B 0467 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILDING-MAH7I'RICAL PERMIT NO/�fe
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI 90 4 6
IIUII.DING I'ROJI:LT IDEM'IF'ICA'I'IOR
BUILDING ADDRESS: SANITARY NO. APPLICATION SIJBMITI'AL DATIi
5s I L� S-1— 5-`�,
OWNF:R:S NA E: PIIONH: CONTRACIOR'S AMC: LIC NO,
NIC CONTROL#
pRCHI'fECf/ENGINUAWM! VU RISIL .IC O: )D ISS', z ❑
CONTACT: Z/ HyQN:: - BUILDING PERMITINFO
(� � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
lwG
LICENSED CONTRACTOR'S DECLARATION s
QTY ELECTRIC PIiRMiT FEE
I hercny orlon tem].at Iircnaul,Inger mnvista,a...Code, 9 dom,narrea JOB DESCRIPTION
paZ with Stt'ILa 7C(p)ofDivisionJofthe Busi,msr and Professions Code,anJ mylicense is RESIDENTIAL;
IL OO PERMIT ISSUANCE
C-I" Wlllbrccand cRud. '� ler 4�L ❑SFDWI. ❑KITCHENREMODIH.
aVUU License Class.g.��6 Lia#—t - -C(.�� APPLIANCKS-RUSIOHNI'IAL ❑ADDITION ❑PLUAf IiINf RE-PIPE
y<0. Date Contractor
• - ARCIIITECTS DECLARATION � /AA411 PANEM �I ❑MUTA 1-UNIT ❑S'I RUCTURAL
Z O y Z 1 aj;aaml y plans shall Ixaused a puhlie rccnNs MODIFICATION
OZ-.Q - IJP'fO2(X)AMPS I []INTERIOR ❑CHIMNEY REPAIR
F��LLI Licensed Professional 101-I000AMPS IMPROV13MENT DSWIMMING POOLS
OWNER-HUILDIiR DECLARATION OVER 1000AMPS
C fH REh10D1iURIiPAIR ❑DI%MGLD'[ON
6 1 hereby affirm that I am exempt from the Contractors License Law Por the ❑(#'HER
O'L V following reach (Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
LL13 u•F which nw.ims a permit m connme6.liar,improv.,demolish, a repair any structure
O prior to its issuance,also requires the appliam for such pe,mitt ftieasignedsramment SPECIAL CIRCUMMISC.
Inet he i.s licensed purse onto the prrvixinnv of the Gmvacmr's License lrw(Chapter9
IYpO (commencing with Section]IMXp of Uivision3 ofthe Business dPmfexaia..Collator THMI'.MI:IF.R OR 1101.I7 INST COMMERCIAL'
that he is exempt therefrom and the M1sis for thea ed axe rico.A violation of ❑NF.W BLDG/ADDITION ❑DEMOLITION
Section 70315 by any applicant far tsuhjec t pli Inn civil pcnaltyof 1'OWHR DEVICES ❑IHNANT ❑FOOD SERVICE
not roam than Five bun dollars IS a).
F.ZY IMPROVEMENT
C 6 Lwinsurroffle ropeny,or by twit wag sae tiairsole eompcnsaion, SWIMMING POOL L'LECTHIC
2 C will dothework,an the s"'I is no' nd ora ere nr sole lSee.704,4,Business O ❑OTHER _�,..�
and PrnleW is de:The Co trannr L, .e Law Jas nm apply m on auner.f OUTLIOS-SWITCHES-PIXTURFS (�"�'��' —�
.. pmpeny who h Bar
iia a Them end who does such work himself or through t I +
his own emplu ., , as N h allow
are not intended ur offered(or NEW RFSIDF.MfIAI.ELECT SQ FE
sale.Khuweventhob Ming prim rvemem is soltl within one year n[rnntplctiam late I� FI'.FL(IOR ARRA 'S .IT.
