S 3363 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fill]LDIN'O-ELECT RICAL, E'ER IT NO
BUILDING DIVISION APPLICAT•ION/PERb1IT PLUMBING-MECHANICAL 3363
BUILDING PROJECT IDEM IFICA'11ON
NllILl]jC'G AI]j]EI� ,M� SANITARY NO. APPLICATION SI111h111TAL DATIi
(1 rW�Y.RS1N`;✓/�JA:VMI,i'i �(1 C)N'I' fOR'S NA LIC NO: ~/ r�
C C�'O IC C(IN'IHOLM
ARCHITECT/ENGINEER: )RI[$S: - _ ❑
jl�'
INTACT.. PHONE: 1{U ILDING PERMIT INFO
.Q 1�q ❑ Consultant Fccs Paid by Applicant(Initial) BLDG El li Jacf PLUMB MECH
Ej F-1
LICENSED CONTRACIOR'S DECLARATION QTY EEF(-`TRIC PERMIT FEE
I It
amrm Wa 1 am licensed under penvLdons of chapter a kommencing JOB DESCRIPTION
pWOZ wdh Sxe imT7000)ofoivisinn 3.Ohe Business and esr of .and myhcen— RESIDENTIAL:
Wpp -� s PERMI"f LSSUANCIi ❑SfUWL El KITCHEN REMODEL
W F- in full force un lies
aUU Liccn. Lic'M APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'Ll1MNING REPIPE
FZW U:ne Coovace
Nab' ARUTH'IIiC'I'$DECLARAfION PANI],S ❑MULTI-UNIT' ❑STRUCTORA L
F N L I underewnd mY d.ux x1m11 he—cl o public records 99 %� MODIIICAI'ION
OZ-M UPTO2WAMP5 Z/ ❑INTERIOR ❑CHIMNEYREPAIR
F4L, l.iamwd Professional 201-10MIf1AMP5 IMPROVCMIiN'I' SWIMMING POOLS
OWNER-C Q 1 hereby affiom W I am lcxeml+l ham We Contractor's License Law for the DVER IOW AMI•ti ❑BATH REh10Dlil/REI' IR ❑I iM I'I'ION
3:0W
p IL U tunnel.,reason.(Sermon 0(131 5,Business and professions Code:Any city or county SIGNS ELECTRICAL, [I EITHER
W�+LL ya which requarn,sa ralla to construct.alter. Top demolish.or rep r any [ ctere ' -
pJ P,unto it, L 4 W ppl' 11 h Kuma b.filca,i,r,d,om1rwrt SPECIAL CIRCUIT/MISC. V
CWdn
that he : Il : t",,he p Id C a a I' (Cleopatra
W��p oe arms with Sau 70(Xb fD 1111 B ` and 11 Cde)'r '1I:MEMET13R0141'OLI3INST. COMMERCIAL:
d d e C that he a exempt Boredom and the basis for the alleged exemption.Any viola'on o[ ❑NEW HLDG/ADDI'110N ❑UI?M(11,1'TION
-h
Section 7031.5 b,la,applies.'for. —it subjccu the upplicam p+a civil Penally of POWER DEVICES ❑'TENANT ❑1-001)SERVICE
not more lean five hundred dollars($500).=O IMPROVEMENT❑Las mvner of'hc pmpeny.or my employees with wages as Wcirxole co nsmion, SWIMMING FOOL ELECTRIC
P., will do the work,and the structure is not intended oro0ered for sale(Se Business El
Wm and Prufexsmnc Codo the Conlmnor'u License Law does not o Y m un owns of nUl'hFTS-SWI'TCIIES-FIXTURES \ ( Q
pu,,uy who hard,of improves ahercon,std who docs sac ark himself or through
his own mnployce,provided but such Imprnvemrnn nos inlundcd or offered aur NEW REST DIT I'IA1.1?I.1!C'!'R SQ FI
sale.lL however.the building or improvement rout Min one your ofcnnpleioa theSin" SQ.FT.BOOR AREA S/SQ.Ff.
cr•builder will have the burden of pm ing a be did not build or , ar .a fi+r car
pownf.mlcJ. v 'T. AL %1
n h as natural the imr,.,,ma xc1 vel,<maractim,with Iiccn,cJ nmvacmrs m L/
construct the Project(Sec.7011,Bu cas and Profession,Calc:)IfitoCornmentrc LI-
nmLawdnasooa,plyn.a rofpmpany who mildsor improve.dercon.and QTY PLUMBING PERMIT FEE
who contracts fit such pr. iah uu+mmcloo,)licereed pu,letal the Contra noJs
I'veae,Law. PERMIT ISSUANCE.
