S 1765 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECPRICA I. PE IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1765
BUILDING PROJECT IDICN'I'IFICATION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DAT(
OW F ; ME: 'HON CO 'S NA E. IrfC�s:/�
V J U�^^ NIC CONTROLk
ARCHITECT/ENGIN R: LIC NO: D RE ❑
CONTACT. PHONE. BUILDING PERMIT INFO
I. ❑ Consultant Fees Paid by Applicant(Initial) HIM ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. FLECTRIC PERMIT FEE Nr
L hereby affirm that l am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
GR•Z with Section 7Wgwf Div 'a"Sof the Ehnadtsstnd Podeessims,Code.mal my'eeose is RESIDENTIAL
FOO full force and effect. r PERMIT ISSUANCE
a1" +n ❑SIVWL ❑KITCHEN REMfUCI.
�UULicense Class
ZLCick APPLIANCES RESIDENTIAL - ❑ADDITION ❑PLUMBING Rh PIPE
HW Dv¢ ommsror - _
ARCHITECTS UECL 1' - ❑MULT4UNIT ❑STRUCTURAL
z O y 4 I undcrsmnd my plana shall he used vs Public records PANE MODIFICATION
OZ— UI'102WAMPS INTERIOR ❑CHIMNEY Artl R
[=. W Licensed Professional 201.10WAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IWOZPS ❑BATH REMODEVREPAIR ❑DEMOLITION
C a Q 1 hereby notion that 1 am exempt from Ne Contractor's License Law for the
�qqi(SO W U following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑(71'HF.R
tL 3 LL P^ which requires n permit to consuv t,alter.inmrove,demolish,or repair any vuuchre
0 prior m its issuance,also requires the applicant for such permit to rile asigned statement SPECIAL CIRCUITIMISC.
} that he is licensed pursuant it)the Provisions of the Commi License Low(Chapter 9
Q� (communcing with Se��on]IXN])o[UivisionJof the Nosiness and Professions CnJe)nr TEMP.MFFER OR POLE INST COMMERCIAL'
d y e C that he is exe npt therefrom+and the basis for the alleged exemption.Any violatinn of NEW BLDG/ADDITION ❑DEMOLITION
�4C7 h• Seeliun]031.5 hyany applicant for a permit s.hjectsthc.ppIivma mu civil penultyof POWER DEVICES TENANT [I FOOD SIiRVICF.
nm more than five hundred dollars(SSW).
z} OTHER IMPROVEMENT
Q I]L:rsowmrk,the property,re I,rat rumdeswim was hoodeiSec. 0t 1,Bu mien, SWIMMING POOL F.LE IC
E a IJntMwork,and the no C.m is notimeiceddroll'ercdfmsale(Scc.]B1aownnees ❑OTIfER
Iral property
erty It.
Code:Thu Cas there's Liconso a do dews nm work
hi to if mann nf• OUTLRTS-SWITCH! RES
G progeny who builds or improves thereon,and who tun such work amended
or or through
his own employees,e provided r m such Improvementssoldw ore on iyearof or offered for NGW RF.SIUIiNTIAL EI.IiCTR SQ F1'.
sale.ILhowever Jhe building or Improvement iv soldwithinone yenrofcumpiniun.the SQ. � . AREA USQ.FT.
owner-builder will have the ounlen of proving that he did not build or improve far per-
pose of sale.). - - UM 5 gNS'D
❑v,as owner,of the property,vat exclusively cormeting with licensed conuacl m - TO
cmI
mc'
the project(Sec.]1HJ,Business and Rvfessionx CWe:1'fhe Conuacmr's Li- "C --
cenwmc'd`dswmd".pPlyo+act owner ofpmpeny who M1uilJs nal improves thereon.onJ QTY. PLUMBIrvd,;y �� . E CI Uh LUr
who corrdc�lin such projects with v conuuemr(s)IicaraW pursunm m the Comwctnr's Col 1 U Y V
Lice'ise Law.
