S 0704 (2) ATTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL I'H§TT NO
BUILDING DIVINION APPLICATION/PERMIT PLUMBING-MECHANICAL 0704
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANI'T'ARY NO. APPLICATION SUIIMI'MAI,DATE!
U ( �/� (11(4 �7
NER'S NAME: I'I ONE: CONI R OR'S NAME: LIC NO'.
G CIIN'I'NOLp
C h'EL!:'GI,NEGR: LEE:NO: ADDRESS7/Z
: L b J ❑
/
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLIXi BLECT PLUMB MECH
❑ ❑ ❑ po
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arum mat 1 am licensed under provisions of Chapter 9 commencing JOB DESCRIPTION
QKZ with Section)Il(111)of Division 3 m dIm lhomes.and ltnfessions Crdcand my license iz RF.SIDFNTIAI.:
W O p PERMIT ISSUANCE.
W-EF in fun Torre ante G! S C? ZL2 ❑SI'DWI. ❑KITCHEN RIih1OUli1.
a_u License Class r Lic.p 7 / APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBING RI PIPE
o:<= Date TS DECL w 11CIN
'A CHITECTS DECLAQAhf(1N ❑MUI;TI-UNIT ❑STRUCTURAL
Z O Rs Z I undersmnd my plans shall theater.,public records PANELS MODIFICATION
OZ-C UP To 2W AhtPS ❑INTFRIOR ❑CHIMNEY REPAIR
W Licemed Professional 201-10DOAMPS IMPROVEMENT 0SWIMMING POOLS
C C C Q I hereby affma OWNEthat I R-BUILDER
exempt
rser he Contractor's License Law for the OVER I(N)0 AMPS ❑BATH REMODEL/Jy'{'AIR (]UEMOIHI4
3 F following real.(Section 7031.5,Businex,and Prolati ons Code:Any city in county SIGNS ELECTRICAL ❑OTHER —� �
y which requires a permit m construct,alter,improve,demolish,or repair any Structure
F E•Og poor its issuance.also requires the applicant for such proud to file a signed statement SPECIAL CIRCUIT/MISC.
fly that he is licensed pursuant to the provision.of the Contractor's License Law(Chapter 9
WCL�0 (commencing with Section t(XX))of Division 3 of he B.Noecsand Pnd®siom Cadc)m TEMP.METER OR POLE INST. COMMERCIAL:
E a o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDIV'ION ❑DEMOLITION
X^I'- Section 7031.5 by any applicant for a Permit subjects the applicant In a civil penalty of POWER DEVICES
m^w ❑IMPROV' Cl FOOD SERVICE,
m mare stn EVC hundred dollvrs($51X1).
F Z T IMPROVEMENT
_< will
La,do the waradthe thcoaay,ar,i, et intended with wage axaltheir(sole cont,Businesson, SWIMMING POOL ELECTRIC
W F.Q and
Professions
sions C d e'Me Core is not intended J nr aw dos not apply.t11M1.owner sit ❑OTHER
L 3 w and property
who builds G (it imc Cnmranm'e Lice me law Ines not apply to vex owner of OUTLETS-SWITCHES-FIXTURIS
property whooyesm improves thereon,and who Joel such work himself or through
his own however,
the provided hal Such mentis old w um nm intended or offered for NEW RESIDENTIAL ELECTR SU FT
sole If,hsnvever.the building or improvement is sold within one year of ummplelion,the SO.PI'.HOUR AREA S/SU.I9'.
