S 1284 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO APPLICATION/PERMIT BUILDING-ElAiC'IRICAL PE 1''NO .V-TBUILDING DIVISION PLUMBING-MECHANICAL 12
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BUILDING=PROJECT Ill IItFICAT10Nd
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1"fAI.DATE
CONTRACK I2S NAME: I.IC NO:
MAj*T N/C CANTROLtl
ARCHITECT7F.NGINEER: _ LIC NO: e ADDRESS: _ ❑
CONTACT: PHONE:' a t" '' 'BUILDINGTERMIT INFO '
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLIUUMM13 MECH
t, ❑ ❑ D - ❑
IICt NSFD CONTRAC I ORS DECLARATION TY ELECTRIC PERMITS .. i .�t FEE; '
In by n that 1 d p fChrpt 9( s Q •f JOB DESCRIPTION
G4•Z win S i 700lofU " 3latents dProfessions Cde and m3 license's RESIDENTIAL-
in
ESIDENTIAL' -
W O PCRMO ISSUANCE.
F ly� ofail fdffA. ❑SFDWh ��KITCHIiN RCMODEI.
�UV
License
less _ Lic# APPLIANCES-RESIDIPSUAL ❑ADDITION- - ❑PLUMBING RE PIPE
W Data if
Cmnradnr
¢PP.• ARCHITECTS DEC gwFqrN ❑MULFFIJNIT. EISTRUCIURAL
Zp�7z I understand my plans shell be used as Public recnds PANELS _ MODIFICATION
OZ-� UPTO 20o AMTS Ll INTERIOR _❑CHIMNEK REPAIR
H Cr4.E]W Licensed P..Hainut 201-1000AMPS IMPROVEMENT _ ElSWIMMING POOLS
gp; OWNHIt-BUILDER DECLARATION OVER 1000AMPS ❑BAT]I REMODEUREPAIR 0DEMOLITION
^d I batch,adorns,I ame
�Dxantpl limit the Centuremna License Low turns yU followingmason.(Section DDL5,Braine—rad Professions Coder Anycilyorenunly SIGNS ELECTRICAL f?OIHLR
�3Wywhn requires a incrandl Yafter, p demolish, , ).sone
p,I Wo lsucqmaa,n pre II hP .I to file L da erami SPECIAL CIIICUI'DMISC.
y
but IP 1,fla,uosorriah C 1 Law Cape,
�a� (eo tenng s With Sam m 70f3(0nrDvumn Softhe Businessand Professions Code)or 'ICM P MB FER OR POLE I NST 'COMMERGAI: -
a pt o a that he is er empt Ilmrerrom end tM1e nasi.finite alleged c.e rdion.Any violation of El NEW BLIIO/ADDITION El DEMOLITION
W ti V,, Sectam 7011.5 by any applicam fill a panni,ansenls the applicant o:a civil Penalty of POWER DEVICES 0 TENANT ❑FOOD SERVICE
y national than live hundred dollars(55001. IMPROVEMP:N'1' "
�d 1,a, wacroflhcn CTRIC
pmpe y.or my employecv with wages as their compensation, SWIMMING POOL ELECT
.O ill do the work,and the s¢ are uais not intended a on rusi beside(Sec.9044,Business ❑O'IHIiR
w ,
mand Pmfes.. as Code:The Count License Law does'her apply,o an owner of OU'I Lt.I's-SWITCHES-FIXTURES
property who mi Ids,,,reprove,thereon,end who does such work himself or through
his own ennployces,provided that such improvements me not intended or offered for NEW RESIDEN'l Al.ELECfR SQ IU'.
,aleIf,hawcvm,the hailding or impmvemmn is sold within oneywr of wmpI t";,lb, SQ. � .00RAREA $/SQ.PI'.
er-huilder will leave the burden of pmvfng Thal he did not bold or improve mz par- _
lose of sale.}
0 1,as owner of the pro'do,am exclusively col meuny with;irar.d contractors to TOTAL:
,trodoct th P ,.1 I Sea,7044 N_ d Pomerania,C I )I he Contractor 4 IJ- S.
