31433 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELECTRICAL PERMIT NO, �a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL X11
BUILDING PR13,1 icr IDENTIFICATION
HUILDINGGADOREI - SANITARY NO. APPLICATION SUBMITTAL DATI
IV J s S'a
OWNERS AME: PHONE: C TRACTORS NAME: LIC NO:
s; NIC CONI'ftOLN
jw' u, �l r r
R Cvm d WINEmyfi LIC NO: ADDRESSaAl
/ J .s ❑
CONTACT: PHONE: BUILDING PERMIT INFO
// ❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
FratL S3-C'6/8 1 ❑ ❑ Cr ❑
LICENSED CONTRACTOR'S DECLARATION QTY. IiLECTRIC PERMIT FEE
1 hereby iflirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with S,rI1Im70pB.f Disisfim3.f lM1eBoin<ss and l'mfessions Coek,and mylicenseis PERMIT ISSUANCE
00 RESIDENTIAL:
in full force and effect.
aVV License Class Lic.p ❑SFDWL [I KITCHEN REMODEL
��w Date Contractor APPLIANCES-RESIDENTTAL ❑ADDITION ;i'LUMBING RE-PIPE.
Z8p'L ARCHITECTS DECLARATION PANELS
[]MULTI-UNIT []STRUCTURAL[] I undersand my plans shall t inial as puhlic records MODIFICATION
CZ-0 UPTO 200AMPS [I INTERIOR ED CHIMNEY REPAIR
Apio:al Licensed Professional 201-1000AMPS IMPROVEMENT
j _1OWNER-BUILDER DECLARATION OVER IOXAMPS ❑BATH REMODEURF.PAIR [I DEMOLITION
K Q 1 hereby affirm that 1 am exempt from the Comnmtm's Licence Law for the
a6 FV following reown.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Oyj which requires u permit to readmit site,,improve,demolish,or repair any structure
rQl prior to its Issuance,also requires lheapplicant tat such facania to file a signedsmament SPECIALCIRCUIT/MISE.
�} that he is licensed pmaterm to the provisions of me Commiswes License Law(ChapxrY
aJwoo (commencing with Section 7011(1)of Division 3 of the Business and Professions Code)a, TEMP.METER Ok POLEINST.
M a o�' that he is caempt therefrom and the basis for Ne alleged exemption.Any smat on of NE DG/ADDITION [IDEMOLITION
Semon 7031.5 by any applicem far A p.i,s.bj.ta the Appleton to A civil Emahy of POWER DEVICES
�Y T ROVEMENT
not more than five hundred dollars($500), ❑FOOD SERVICE
1
Q ❑ I,asawner ofthe pmpedy,nr nrycmployees wimwxges vs meirsnlo aonpensmion, SWIMMING POOL ELECTRIC
will do lite work,and the structure is not intended ornfl'mod forsale(See 7044,Dnsiness ❑ HER
and Professions Code:The Contractors License Low dues not apply to un owner of OUTLET'S-SWITCHES-FIXTURES
pmperty who builds or improves Iherenn,and who Arcs such work himself or through
his own employees,provided mat such imprnvnnems sem not intended or offerW for NEW RESIDENTIAL ELECfR SQ ET.
sale.If,hawevcr,the buildingorimprnsinumaissoldwithin ane yearofcoaldnfi n,the SQ,ET.FLOOR AREA $/SQ.Ff.
owner-builder will have the burden of proving that he did not build a,improve far par.
posc of sola).
❑ 1,os owner of the pmperlY•em eadusively conmmiing wish licen.eeJ eommnnrs to TOTAL:
construct 0x pnsjem(Sea 7144,Bootless and Prvlea,i a;Code:)The Coalmchrcs Li-
censeLawdoennutapplymannwncrofpropertywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who ormmms far such projecm wird u conuacrm 0laenaW pursuanuo the Conttnme.