M l me exempt under:c ,1{&l'C hu has¢axon
ALTER-DRAIN&VENT-WATER(G) VALUATION
Owner Dam
ORKER;S COMPENSA ION DECLARATION RACK ROW PROI HC`L DEVICE
I hereby o)M under Penalty of perjury one of the following declarations: zz
M I have and ill netimaimaCcamicmen(Conwnno adf--insure for Workco4Compen- DRAINS-FLOOR.ROLE,AREA,I STORIIS TYPI:CONSTRUCTION
,inion.as pmvidcd ter by Section TRIP of the Laher Code.for the Performance of the
r which this permit ix issued. FIXTURES-PERT RAI'
I 1 have and will mainmin Worker',Ca+mpen,aa Insurance,is required by Section
37 1the labor Codr,f+r, the pormoranee of she work for whit This permit is isautd, GAS-ISA.$YS'I'IiM-I CNC.:DUThIi'I:S OCC. AI'N
My Wor 'n""let and Policy
Car
.. _PnIicY No.: GAS-
EA.SYSTIiMOVER i(F,n)
CEfUt"CAI410N FROM N'ON OMIT� '
COMPENSATION INSURANCE GHEASCIINUUSfRI.WASTE INT[RCIiYD)H BUILDING DIVISION FES _
G)li,smlan nwJnot he completed floc permit is forone hundred dollars 6100) GRL'ASETRAP.
or Ids.) PLANCHECK FEEIccnl01;11Latheprothemeneot,he wads orE0 thispant:'ivi"a- , holl SBWlik-SANITARY-S'IORMBA.2001FI.1111 1
a h+become s heat h+the iso. �Ca 1?NIJ2GV Ild17
mplu'any lzrs nnym nnu so x vl ml+eo-
Z xmion Laws of California,Date a WAIL?R HEATI3R W/VEM/ELECfR
2 O Applicant GRADING I'131i
NONCE TO APPLICANT:If,after making this Creih v of Exemption,you should ` WATIiH 5 fiA1RRR.n'RNG
a ; become subject m+the Worker's Compensation pow m of the Labor Code You must •^ SOILS lEli
hmhwillo comply with such provisions or this nit shall he deemed mouked. I�RESIDENTIAL
ICE
5z CONSTRUCTI LIiNDING AGENCY I'hMB1PERMIT PAID
b0rDm Racip[p0 1� � he wrk far which shinpennia' swelllSm,31N)],Civ.CJOLender's Name IYITAL:
U 1<ndcrs Addrea 1 cedlY than 1 ave mad this application and gate Wal the above informaion is BUILDING I+Py rome'.Iagreem reply with n11 city and county ordinances anal stem laws retrains to Q'� ECHANICAFF.Ii SEISh11C FEIi
VZ building ams[ Inn,and hereby authorize representatives of this city to enter upon the
ahoye-nenli cdpropeayfor inspec[ia I purpuwx PERMIT ISSUANCE PL I3
( uglec tu eavq indcaludy call kccp harmless ahs Cily rl Cupcnino agoing
Iiaohn .jndgmwnquuxlxanUcxpnacus which niay In any sully uc:rucuguiml sail CllY ALTERORADD'I'OMECIL PLUMBING Il13
i.e. of the granting of[his permit.
NT UNDERSTAND WILT.COMPLY TI ALL NON '01,T AIR HANDLING UNIT(TO 10,00CFM) MECHANICAL PER
x/ AIR HANDLING ON]T(OVER 1(1,11(10 CITE)
CONSTRUCTION IAB
Staunton ofAp,li.myCoe ac Dec EXHAUST HOOD(W/UUC) HOUSINGMITIGATI(IN IEE
.IIA%AR DOHS '11iR DISCLOS RE
Wdhircupplirnmarfmurchi' logo :punt xhac ar handle bunudnus amount IIEIUsGIINI'I'('IU TIMIIXMI BTU)
as defined by the Cupcnino Munmtpal Code.Cb:q+mr 9.12.unit the 1fea11,mall Safety
Cole,Section 25532(x)] BEATING UNIT(OVER 100.0(1(1 BTU)
YesVENTILATION FAN(SINGLE RESID) PAN Date Receipt s
Will 11'.upplicam furan bui
nr lding occup tit use equipment or devices which IfO1LLR-CON11'OIIP OR 100,0X1 RTU)
emit huzurdous air contaminants as defnd by the Bay Area Air Quality Manugemem
Dimric['?
❑Ycx //]r'�`pt� 11UIhP,R-C(Mfl'((IVER IfM1.INM)B'1'U7
I have read We hump} Jmuicum,cquacrium-under Cm,r,axa5 of the Cali- AIR CONDI'lIONHR ISSUANCE DA'tli //
*Owthunictio,cals�
Safety Csdrs S ions 25505,25537 25531.I umlemanJ a u if c NEW RF_SIDENIIAI.MECB. SQ.Fm 1 n/ q y
Iwglmaill n+am,W]t Ta to i litY In tali fylhe a / `�—/� O
lane 'TOTAL: ISSUED BY: , r
OFFICE