S 0466 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUDDm'G-ULLCTRICAL PFg TT NO
BUILDING DIVISION APPI,ICATION/IaERMIT PLUMBING-MECILwICAL 0 4 6 6
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING kill � TR✓lu�
OWN1L Cc q
ev31y's NA�JM,,R PHONE: CONI'RACTOR'SNAME: LIC NO:
Itt" - F,s A, STC-)Z s .Ff1. S' OC $ N/c CON]'Rill,If
ARCHH ECT/ENGINEER: LIC NO: ADDRESS: _
CONTACT. PHONE - .BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I .DG F. :CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Q'py ELECTRIC PERMIT FEE UESCRII'TION
1 herebyaffirm that I am licensed under provisions of Chapter 9.ommerism,
OW=ZO with Section](XID)ofoivisionJofthe Businessland Professions Code.andmPERMIT ISSUANCE:
ylicensc is RESIDENTIAL
zul- Lifull carrefarce Class
eRed. ❑SPDWL ITCHEN REMODEL
Ft. U Lreen.w Class Liaa - APPLIANCES-RESIDENTIAL []ADDITION AMBINGRE-PIPE
0. Dam
N< Cotnmctnr
ARCHITECT'S DECLARATION PANPIS ❑MI1LT1-UNIT []STRUCTURAL
O w smy,lann shall he used nn Whdo records k10DIFICA'TION
ZI undctmnd
Orvr�]� UPTO200AMPS
OZaq [I INTERIOR [I CHIMNEY REPAIR
Fin w Licensed lnd'c,sinmd 201-100OAMPS IMPROVEMENT E]SWIMMINGPOOLS
4 y OWNERAl11LDIiR Uf:C1.ARA'1'IONOVER 1000 AMPS ❑RATE RE2100GUR2f: IR DFiMOLITIO
g a 1 hemby affirm that 1 am exempt from the Commdurs License I...Inc the onOTHER
iF
O W U following reason,(Seoul.9031.5.Business and Professis Cole:Any city or county SIGNS ELECTRICAL {—T-`
31i F' which requires a permit to consen t,ulmr,improve,demolish,or repair any swcmrc
^u'O prion,its i.....ce,alsorequiresthe...heart for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
F, Vo that he is licensed pursuant to the provisions of the Commoner License Law(Chapter 9 j
o� COMMERCIAL
WCCO (commencing with Section 7(W)of Division 3 of the Business and Professions Ctdc).1 TEMP.METER OR POLE INST.
Q.CL c�, that he is exempt therefrom mal the basis for the alleged exemption.Any inimical.f ❑NEW BLDG/ADDITION ❑DEMOLITION
" woe Section 7031*51y nnyaFliarom forapemtit suhjeasde applicannoarml penally of POWERDEVICES C1 TENANT 01'001)SERVICE
t more than five hundred doll..(5510). IMPROVEMENT
ZaOI,ere owner of the pmpenY•nr my entpinyccn with wages ns their sole rompcnsati,n, SWIMMING POOL ELECTRIC ❑OTHIiR
WW will do the.... anJ the nmcwreinnrn imcndeJ nrnacreJ fnr,ale(Scc.9fN4,Business
de:
and Professions CaThe Contracmis License l.aw does not apply In an owner of OUTLETS-SWITCHES-19X'ifiRcs
properly who hal Ids or impai ms ihercon,ant]who docs suit)work Introit or through
his own einplo,mx,provided that such ingtovcmenm am nut intended or offered lin NEW RESIDENT Al,I?I.IiCI'R SQ
sale,M however,the building or improvement is sold within one year ofcompletion,the
SQ.lel'.FLOOR AREA 5/SQ.PI'.
cosom-buildi,will have the burden of pmving too he did not build or improve for put.
