S 1755 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELBCI'RICA], Tilt IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 1755
BUILDING 1'I incur IDENTIFICATION
BUI LDING ADDR SS: SANITARY NO. APPLICATION SUHMITIAL D61'E
OW I?R;S NAM : PHO C THAC OR:S N Mf:; LIC NO:
0� �I '` NIC CONTHULb
^ARCI IITECTIENCINEEk: L 110 NO: pD)H'SSS: ♦`� B ❑
CON'T'ACT: PHONE: i/ /s,' HUILIJING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEPCI/
E:19� E] E✓i
LICENSED CONTRACIORS DECLARATION QTY F:LECIRIC PERMIT FEE
1 hereby affirm mat 1 am licensed under provision%of chapter 9(commencing JOB DESCRIPTION
ocoZ 'm Section]IIf1(BofDiOxcln Jorlhe Businessland ltadeaslons Cork.mul an, esomse is RESIDENTIAL
F00 wufnll fano and elect. QQ PERMIT ISSUANCE -
yulF„ in !�( J ❑SFDWL ❑KITCHEN REMOUEI.
QUU Lteaue Cl s Lick IYA APPLIANCES-RILSIDENTIAL L1 ADDITION El PLUMBING RF.-PIPE
y�u1 Dom Cnmmctor
FFARCH1II!C'fS DECLARATION ❑MULTIUNIT ❑STROM URAL
[..D N
ZO, �y IundnscrsmnJ my plaxhull he tercel sex public annePANELgx MODIFICATION
CZ- uPT0200AMPS EINTP.RIOR ❑CHIMNEY REPAIR
I❑❑'ly Licensed Poll...innal 201-10dro AMPS IMPROVEMENT' E]SWIMMING POOIS
�sj 2,,j OWNGk�11U11.UIik DECLARATION OVER I00)AMPS C1 BATH REMOIyi(IRIiP Ik DEMOLITION0.0.''�Q 1 hereby affirm that I am exempt from the Contrachms License Low fine the /L4•
3 a tU- following reason.(Section BOJ I.S.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W m which marines a pemtit to construct,alcor,improve,demolish,Alto any structure
F�-OG priuran its issuance,also requires the applicant for such Permit file a signed smtcnem ' SPECIAL CIRCUIT/M ISC. I
mw} that he is licensed pursuant m me provisions of the Contractors License Law(Chapter 9
W C) (commencing with Section 7")of Division J of the Business and Pmfessinnx Cole COMMERCIAL
)at TEMP.MGTER OR POLI?INST.
A.q o q teat io is camps therefrom and the iasis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑FOODDEMOLI
SERVI
W rn
Section 703 LS by anyap,Iirunmra Pemtit subjects the nDPlicanuu ncivil ps:nnlry of POWER DEVICES El TENANT [I FOOD SEkVICF;
^ y, nt more than tofilm property,
r yco,h IMPROVIih11iN'I'
QQI,axowner ofthu Pm,cny,oranyinpinyccx with wred fo,meirso.cnat,cmntion, SWIMMING POOL I!LEC'[RIC
Ca will Antbcwons andmese,Contractors nue
Licauale Lawdo%not ap,uc.]1149,owner
❑OTITLI2
43$ and l'ry,wh ons Ctale:'fheovwx tore License Laws such
Nob :l riwncugh OUI'LEIS-SWI'ICIIIS-FIXTURF:.S
I nawrly,who hulls,or improves thereon.and wcoo does ouch work Nobel or through
codaownemployeese Provided and oncementis sold sorenm iyear of orplfemd Ise NEW kF.SIDC:NfIAI.ELI?Cllr SQ IT.
