Q PAID
7 CUNhem is� IONons LENDING AGENCY NEW RIiSIIl1iNT1Al.I'Lh1H. SV.FI'' Ilalc R 9
U O I for
r w hichimuhenherc issue See.o.lc.ding .) 4,r the performance of
1, F" Inewad farwM1ichiris permit is issued(sea.31N].Civ.CJ
bender s Nims TOTAL:
I..) I<ndcr,AJJresx '1 DIAL
aI ccnify then 1, read this epPlicaion and sir¢then the aMrve infnrmaion i. BUILDING FEE
F-' N correct.l ugreenitply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC IEE
OZ build ing.nttscacti n i,inW hereby amhoi,,tepree...afl—efmisdty to em"clu,the
above mentioned properly ter Inspection purpnws. PERMrf ISSUANCE Ell FCI'RIC FEE
(We)agree tri inde army ami keep hannlez,Inc City of Ca,eina r,mr,t
Iiahilid,judgments eats and c,,,aWs which..,an any way arcane.Fauna said City ALTER OR ADD TO MECH. PLUMPING FEE
I.......... of the gnmting of 1111,tix permit.
AI'PLICAN'IUNDI?Ii51'ANDS AND Will,COMPLY WIll ALL,NON-POINT AIR HANDLING UNI'I'(B)I0,(XX)CFMJ MECIIANICAI,hili
SOURC17 REGULAI IONS.
O AIR HANUEJNG UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
Slgnuerrot'Appl,C Contmr Ilene EXHAUS'TH000IWIDUCI') I IOUSINGMITIGA'IIONFEI:
AZ.ARIN)US MATERIALS DISCLOSURE
Will the applicant or future building occupant store of handle hvandous material HEATING UNIT(10 10(fli B'I'U)
as deficit by the Culwmoc,Municipal Code.Chapter 9.12,and the health and Safety
Csdc.Salina255]20)! HEA'1'INC.UNIT(OVER (10,00013'fU)
Yes e VEN'ri IATION VAN(SINGLE RF_SI D) PAID Dare Rcccipta
Will the applicantmf/Iuttuure building occupant use cq.ipmem It'theism which pOILER-COMP(9fIP OR lIX1,IXXI BTU)
s
mit heuodnus air cnmmutinalus as Jefred by the pay Arc,Air Quality Mune,ou,na TOfAI'
DiseiclT ISOILER-COMP((IVER 100.1000 BTU)
❑Yes.
I have rend the haaodmn ntasri.lx res ' tx[[oder Chapter 6,95 of the Cad- AIR C(1NUI'TIONIiR ISSUANCE DATI°
gma'men 1 �r
bu Id Ocular v &Scurry tly ba Sections 25505,is lay and 25514.1 i ndcxwth that it Oe NEW RIiSIDEN'I'IAI.MECII. SQ.ITT. T
or Id tines not .Which bust.tenant.matit is ce oft ertiycaramifythepency.occupant
n 1mr}„�tams wmen moa ham. [prison issuance oft Certificate nr<xrapa.rr. r
-a-- AZAI" AJP-.ills- � ('V4' TOTAL: J
Own tmuhoneala tat Data ISSUED PV'.
Za OFFICE