S 0705 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0705 7 0 5
BUILDING PRU,ECT IDENTIFICATION \J
HUILIJINGADDRESS, SANITARY NO. APPLICATION SUBMITTAL UNil;
tis;lij _5• DW :R'f
NV CONFR 'IY) 'SN M" LC NO NIC COM'HDLM
'r ARCI Tit n3N(A EER: LIC NO: ADDRESS
'IiCONTACT PHONE: BUILDING PBRMITINFO
❑ Consultant Foes Paid by Applknint(Inulol) BLDG
LICENSED CDNI'RACIOR'S DECLARATION QTY ELECTRIC PERMIT - IEE ❑
I hereby aninn font I am Iuemd made,ptoviarm of Cwvue,9 oem.etcmg JOB DESCRIPTION
WOO with Sectim] i)(ft e'Diskiem 3 of lbe Businax vtM Prnfesnma Cnde.erd my liceme is RESIN
PERMIT ISSUANCE
WOO
in full farce un�tR ,@,L`. 3 ❑SIUN'L ❑KITCPLUMBING
RIi E-PIPE
b G Data�¢�—77V7
L//��'�� /���.�� Con meta APPLIANCES-RESIDENTIAL CIADD T ON ❑PLUh1BING R&PIPE
i ' - '/aNh HII1:LT$Dli ION ❑MULTI-l1NR ❑STRUCIURAI.
w PANELS MODIFICATION
ZO Z 1 undamud my phos shell he used ax public raiNds
OZ O UPT0200AMPS ❑INI'F.RIOR ❑CHIMNEYREPAIR
I LicensN Pmfcsxiavl 201.1XXIAMPS IMPROVEMENT SWIMMING IN K)I.t
ger P-� OWNER-HUILDER DECLARATION OVER I001fAMPS ❑ DE1 BATH REA10jiPAIR DCA OLITIO '
"'W Q 1 hereby affirm that I am exempt from We Cuntintem x Licrnse law for the
V fallmwing r¢san.aSe<tinn T1J15.Busirhw and Pmfeuitm Csdc:Any city n aunty SIGNS ELECTRICAL. D(TIi{FR
XC'
1x13 a which requires a patrol,to conslmel,chat,impose,dmm,nM.or repdr any structure
F-�O Priaw its i.ssuance.LL.o rcyuim mati,icmnt fnrntcn permun File exignal.aavhrnt SPECIAL CIRCUITIMISC.
SSS } tMrwic liccmd Purusenl to the provisions of the Canhncar's Lintuslas(Chvper9 COMMERCIAL
O (mmnrncingwith Sewlsm 70diHof DIVom 3ofthc Bee, au eeasaRofaesionsCodc)ur TL'MP.METER OR PALE NST. Ile I
a aa a� roar he is eaem d marcome and the basis for the alleged!exemption,Any vies-mon of ElNEW BLDG/ADD HUN El DEFIOLITION
h
- Section'l01 lS by any applicant for apeeetdt wlycca the applwsnt 10•civil Penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not more hone five hundred dollars H50pi IMPROVES/ENT
�I,us owner of hhr Wapuny,axnhy amPN'yces with wages an lhcirwle srwtprnwtion, SWIMMINGPOOLELECIM1tI
=SO will do Re w,.,mrd th eWeture u m intended or offered for.vale(Sec.'IOM,Bouneu [I OTHER
F
L3 ad Prnfwn,h Crdc:Thr0 is Licensealso does
wvkplytolr ,whoa,of OVf1.E1S-SWDCI{i!S ES
pmpany annn wIIJs or improvesthhhmch vol wtto dtas ouch work hmwif ci IhnugM1
bit own empbyem,Pori toot such hent is hent are m immdd or offered foe NEW RESIDENTIAL EI.ECI'R
sak.If.M'ever.the wilding ax imptmrnrnt issold within are Year of compiniart.the SQ.FT.FLOOR AREA g/SQ.FT
cr-huider will here the burden n(Waving that rte did out build m improve fur Wer-
pre of-al'.L
m
0 1,u earner of me propertaexclusively convening with licensed emuaun to TOTAL
y,
unarvct the mejert(Sec.7H4.Business'and Rofnssinev Cn a:)One Gmem—LJ- I- o
tt,Law'Iacsm apply to an Asocrof property whobui or-improve pies,and QTY, PLUMBING PERMIT [ZEE
who mntracrs for catch pmj¢a with a mo memo(s)licensed quvuN to IM Comrentds 0 f
Creative Law. PERFIIT ISSUANCE {I 16
M I ran exempt under See .It R V C lir Nis rrtvam
ALTER-DRAIN&VENT-WATER(EA) Cp Vr nLUAT10N
Jearrer Date
WORKIiN'S COMPENSATION DILCIARATION HACK FLOW IB(llliCC.DEVICE �ur�hJJJ ( O,
1 thereby allitm undo paaalty of perjury core,of the fnllmring dealamrwm.