owneolmilder will have he burden of proving that he dud not build or inmreve for pur- M
P A
Oso 1uf eowo` of The propury,v xrlusiwly a,a,...in,with licensed cuntmemn o, T Ifs
moos the pmjua(Sea 9014,Huxlnesn and Prol'n,ions Cade:)The Contractors Li- 4 �� pr/Iryk
cerse law doe not apply too owner16 INYXI
of properly who builds or improves hereon,and QTY. PLUMBING PERMIT P. F4LL1V:Uu
who c mtrnet Leitch projects with a umlmeltaW licensed punuo
uavthe Gmmmnd
n
License Law. PERMIT ISSUANCIi
ElI vex ex,npt under Sec. .11 h P C lar This m;....n Ci TTY Ur lrUYtl'1 I IPU
Owner Dam
ALI'BR-DRAIN S,VENT-WATER(EA) VALUNI'ION
WORKER'S COMPENSATION DLCLARA'ION BACK FLOW PROTECT.DEVICE
I herchy affirm under penally of perjury one of the hollowing derl...donv:
I hove send will maimuin uCenilicale of Consent to ndl'in.urc for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. S'IOHIIiS '1'YI'IiCONS'fNUCI'IUN
nation,as provided for by Section 3]1X1 of the Labor Code,for the performance ofhc
work far which this pernmit i.Issued. FIXTURES-PER TRAP
1]1 have and will maintain Worker's Compensation bromine,an required by Section
3700ofthe Labor Cute,for he petfarmancc adthe work for which this Permit is issued. GAS-F.A.SYSTEM-]INC.4 OUTLETS OCC GROUT' AI'N
My Werke Cts991mPc'pNotion Iyrorance carrier and Policy nun f _
Cartier: '•97Z u. / . Policy Nn.:/L IL TS' jy GAS-F.A SYSTEM-OVER 4(EA)
CERTIFICATE.CATE..OttXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thinseetion need not be completed if the pemmil in far one hundred dollars.IS 108) BUILDING DIVISION PERS
or less.) GREASE TRAP PLANCHECK Illi
I cenifYlhat inlhe perfannanceoflhc weak far which this permit i,i...oc shall SEWER-
ymannersoan j SANITARY-STORM EA.2110 F'K
not employ any person in an 1st Mnmmc.wh ca em me Workers' ENERGY PIi13
O Z Nation Laws of C.liondit.Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
.OLIN NOTICE TO APPLICANT:IL after making thin Cenificalc of lixmnption,you should WATER SYSIEM/TRBATING
> become subject to the Worker's Compensation provisions of the labor Code,you must SOLI S FEM
DJ 04 forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
5 Z CONSTRUCTION LENDING AGENCYNF.W RESIDENTIAL PLMD. SQ.FT PAID
V O (hereby affirm that in a comtruction lending agency forhPerformance e Perfoance of Doc N -ipt
H. F' he work for which his permit is issued(Sec.3097,Co.C.)
0Lenders Name TUFAL:
WLenders Address TOTAL:
0. 1 certify that 1 have read this application and slate that the above information is BUILDING PE
h cover,l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL.PERMIT FEE
U Z building construction.and hereby authorize representative%of this city to enter upon the SHISMICF
above-mentioned proprny for inspation purposes.
(We)agree to save,indemnify and keep harmless the City of Cupcnino against PERMIT ISSUANCE F.LGCI'RIC FEF.
liabilities.judgments,cents and expenses which may in any way arcane against said City pLTEN OR ADD TO MF.CH.
in consequence of the granting of this permit. PLUMBING F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANIC/.FEE <s
AIR HANDLING UNIT(OVER IkyBd CFM) CONSTRU ❑. TAX
Signature of ApplicanoContructor Dam EXHAUST HOOD IW/DUC7D I IOUSINGMITIGA' ON I -E
HAZARDOUS MATERIALS S DISCLOSURE
Will theapplicantorhme buildingmcapant.tnr handle hazardous material HEATING UNIT(TO 1080X0 BTI)
as defined by the Cupvnino Municipal Cade,Chapter 9.12,and the...11th and 5afity
Code Section 25532(a)'/ HEATING UNIT(OVER 100.008 BTI)
❑Yc.. E]No
VENTILATION PAN(SINGLE RES[HE PAID Dom NeceiplM
Will the applicant m('mum building occupant B use equipment or Mon which
alt h rdnun coli<nnlaminunn as ddincA by he Iluy Area Air Quality Monu grmem BOILER—COMP(3HP OR I W.(XXI BTU)
Dixmctl
'TOTAL..
❑Yen E]No I BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
I have icdlhc hu rardmnmutcids reamaryianneath 1shl Chaple,r'a)5ofthe Cali- ISSUANCC DATChu rarduwneteiAs le,iamcnh u1shl ClnPler rt05ofthe Cali- ISSUANCF DATC
G..tia Health at Safuty Core Section,255115,25533 rd 25534.1 and rswnJ that it he NEW RESIDENTIAL MECH. Sy rT.
huildir J0cs not currently hour.tc1anl,Ihtit is myar"ar,ihih"tonotify theata.punt
,(h• . cmenn which muo,k,o•f pJano�swomcola Cemicmnl fau'amy.
Ow c num n c agent pro TOTAL: ISSUED IVY:
OFFICE