PERMIT ISSIIANCU
❑lam aempl untkr Sec. ,BBt YC for this rcmnn - -` --
Owner Dam ALTER-DRAIN&VIiNT-WAl'ER VALUATION
WORKER'S COMPEN SNI ION DECLA RATION BACK FLOW PROTECT.DFVICE
1 hereby affirm under penalty of perjury one of the following declarations: -
I national will mainlnina Cenifcam of Consemmalf-insure for Workers Compen- DRAINS-FLOOR,RODRAREA,GOND, ST IFS TYPE CO TRUCI'ION
n Item,ns Provided for by Section 3700 of the Labor Code,for the performance of the
r - - work fawhich I 's permit k isnot. FIXTURES-PER TRAP
❑ 1 hove onU I maintain Worker's Compensation Insurance,as reyuircJ by Semina
37100o1"he rCodr,fonbeperformnceof U+ewurk brwhich mix Per.1. 1 upl. GAS-GA.SYSTEM-I INC.Y OUTLETS OCC.GROUP APN
My Worke -tion Insurance carrier and Policy iwN/f//
' 'ec - Policy Ns,.: GAS-F.A.SYSTEM-OVER 4PA)
FI A, KIiRS'
O O 1 1 A CE GRF.ASIVINDUSTRLWASTE INI'IiRCEPI'OR BUILDIN' (VISI I9!IiS _
( isseretion rood not becro pi I us fnkorchundbeddellnrs(SIW) GREASETRAP
nal leen.) PhANCHECK FEE �•
Icerlfythal tome perlormancoofmv work Imulachthispennit ismued,Ishall SEWER-SANITARY-STORM EA.200 FT.
rat employ any person in any ammor so as to become white,m the Workers'Conmen- ENERGY THE
tZ .it..Laws.1 California.Date WATER HEATER W/VIiNT/ELECI'R
�O Applicant ` GRADING/-
4NOTICE TO APPLICANT:IL ufer making this Cedifcme of Exemption,you should WATER SYSTLM?RIiATING SOILSF Fr become subject m the Worker's Compensation provoiams of the Labor Cale,you ramal
onhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a�
7z
CONSTRUCTION is a IONLENDINGAGENCY NEW RCSIIIIiNT1ALPLM1113. SQ,IT. PAI Date Receipt
affirm k
V Q (hereby irm mtnhere is cunswctinn lending agency for the performance of
me work for which this permit is Issued(See.3AP.Civ,C.)
I2. Lenders Name I A
Lender's Address TOTAL:
Lot 1 certify that 1 have mad this application and ,.at that the above information is BUIL 'lili
Vi correct.1 agree to comply with n11 city and entry odinanocx and slam laws relmine In QTY. MECHANICAL PERMIT FFE
C.>z
building construction,and hereby amhuriac rcprwentmives of this city or enter upon the SEISM IC FEB
"r above"mentioned property for inspection parlwus. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of CuPenim against ELECTRIC FEE
Iluhilities,judgmems.cams tad expenses which may irony wayaccmeagainn said City ALTER OR ADD TO MECH.
PLUMBING FEEin consequence of the granting of this Permit.
APPLICA, 11 DERSTANDS AND\ LL COM WITH ALL NON-POINT AIR HANDLING UNI"1'(TO 10,000 CFM)
SOURCT IFC. LATIONS. MECHANICAL FEE
_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S loam Ke anV nnuuct r Uric EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
1 LARDOUS MATERIALS DISCLOSURE
W+Iltb cant or furore building occupsomstore or handle haemdous material HEATING UNIT DO I W.000 BTU)
as defined by t e Captions,Municipal Cole,Chapter 9.12,and the Health and Safety
Cade,Section 25532pd? I(EATING UNIT(OVER 100,000 BTU)
❑Yes 0 N VENT]LAI]ON FAN(SINGLE RES I D) PAID
Date keceiPt M
Will the applicant or fumm building occupant use equipment or devices which.
emit hamNrus air commnimmts as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,(010 BTU) TOTAL:
District? BOILIJ2-Cf3MY((JVI?R 100,0011{'fl))
❑Yen ON. Ike
I have bead the hm
azardous nmdala requircmetns under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCIZ DATE
lnmia Health A Safety Gale,9ectlnns 25585,2551)unA 255?4.1 mairrmand thus ifthe NEW RESIDENTIAL.MECH. SQ.Fr.
hmldingdoex amt curealylascife blAv.t it is my res,owhility tonality theocca,ma
of be requinmems which lana be met Prior or roansvil a Cenilicate of Occupancy. VY {
Owneraramhori,d agent - Deet TOTAL: ISSUED BY:
OFFICE
1