r-hmildcrwdthme banderol proving Nalhe dmnm build nrimpmve fm par I4 Y 0 5 199
,ow.f sola.), _J MAY
❑ I,as owner of the pro ny,em exclusively contracting with licensed cnnwnnn to - L: �Sf 11
construct the es not o an owner
(if and properly
who hu Cade.The vet thermr's
c se Law does such
acus 4th. ofpropeny who licensed
ramp to
Contrmand QTY. PLUMBING PIiRMIT - FEE
cel a contracts for such pr.jens with a nmtrvctor(p licensed punuwuo the Commctor's Bid
Lice low. PERMITISSUANCE Q
❑I am exempt under Sec. .H&P C for Nis mason
Owner Data ALTER-DRAIN&VENT-WATER(EA) /,1 VALUATION
"Pum
COMPENSATION DECLARATION HACK FLAW PROTECT.DEVICE 6 o -\
I hereby under penalty of perjury ane of the folhwmti
ing decloens: LJ
•❑ l have and will maintain a Certificate of Consent in self-insure for Workers Compcn- DRAINS-FLOOR.IIOORAREA,GOND. S'. RIGS
perTYPECONS'IAUCTION
smion,as provided for by Scclmo 371X1 of the Labor Code.fanm
he perfolance oI the ,^ 1
work for which this mit is issued. FIXTURP_S-PER TRAP 0 ' /N
❑ 1 have and will maintain Worker's Compensation Insurance,m required by Section (�
3700 of the Labor Coda for the perfommnee of he work for which this permit is issued. GAS-EA.SYSTEM-I I NC.4 DID LETS OCC./ \ '662—
GROUP pAPN
My Worker's Compensation Insurance carierand Policy number are: ////// ( —Z_/
Carica Policy Nn,: GAS-EA.SYSTEMAVER 4(FA) // 3
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASGINDIJS'IRI.WAS'I'U IM'CRCITT(lR BUILDING DIVISION IMES
(This section need not he complrad if the pariah is fol.ne hundreddollmh(S alp) GREASETRAP -
or ka,$) PLANCHECK IEE
I certify that in the perfarmnnce of the work for which this pemtit is issued.I shall SEWER-SANI'T'ARY-STORM EA.200 F'L
not employ any person in any manner so as to become subject to the Workers'Co.,.- ENERGY FEE
Z. satins La (70ificrnia.Du NATER HEATER W/VENT/HLHCTR
O O Applicant ( GRADING FEF.
17 NOTICE.' APT LI Iter mI.ng this Cataluna,of F.xerialumn,you should WATER SYSTEMOREATING -
abecome subject to m Workeis Compensation provisions of the hvMr,Calc,you must _ SOILS FEE
W Q forthwith comply with such provisions or this Permit shall be deemed mocked. WATER SERVICE
UO irm CONSTRUCTION LENDING AGENCY NHW RHSIDENI'IAL PI.MB. SQ.FI'. PAID Receipt#
1 hatch,affIbu ffia a is a man
conaruction leading asm,forthe perforce of
the work for which this permit is issued(Sec.3097,Civ.C.)
W I"I Lender's NameTOTAL:
O U Lenders Addren TOI'AI:
>1 W I ramify that l have ad his application and state that the above information is - BUILD[[ui� iC
U z burdingco reelommand with yantyand wumtyaatives ofand atom fauxr Upon the
QTY.' M[?AfIANICAI.PERMIT FEE
U ,`L, building emnnmtion,and hereby amhnrimrtpresenmtives nfthis city to enter upon the 11 N SIiISMIC iT: �
nbovomentiired property for i nspeaio i pillows. PERMIT ISSUANCE 3
(We)agree m sloe,indemnify.od keep harmless the City of Caper ino.gamo - CAMM. r
obilitics,judgnums,cons and expenses which may in anywayarcme against said City AI;TERORADDTOMECH. O
ire ro,uaceofna graining of this permit. PLUMBING '.0 3
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 111,1X0 ChM)
SOURCE REGULAIONS. MECHANICAL FEET
AIR HANDLING UNII'(OVER 10AX)CPM) CONSTRUCI'IONTAX
:igMicleo AppllcanV ormuctm Da IiXIIAUSI1 IOOD(W/DUC'n HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicants Nora hadding occupant store or handle haxuNnus natedal / HEATING UNIT(TO 100,000 BT U) 2,• 2�
as defined by the Cupcnino Municipal Cana,Chapter,9.12,and the Health and Safety
Code.Section 25532(a)7 ,�.