1,o over of Ne progeny,,B exclusively Protracting with licensed mel stmen it
antamm the es not (Sec.]1144,Business and Professions Ws Corr,:)The Can aims.and
- - - //,�I
c ncl.uwd«sroapplYroan with
aofpropenywhosed or improveetbetmov unJ QTY. PLUMBING PERMIT FEE �'I A
who n,mmeta for such projects withacnmracetgs)licenced pursuam it)the Comrvcmrs w C/
License Law. 1 PERMIT ISSUANCE P
El lam exempt under Sm. - ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) �� ,YyUATION
Owner Date - u
WORKER'S COMPENSATION DT:CIARATION BACK FLOW PROF[TCII DEVICE L(/�.0 V�V
• I have
hcrthy affirm under ptntdty of perPny one of the following dcclamdoms: ayY/
and will maintain aCertifcmc ol'C,nmmt toself-insum fnr Workers Compcn- DRAINS-FLOOR,ROOF,AREA,COND' STORIGS 'I VI'13 CONS'1'NUCTION
,anion,as provided fnr by Section 39(10 of the Lots.,Code,for the performance of the
work far which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensntinn Insuranceu as m mal by Section
31110 of the Labor Code,for the performance ofihe work for which this pernot is issued. GAS-EA.SYSTEM-f INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier unit Policy number are:
Cartier: Policy Na: GAS-EA.SYSTEM OVER 4 WA)
CERTIFICATE OFF EMPION FROM WORKERS' GRGSFIiNDU$TRL WASTE,INI'ERCF.PNR
COMPENSATION INSURANCE. BUILDING ION FEES
DIVIS
11
(This section needrim M mrsplemd ifthe pe.,I,is turner,hundred dollars(S100) CREASE.TRAP
.r less., read
1'LANCHECK FF.F.
I crifythatioda,mrtomtance ofthc work far which this permit is issued,I shall SEWER-SANITARY-STORM EA,200 FT. HN
nut em y LICANT'IL Mier making thtc Cenil1 of Exe pw my Cnngcm GRADING
G H6
.,n in any amnneraoa,inl ca
on
Kt �%ppliarh ectyw WATER HEATIiR WIVENI'lI1LEC'I'R (31XAUINO FF.F,
saRnn I ( Calif
th
icon
z+ t^ nu shnnlJ WATER SVSTF.M/fREA'1'ING
F hcenm the workers c,mpe..mbttt pr,viainn,nnnr,Labnm tale.y,a sons Isar:
u p ith such provisions or permit shall be deemed revoked. WATER SERVICE6
9L. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.TL PATO )me Receipt a
U O There y about that hem is o cunxvuNon lending agency for the importance of
U. the work for which this permit is issued(Sm.31197,Civ.C.)
TOTAL:
TOTAL:
O V lenders Name
W Lcndets Address
1t 1 minty that I have mad this.,,fiction and sone that the above information is BUILDIN 'E[
W) a,rect.l agree to comply with all city and county ordinances and state lows relating(1) QTY' M ECHANICALPERMIT FEE SEISMIC FEE
U huilding madmninn,and hereby authorrrc representatives of this city m enter-No the t -
uhnve-mmati,neJ progeny fill inspection pugtnsex. PERMIT ISSUANCE IA.Ecrimc FEE
(Wo ugm,t.save,Indemnify and keep humilis,the Chita Cn,,Iino sternum
liahilitics,judgmen.,cos..md expenses whichntny if..,emy.mam.,mm,t,md City ALTER OR ADDTO MECH - PLUMBING FEE
onemuemce fthegramingoftblspermit.
APPLICANT DE LANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10.0111CPM) MECIIANICALFEE
SOURCE RF i IAT} NS.
1111 AIR HANDLING UNIT(OVER W.000 CFM). CONSTRUCTION TAX
Signature of/ I-ant/Cunuamor ale EXHAUST HOOD(W/DUCI} HOUSING MITIGATION FIiI:
A(/ HAZ RDOUSMATERIAISDISCLOSURE
W t cap scant. mance Wilding tccupam mare or hanJlehamNon,.. viol HEATING UNIT QO IIXI,IXXI1f'IV)
as defined h)the genion Municipal Gxle,Chuplcr 9.12,end the Health and Safely -
CndaScetlon 55 (a)9 1 IHATING UNIT(OVER 100.001)BTU)
C]Yew - - El No VENTILATION PAN(SINGLE RISID) PAID --
Date RePalnt
Will the applicant orfuture building a......I use equipment or devices which BOILER-COMP(3HP OR 100.00 BTU)
emit Wourdnus air contaminants u,defined by the Buy Arca Air Quality Management '1'OI'AL:
•L'immm,
BOILER-COMP(OVER 100.001 If FU)
Cl 1:1 No
have read the hazvdous materials anuirtments under Chapterb95 of the Cali- AIR CONDITIONER ISSUANCE DATIi
&Safety Calc.Sections 25505,25533 mad 25511.1 made.tamd the if the NEW RESIDENTIAL MECH.
ma currently have a tenant,dint it is my responsibility to notify the occupied
—"which mon be met prior u,ovi.a of a Cenlbeam of omalso.y.
hodmd agent Data TOTAL: ISSUED BY:
OFFICE