S 0506 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELKCFRICAL PI? TT rvo
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-NIk:CHANICAL 050,6
1 BUILDING PROJECT IDEN'I'HLCATION
BU1LDINOADDDJRESS: 'n I SANITARY NO. AI'1'LICAI'ION SUBMI"FLAL DAI'li
Ap/ly_ q
OW E ' N `Ii{}Vfj _��? C HACI' R'S NAFN'.: %IC /'I�S
WW L(.�f (O V (� y NIC CONTROLN
•ARCHITHCVENGINEER: - LIC Isl - I)Hh.S$gA - _ ❑
CONTACT: BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) I
BLDG EIEC' P MECH
LICENSED CONTRACTOR S DECLARATION ARATION ! e l ❑ ❑QTY f { CCECTRIC PERMIT I 1 n ny mon m r I E m.«I d p '" r ctr Pmr 9 r 'tmtt g :.. ]0E DESCRIPTION
Zwbns i ]t(xE ofD l rnIlm rte a Uroa((en:cdc,m y1,me. ESIDENTIAL:PI RMITISSUANCE.fllfm d Bcel'(iqj /,, gly SPDWI. ❑KI'I CHIN REMODEL
<UU Licens FJ x�Y �Lic M APPLIANCES-RESIDEN AUDI IION ❑PLUMIUNGRRPIPF.F-zW Dam�sj__�Q�__�Cmdrvcmrm<c. MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARA'1'I(m ' PANELS CHIMNCATION
zOr�,z, lundersmnd my plum slullMuxe as puhlic rccnNs UP'102fIf1AMPS IM F [ORROVE ❑CHIMNEY REPAIR
["-,y„I"Iy License)Pmfexsinml 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
dQ' '� OWNI4111 11LDER DE Ce Cnnt'ION OVER 1000AMPS ❑BAFII REM DL'LIRI?PAIR ❑ MO IO
Y�
6 1 hemny vffirm that 1 ran exempt from the Cnmmclms License Low I'nr the
XO: F. )city or county ❑OI'HI?R
FWOy following h 4rc. (Section]Gilt m Ire p Pr f 1 1 hede,or P rYwnare SIGNS EI F.CTRICAL III V%J
-
tan poor t t I req 'tn 'ppI tf such pc tt flsignedsttement SPECIAL CIRCfIII'/M111SC.
E} that he I . Ip pursuant t p fth C a t L I (Chapter9st
�p0 (n menc g Is lh Section 7000)ol'Dl vision J ofth lui:iirwsa ad ProrestiansUde)It 'I IMP ME TCOMMERCIAL
OR POLE INSI _
0,pie�e c that he is asv pt bacterium and the basis mor the alleged ancor,tion.Any v,alcl nn of ❑NEW BLDG/ADUI'I'ION ❑DEMOIA TION
WM Section 7031.5 by any applicant for a permii subjects the applicant to a civil preally of POWER DEVICES rn not mom Than five hundred dollars($500). ❑IMPROV El FOOD SERVICE
F=Q ❑ I...owner of the propene,ornry employees with xmgs ns their sole cnmpcnwtion. SWIMMING POLL ELECTRIC IMPROVEMENT
F will do the work.and the structure is not intended oromered for sale(Sm.]MY.liminess :TOTAL: ❑OTHER
nd Professions Code:The Contractor.License Law docs not apply to in owner of OUTLETS-SWITCHES-FIXTUroperty who builds or improves therum,and who docs such work himselfor through
his own cntploycea,provided tbm such improvements arc not intended ar oficred fnr NEW BESIDES I[A],ELECTR sale,If,hwever,the buildingor impoommad is sold within one yearofnvnpletion,theS T. L l! R. $ISQ.fT.