Law'does not apply l t propstarty won builds or radiancestheratan,and QTY - PLUMBING PERMIT, PEP. r
wn mreusloe t,hlr leas with ae mntn(s31'unsulp .avow the Ctmn ern rs
License Law. PERMIT ISSUANCE O
O l am exempt unlc,Ser. ,B Y P C births rcawm
Owner Data
ACI'ER-DRAIN k VENT-WATER(CA) VALUATION
,
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTHCT DEVICE
I hereby affirm under penalty of Perjury one orthe following declareGnne
❑Ihave,mdwillmainuinaCerlifiwaof G�nsenttnselr-insurcfor Worker's Compen- IIRAINS-FLOOR,ROOF,AREA,COND. SfONIHS 'I'YPECONSTRUCI'ION
sauna,s provided for by Section 3710 of the Lahnr Code,for the pedoroance of the
walk rnr which this permit Mother, FIXTURES-PER THAT
have and will main win Worker's a n e of
e w work
for which
h required by Section ,
l ufthc Labor Code,loathe performance of Ne work for which this Pamil In issued. GAS-EA.SYSTEM-I INC OOU'fhF.TS OCC CROUP AYN
Work sgCgytpynlati,p 1psurnnce�cam recd Policy nun �p
' Cartier. 4—IJ ePoliey N,:Q� n^��I�� CAS-EA.SyXI1FM-0
CdVBRd(EA)
CPJtTIPICATF.OP P.XEMPTION PROM WORKERS' GRHASMvIll115TRL WASTE IN'r13RCFJ•rOR
COMPENSATION INSURANCE 6Q14OIjJGIIIiVLS10N 17E1}.S
(Thisxwtlon need not be,ompleted iflnepermi,is rotund handral dollars($100)
or loss.) GREASE TRAP PLANCI HECK FEE
Ie,nify that in the performananfthe work Car which this pet itis issued,(shall SEWER-SANITARY-Sri ORM EA,200 IT, "
ml employ any person ie any manner so vs to become...asd or the Workers'Compen- ENERGY FEE
Zi -sntion Laws of California.Dam WATER HEAl FR W/VP.NT/P.LECTR
Q Appheant t GRADING FEE
r% NOTICE,TO APPLICANT If,after making this Cerlificaie of Exemption,y,a should WATCH SYSTEM?BEATING -
f"I N Iwcnme sonjeetm the Weaker'a Compscron nn provisions of Inc Let.,Care,you must SOILS FEE a
forth%iln comply with such provisions or this panto shall be deemed revoked. WA'PPB SERVICE
61Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,FT. PAIU t
UQ I barely affirinlhal there is same...for lendau,ngency fill the Pcifnnnwnmm Dam eipt
ma
the work for%Inch this permit is Issued(See,3097,Civ.C)
0 I"I Lenders Name TOTAL k
L) Lenders Address TWA
y[' 131
T.wi
am hrformer
S . •.
BUILDING t" UrI rtyN lJ ) o Tt that n Information 1 1
correct,tomply 'n all a an ty ordinances state btotaling to QTY' MECHANICAL PERMIT PEE
V 7- nn I1 g construction, d h any vmnoiz P c enw,ve. fN u'ty vU
Ino len po she SEISMIC CGh
anovnmwm,ned property for inspection perl PERMITISSUANCE
(W,)agree to save,indemnify end keep harmless me Coy,f CnP�mu against ELECTRIC FEE
liabilities judgments,costs and expenseswhicbmay in,my way uccmeagaimt said City ALTER ORADD TO MECH.
'onseyuarc ofd,granting of this permit. - PLUMBING FEE
APPLICANT I' E NDS AND WILL COMPLY WITH ALL NON-POINT
A IR HANDLI NO UN IT(TO 111.000 CPM)
SOURCANI L ' l) - MIiCIIANICALPEN
�g p� AIR HANDLING UNI'r(OVER 10,00(0 CFM) CONS'IR0CON TAX-
Sig alum ofApplicn ntradnr Dante EXHAUS'If 1001D WIDI JCT) HOTS ING MIIGM ION FEE
HAZARDOUS MAIfl RIAI.S DISCLOSURE
Willtheapplicant or future mildingxeupant.tme or handle almobmnatenal HEATING UNIT(TO 1f10,IM3(113'PU)
its dclined by the Cupcnlno Municipal Code,Chapter 9.12,and Ila Health and Sandy
Cocks Section 25532(,)? HHA'I'INC.UNIT(OVER 1001)1111 131 U)
L]Yea T]No VEN'III.A'IIONFANNINGLEREMD) PAID -
Data Roa
Will the ,r metrebuilding all ea iwhich 1U
emil nmrdousaur contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(31POR IIN,1109TO
TAL:
Disnie7
Vers No BOILER-COME(OV ER 100,000 BTU)
- ❑ - -
Ih,ne mud the hazuNnuv mmenols�timnadls audio Chapter AAIR CONDITIONER 95 of the Cmll- - ISSUANCE DATE
fomia H,allh&Safety Code.Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MHCII: SQ.Ef- �1 2-q0A
building Nus not currently have a tenant,that it ism,acspensibila,to notify the LmtmPam U
of fle w,hu mems which must be at print to i...wa,e nfa Ccnificua of Occupancy. ,
Owner m inflmn,ted.gent Dam T(YI'AL: ISSUED BY. t .�
OFFICE