wlu.If,however,the building or improvement i.sold within one year of completion.the SQ.FI'.PLOON AREA 90 len
owncr-buildcr will Ince the burden of,musing that he did not build m improve for pur-
Towe of sale,. Cl
❑1,as owner of the properly,a mr
exclusively contracting with licensed contmes to T 'AL:
construct the project(Sec.]1141,Nosiness and Professions Cover)Tom Cnmrac nr's Li" so 67
cetem Law does not apply to an owner of property who builds or lmproces thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects with a crnamclo{s)licensed pursuant to the Corollaries
Liccrsc law. PERMITISSUANCE
I.,t exempt under Sec. ,B is PC for this msor
AI:PER-DRAIN k VEN'P-WA'I'1!R TA) - VALUA'T'ION
Owner Date !` v
WORKER'SCOMPCNSAI'ION DECLARATION BACK FLOW TItQI']=DEVICE /� �
1 heon,affirm under penalty of'Pe jury one of the following declarations: G
l have and will maintain a Ccnificmc of Concern to self-insure for Werke'.Compiler. DRAINS-FLOOR.ROOF,AREA,COND' S' RIBS TYPE CONSTRUCTION
ration,as provided for by Sttnion J]W of the labor Cee,for the I'erfunnunce of the
work for which this permit is issued, FIX'I V RES-PER TRA'
❑1 have and will command Whole,Compensation Insurance,as required by Section
3/00 of thhje Labor Code,for fartchuuraannccee of the work for
which
Ons returnit is/i�ssued. GAS-EA.SYSTEM-]INC.4 Off[LEI'S OCC,GROUP APN
Carr n r:rAi� ns tpP 111onJnxuran{TM 1'n lay Nnnd YN��IT»c& OAS-EA.SYSTEM-OVER 4(P.A)
curIFICAT'EO11EXI ITIONFROMWORKERS' 5;c 4XCX—
COMPHNSA'I'ION INSURANCE. GREASOINDUS"I RL WAS 1'17,IN]ERCEPFOR v�
(IIixncaica need not becontpined iOee,erntit is fnronc hundauldalam(S Into ( NII •R l D .I(NFIB3S _
rir less) GRIiASI?'fllAl' PLANCHECK 'Ili
toy any thminmeperfnnmmee o ,41 work rwhichthl.theill.l isiasuCon,s IJI SEWER-SANITARY-S'T'ORM EA.21X1 Fr. NAP-
,a employ any penis nosy manner stynyttlb�usWl+subjed latheill Cnmpem
zz action laws of Cab n ate (O/�l//1� WATER 11HA'1T:R W/VENT/ELECfR
Applicant a .1 r ��/� GRADING ILII
NO'T'ICE TO APP T':If,after nmking this Cenifcmc of Exemption,you should NATER SYS'(HMG R RATING
a , bemmcmbjeO m the W..kees Compensation Provisions of the L thor Cafe,you mol SOILS FEE
W bufflo th comply wimsuch masmoreor this permit shall W deemed revoked. WATER SERVICE
C4 G7
V O CUNST'RUCT']ON LENDING AGENCY NEW RFSIUI!NTIAI.I'LMH. SQ.Pf. PAID Date Receipt A
I beruby affimuhauhcrc is n ausl(Set.30 lending ogeney for the parfnmtwace of
tbo work lin which mite pemtit Is issnul(Set.]111],Civ.C.)
Iia h Lender's Unum TOTAL:
L) Lender's Address 'I'OIAI.:
>' y I ccttify that I have read this application and sface that the above iaf...nation is BUILDING PER
IA comeel.l agree to comply with all Guyon]county ordinances mdslntc lavolmating In QTY. MECIIANICALPERMIT 17EE
L) Z building commuclum.and hereby rethmile representatives of this city to enter upon the SEISMIC INE
aMsve-mentioned property far imp a ion purposes. PERMIT ISSUANCE S(`
(we)agme m save,indemnify and keep harmless fine City of C.Pertinn against -s-0 ELECTRIC IFf: .,
Retail hies,jud,numb,costs and expenses ofhichney in any way acerae againstsaid City AITER OR ADD'TOMECH.
in asequence of dre lamming of this permitPLUMPING FEE
APPI %NT UNDERSTANDS AND WILL COMPLY WITH AL1.N)N-POINT AIR HANDLING UNIT(10 10,000 CPAI)
SO C tF ULATION. MECHANICAL IFF, y y
/ 5 10 AIR HANDLING UNI I'(OVER 10,1130 CPM) CONSTRUCTION'H'AX
.igna a' APPI' nt/Cnntmcanr (� lam EXHAUST Pill)t W/UUGF) HOUSING MIGATION INH!
HAZARDOUS MA'I ERIAI S DISCLOSURE
Will the applicant of future building occupiitsmre officiate occultism mamfial HEATING ON]'1'(TO 1041UO P-ru)
as defined by the Carnation Municipal CMG,Chapter 9.12,and the Hwlth and Selety
Culde.Section 25532(a):' HEATING ON]'I'(OVER 10(),000 B'IV) // p
❑Ycs 0N PAID e+ SIp I
VENTILATION VANS INGLE REMD) Dam Refeipt4
• Will the applicant or future building occupant use equipment or devices which
emit hamndous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 10,001 BTU) TOTAL:OwnerI 16y
?
❑Ycs El No BOILER-COMP(OVER 10(,010 BTU)
I moemad the hvad....uaw6edsrnlnirmnertx under Chupmrf95 of thu Cali AIR CONDI'UONEH 14, -10 ISSUANCE DATE
lemic Ilenitb&Safety Code,Seadnns 25515,255]3 and 25534.1 rndcoomd that it he NEW RESIDEN'HAL MECIL SQ.FC
bnilAingdces not cunently havcamnnn1,mw it l fayre"arrombily of nosily the""'and
for'Ihemcfe anceaswhich must Mtactpdor no i..uance life Cenificum of Occupancy. C� [,^ 7 ✓Na �i
Oscraoradhorioadagent Die IOTA h:-/ -7O ISSUED BY.'
OFFICE