License Law. PERMIT ISSUANCE
❑IamesemptunderSn. ,B&PCfermis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
, KtkS fOMPE.NSATION Of CLARATION BACK FLOW PROTECT DEVICE
usr ya1H sunder penally of perjury one of the following dee ImIImas:
❑Ihave end will mainainx Cmificam o(Conxm mxlGinsurc fm Wnrkcls Campcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCTION
xtlon,as providentfor by Section 37M of the Labor Code,for the perfmmxnce of the
work for which this permit is issued PISTURF.S-I'IiR TRAP
E] I have and will.maintain Worker's Compensation Insurm¢e,ss rale oral by Teenon
3700 of the LaharCole,for the perbrawacenlthe work for which this point,is aned GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work Ctnm nsaio, aur cx r and Policy n tMgs y
Cartier: I, •r O olicy Ns�o e '��GU/ GAS-EA.SYSTEM-OVER 4(RA)
CURTI CATL'OIsMLh ION PR OM WORKERS'
COMPHNSA'I'ION INSURANCE GRRASUINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES(This section need no he completed if the pnmlt is for nnchundred dnllors(SIM)
an less.) GREASE'1'RAP PLANCHECK ITE.
(certify that in the performance of theworkforwhichthiopermitisissuedIshall pen-
notempinyanypersoninanynannersnxamMcnnx subject n,me Workers Compen- SEWER-SANITARY-STORM HA.2M IT.
Z cation Laws of California.Date ) an ENERGY EEC
O WATER HHATER WNENT/ELECIR
O NOTIAppliCE
GRADING FEE
y NOTICE.Tn APPLICANT:If.ea after making this Certificate of Lane,Co,youahould WATER SYSTEM/fRF.ATING
ahccome c nt m me Worker's Compensation provisions of the Lobar ,oke,you must SOILS FEE
fonhwim enngsly whh ouch prnviaions or this permit shall he deemul mvnkaL WAIERSERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
C.JO L hercIshichemlhatmere isecd(Sit,ian lending agency for performance of .pL� fteceiplM
� — the ooh for which this permit is issued(Sec.3097,Civ.CJ
O Lenders Name TOTAL:
y Lender's Address T f
a I sonify Ihol I hove rand Ihia npplicmion and sale thw the nhnvo infonnmion L BUILDIN F'
to cnrtcnJ agree to cnmplY with all city and county orJinanws and store laws reletingm QTY. MECHANICAL PERMIT FEE
V Z building construction.end hereby ardmriu represenmtivesofmis city usenarupon the SHISM]f FF.E
ahave-mentioned property for inspection fampe.s. PERMIT ISSUANCE
(We)agree m save„indemnify and keep harmless the City of Caper inn against ELECIR E
liabildies,judgments,costs and expenses which may in any way accrue agairnt said City
in oresegoence of me gaming of this permit. AISF,R OR ADI)TO MECH. PLUMBING FT
APPLICANT UNDERSTA�AWJLLL.Y WITH ALL NON-I'OINT AIR HANDLING UNIT(TO IILWO CFM)SOUtnCEREGULATI�%yMECHANICA PLP,V/ AIR HANDLING UNIT(OVER 10,11(111 CFM) CONSTRUCTIO, TAX
Signature of Ap a IAannr e47 Uat/e T? ST HCIO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant one or A nllehneurdons mmerinl I 1 GU ),OBIIH 1
as defined by the Cupcnin,Municipal Code,Chapter 9.12,and me Health unA Safety
Code,Section 25532(x)? IA NG IT(OVERLOO.pknl
C]Yet, ❑No ILA I L PAID
'~c / J Date RecciptN
or LIIDS,ndLdlOg occupant sex equipmem or devices which a
tit idea, •�minams us defined by the Day Arca Air Quality Management BOILER-COMP(3HP OR I(XI,(IINIP T AI
District! s`
❑Yen 7 N _19-COMP(OVERIW,NX)RTU)
I have read the harallous materials AIR CONDITIO
requimttenb utMar Chapter 6.95 of the Cali- ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 undemmnd dead me NEW RESIDENTIAL MECH. SQ.EI. O s�
b tiding drcs not dy Bate� t tat my responsibility to notify the occupant D f
at w est n fi
a cnte I m. 2-2
Owner<Owner< o�maiwni du�gent Due TOTAL: ISSUED BY: `3g A
__ _ OFFICE