F1 I have ad will meionon a Ceniricer olCamsmuo valf-inwre for Worler x Canadian- DRAINS-FLOOR,ROOK ARHACONI STORIES TYPE CONSIBUC1lON
as poi For by Section 3708 now Lalwr Code.for the Temor ane of the
wort for which bi,Permit In issued. FIXTURES-PER TRAP
&I buve and will anemone Workda Corn iturat.Insurance.as oatmeal M Section
oftne Lubin Carter,farms crfrmvreoftbe work far w1iahthis pcmuns tewd. GAS-PA.SYSTEM I INC.4 OUTLETS. DCG GROUP AIN
My Wooer' Com Pu cation Iry ,came, al Policy nm
yy v:
Ceenee�!/rYse Policy Na.: � GAS-[A.SYSTFJN�oVERJ(IA)
CEIRTHIPTCATE O .%EMP ION FROM WORKERS' GRIASEIIINDUSTRL WASTE INTERCPPIDR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(TdOxaftonrcdm hare,leted ifRr prnnit Lstwmr hunlmlaWlen 151(X)1 GREASETRAP
a Icsa) PLANCFWCK LLE
I certify that in the peHornwncc of the workfor is Inch thin panni l is issued,I mull SEWER-SANITARY-STORM flA.NMI IT
am employ any n
y paon in any n® ow
er m as to beenver a njaho
t to e Warkenv'Compen- ENERGY FEE
Z smith laws of California Der WATER HEATI'R WIVFNTIEfd-CTR GRADING RI:
Z 2 Applicant -
N NOTICE 10 APPLICANT:If,after making this Certificate of Exemption,you sMwMl WATER SYSTEMTREATING
F ^� become wbjcct to me,Worker's Cuet�emntkn Wovisim n of the Labor Code,you must SOILS FE[
ret. fnnnwith comply with wen prnvis:ns or thin Permit Incl)be dccnrd invoked. WATER SERVICE
D Z
CONSTRUCTIONCoro LENDING AGENCY NEW RCSIUIiM1AL I'LMB. SQ.FT. PAID Dac g
L) O In...whilimhtluttttere is ond] 1097.nwg agercyrah hoe pe,fneetaere of
L'. 'ha wxk❑rtwhim cisp:mnh is Lsxixd(Si(S31rv).Civ.C.) TOTAL:
I" Lander' Name
L) Isvdcrs Acetate; TOTAL:
I cmifY hem I neve readthin apploa ren and un,a Ihet the gibes,informalion is BUILDING ITE
V�1
conat lagream<,Imply with all city and county afdinant and awe Paws refining it) QTY. MECHANICAL PERMIT FEE
V Z buiblin,croswetiv.mind bertbytuthave mprescuetiva.Trois city minter upon the SEISMIC FE
above-mrtioned lrMteny urmspccom pm — I PERMIT ISSUANCE
(We)agm:m save,itdemmry and keep hmmlees hh City of Cupmom ageing FJ.T;CIRIC Rif?
Iiabilitiajudgntena,coats mrd expenses which mayinany way accmevgairt4 said0l, AI.TF.R OR ADD TO FIECH.
in emsnpterce of the'homing of Rhin permih. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PLIM' AIR HANDLING UNI'I'(TO I(L0()CC1,7 MECHANICAL. 'E
SOURCE REGULATIONS.
AIR HANDLING UNIT LOVER 10.000 CI:M) CONSTRUCII( TAX
Sigewure of Applicent/Camtractor Date E%HAUSTHOOD(WDUCT) HOUSING'NIMGA FEE
E RDCUS MATERIALS DISCLOSURE
Will thet fiant...noee building ocapnum user,hatdk waandous material HEATING UNIT(TO 100,000 HIL)
as dcitral by the Contemn)Municipal Cade.Chapter 9.12,and the Health ad Safety
Code.Secdon 553200? - HEATINGUNTOVER I010,000BTU)
r7 Yet, 0N VENTILATION FAN SINGLE R I!SID) PAID Dara Rcccip
Will the slvoicvu or future building oneu,net use equipment or devices which
emit M1avrdws air contaminations as defireal by Rsa Bey Arca Air Quality Mvugemam BOILER-COMP LHI'OR 188.000 BTU) TOTAL
IEurkt? BOILER-COMP(ONTk 100,000 PTU)
Dyes C]No
AIR CONDITIONER
I have reed Phe Mrudlux nuterials ral mo,ov e"under enapte,x'95 of thin Cul- ISSUANCE DATE
fermis Eeehh H Slaty Cade.Satimw 25585,25513 and 25534.1 unL said Nat if the NEW RESIDENTIAL MECH. SQ.ET.
M1midtng dors not currently have t rewv,that it is any ex"insihiliry to mify Rte occupant
Mt mfiremana which mum Ee ort prig to ieaene of a Certificate of(kupenoy
( or.1dindrd egret steep TOTAL ISSUED BY,
OFFICE