caner-huilder will navethe burden ofproving that he didnot build or improve fnr parpo f:I ),❑1 az Rh p pen,' nese ly r i g tde:)Tb eCo nrm t t moswm the es j t p o an li c.p and P f:: Cod ) pr ve mr re L'cert. L e t hplYi et r fp puny h h II rbP eC J QTYjr t / PLIJMBING PERMI'f �' o,PP.E
whoconnotes f udhpmJ tswthammt cmHs)htunedpun a the Coal raclors y 1
Livense La PERMIT ISSUANCE f'+�L'1'IIf1YV
❑1 am exempt under See. B&i'C for this mus
ALTER-DRAIN&VENT WATER WA) VALUATION
Oscar Date
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby umum under pennhy of perjury one of the following deuluraiI
❑Ihava TuN will maintain vCurTifeme of Consennn sclGinmre for WnTkeT§Cnmpcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'I'Y I'IE CONS I UCTION
cation,as provided for by Seen 37W of the Lahr Code,for the Perfunnance of the
work for which this wars in issued, 1'I XTURES-PER TRAP
7 (KC71 have and will maintain Workcls Compensation Immature,as required by Section
-.of the Labor Cade,for the performance of the work for which this permit is issued. GAS-LA.SYS'FIiM iINC.40UThEI'S
.GROUP APN
My Wor}'HS Contpen ti Jet r� apE d Polic 49 p� ere
Camer.""��M nn�T eVYLY,Iicy NUJ,3JK int�iii
:h 4% GAS-EA.SYSTEM LOVER GLA) '
CIIKLIFICATH OFCXEMPTION FROM WORKERS' OliIiASFJINDU51'li I.WASTE IN'1'IERCIEI'TOR
COM PI?NSATION INSURANCE? "ji111LDING DIVISION +Elis
('l his aeclinn need not be completed ifthe permit is fnr one hundred dnlian($IW) GREASETRAP
or Ices) PLANCFlI?CK FF.G
I certify that in the performance ofthe work for which this Permit is issued.)shall SEWER-SANITARY-STORM P.A.200 EL
not employ any person in any manner so as to become subject to the Workeri Compen- ENERGY FEF.
Z soling Lnws of California.Data WA'I'HR'HEATIER WNENT/ELF.CI'll
Q Applicant t - GRADING FEE
ZI NOTICE TO APPLICANT:If,mor making this Cenill,me of Exemplin I.you should WATER SYS'IEh1lT REATING
f, -iIxm
coe subject To the Worker's Compensation provisions of the Labor Code.you must SOILS FEE
[Xw forthwith comply with such provisions or NE?
is Permit shall be deemed mvused. WATER SERVICE
Q
CONSTRUMON LENDING AGENCY NEW RESWEM'I Al.PLMB. SQ,FT. PAID
r7 z Date Receipt«
U0kfier that i is aad(Sea ion 30Endimg n.) fnrthe p,rlivmnnce of _
F 'he wmk Na which this permit is isxueA(See.30%)],Civ.C.1
Ixndcr'e Name - 1'Ol'N.:
U Lender's Address TOTAL:
Ui. ti ' h
j
tl1LDNCFE
E0. I cemfy Net I have rent application tl h ta timing is _
fA drcctncomply with all city
and countyordinances d stateIs miming to QTY MECHANICAL PERMIT FEESitbuildingcomstmninn.and herenyvutndae reprevnmY e. ftbscity v corer uponte ISMIC FEE
above-mentioned property for impection purposes. PERMIT ISSUANCE
(We)agree m save:indcnmify and keep harnlesx the City of C,gcrl ngnin,T ELECTRIC FEE
Iiabilities,judguarls,costs and expenses which may in any way areme against sold City ALTER ORADD'Is)MECII.
I. nsequcncc of the granting of this Permit. PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IJANGLING UNIT(TO 10.000 CFM)
MECHANICAL FEE
SOURCE GUf NS.
/)_ ,/_ 7/��� /y AIR HANDLING UNIT(OVER 10.0(x1 CFM) CONSTRUCTION TAX
Signmurcal AillimulCormcner d FXHAUS'I'GOOD(W/)UCT) III EASING MITIGNI ION Ilii? -
HAZARDOUS MATERIALS DISCLOSURE..
Will the applicant or fnture building occupmn slur,or handle homrdom material HEATING UNIT('TO 100,000 BTU)
as defined by the Capetian Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING ONI'I(OVER IOL000]'TO)
❑Ym ❑No PAID _
VIiNTILATIONI'AN(SINGLE RESIDE Data ReeeiptN
Will the applicant or future hnildial nceupunt use eximiuent(I,devices which BOILER-COMI'(THP Ok IIHI,OfNI BTU)
emit Iazmdous fir cnnmminer s ns defined by the Buy Area Air Qnalay Management TOTAL:
District?
C]Yes In BOILER-COMP(OVER 100.000 BTIB
❑ - -
I have rend the Imard...mmevels requircmemn under Chapmr,695o use Cali- AIR CONDITIONER ISSUANCE DATE
found.Health&Safety Gvie,Sections 25115,25533 un 115534.fear smnJ that,the NEW RESIDIEN HAI.MF.CH. SQ.FT. l 1
building door nol,amemly haven mnunn that it is my respnn.smility to notify The acoupnm IVY_
of the T.gairemmax which mul be unci prior o issuance ill a Cenificutc III'Occillou . '
Owner or authorized agent Date TOTAL: ISSUIED BY:
OFFICE