S 1075 (2) T APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUZZ INC-ELELT'RRAL PERMIT No,
BUILDING DIVISION APPLICATION/PERM1111' PLUME MNG.MIICHANICAL O 1075
1 0 7 C
BUILDING PROJECT IDEN'TIF'ICATION O 1 I J
SANITARY NU. APPLICATION SUBMI-EAI."ATI;
BUILDING ADDRESS
3 a to
�WN[!R'S NA I PHONE: CONIRAt :5 NAh1E: LIC NO:
' SIC CONTROL/##
\ IRCHTFE :NG !ER: LIC NO' AUDRF'_SS: ❑ 1/�
CONTACT: PHONE: BUILDING I+ERMI'f(NPO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG 12.Ff.-1 PLUMB MEC,H
LICEP"ll CONTRACTORS DF.CLARA'IT) QTy ELECTRIC PERMIT FEF; DES
1 hereby uffino tbw 1 tun Germed under pnrvisinnc of CTupter 9(commencing JOB DESCRIPTION
OWQZ uilh Section7M))afDivision3ofill.Businessond pmfcssinm Grdc.amlmy license is RESIDENTIAL:
NW_F, to full lorceand effect. PERMITISSUANCE �SFT)WL ❑KITCHENREMODEL
HZW License Class Lie.# APPLIANCES-R[SIDLNTIAL 1DDII'ION El PLUMBING RI PIPE
un le a Dv¢ Commoor
ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑MODIFSTRUCTURAL
O
F m Z 1 understand my Plans shall be used ac Public reurnds MODIFICATION
ZODy.. UPT02MAMPS ❑IN'DRIOR ❑CHIMNEYREPAIR
F•.��� Licensed Professional 301-BXNlAMPS IMPROVEMENT E]SWIMMING MOLS
rYfj OWNER-BUILDER DECLARA'UON OVER I1N111AMPS ❑RATH REMODEL/REPAIR ❑DEMOLITION
C C Q I hereby affirm hit,twre.(
I nm efrom the Contm uni,License Ire for the ❑CH-HER
k
06 U following raamn.(Section 7131.5.Business snit Professions Calc Any oily or cnuntY SIGNS ELECTRICAL
LL13 W to which regairas a permil m Cnitdtuat,LIN,,in..nrvc,demolish,or repair any someone
OQ priormitn;,,renes.also rcyuim the applicant for such pcmtiuolilc#signed aammcnt SPECIALCIRCUIDMISC.
shat heir licensed pursuant'it'he.nrvi'll ufthn Commcmr,Licensc Law(Chapter 9 OMM -R IAI,
0 IcommencingwishSMinn 9gM))nf Division3ofshc Business and Pmfccsinns CoJe)..r TEMRME'IEROR Its)LEI NSI'.
66 e C that he is eaentpt thercfmnt and the basis for the alleged excindios.Any vinlmion of ❑N nW BLDG/ADDITION ❑DfiMOLI'TION
LLx)�vi Section 7311 by any applicant for alwnnitsubi the applicam soucivil.natty of TOWER DEVICES iNAN'I' ❑FOOD SIiRVICF.
not more than five hundred dollars(BS(XB, PROVE IIEM1T
Sp ❑ I.usownerdthe property onny employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
p., will do the work.and the structure is not intended orotfered lir sale(See JWi.Business ❑DI'HER
a 3 m and Professions Code [he Connell-',License Law,does
not apply ht an turner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himwlf or through
his own employees provided,but such Impmvcntems we not intended or offered for NEW RESIDENTIAL.ELECfR SQ FT.
sale.If,however the building or improvement is sold within ane year ofcomplelion.the SQ.IT.ELIXIR AREA ITT
S/SQ. .
r-builder will have the burden of proving that he did not build or improve for Pur
a
pre of rule.).
❑ L as owner of the Seepro,wriS701 am exclusively convecting with licensedCCn...inon m X p
vemvunthees not
pd,to
buses property
Who
Code)The Cnmmemrs Li- N D
c ser Law titer not apply to un owner nfpmpny who builds or impmvevhercon.and QTY. PLUMBING PERMIT FEF,
whoeonlmets lirsuchptojects with a coremorls7 li,,.,d pursusnuothe Cil drannrs �EB 24
Liccrose La, PERMIT ISSUANCE e
Cl farm exempt r ` .B 5 1'C tier Nps-real i
,act ALTER-DRAINd VENT'-WATIiR(IiA) V� r VALUAI
Dua '
n ER'S (lMPI:NSAHON DECLARAI'I(N BACK FLOW PROI'f:CT.DEVICE ICI; V
lik
her Yaflimt ander penalty of perjury one of the fnlLswing edam, m- #
,I hove will maintain a Cenificatc of Consent 4t sell mum for Wodces Comp
cn- DRAINS-PLOOR,RIX)E AREA.COND. STORIES TYPh:CONSTRIICfIOF
Will..it.......tied for by Stettin TQX)rime Lahr Code,for the performance of the
work for which this penno is issued. FIXTURES-PER TRAP
C]I have.,,it will amimain Worker's Compensation Insurance,is required by Section
TIIM)nfthe Labor Cide.for,heprfommncemOlne work for which this permil is issued. GAS-EA.SYSTEM-1 INC.4lRf1'LETS OCC.CROIUP AI'N
My Wai Compensation lasunmce caoier and Policy annihilate: GAS-EA.SYSTEM-OVER 4(EA)
Currier. Policy No.:
CERTII'ICATE OP EXEMPTION I2ROM WORKERSGREASEJINDUSTRL WAS"1'IT IN'IPRCEPIOR
COMPENSATION INSURANCE tl DIVISION PENS
(Thissenionnee ing becomple,edif Nepnnit isforone hmWreddellius SHN)) GREASE'I'RAI'
or Icss.l I'LANCIII?C +EI!
I cenifYthnafficperfom
rancenw
fthe ..rfientihichtbispnniin i...ed.[,hall SEWER-SANITARY-STORM EA.20117IL ENERGY FE.
all,canday any Iwtmn in an,rem ncr,o as to become lsi Co npco-
Z sxtion Laws or Calder iu.Doe WATER HEATER W/VFNT/ELECTR GRADING FEE
Z O A,,Iieant
'Zr' t%3
NOTICE I'O APPLICANT lf,aper making this Cenifcate of Eeemptinn,you should WATER SYSIEMITREATING SOILS FEE
F� become•object m the worker,Compensation pmvmions of he Calls),Cane,Ina well
forthwith comply with such insist, or this permil Shull be donned revoked. WA'f1!R SERVICE
IIPAID
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL('LMB. SQ.IT. Dale ccci.tp
V O 1hereby'.dBna That is a construction lending agency file the performance of
(~ the wad for which this permit is issued(Sec.31181,Civ,C.) T(TI'AL:
Q U V
lender's Now, l'(
r Under',Addres BU ILDING FEE
L 1 lenity and 1 have Lead all apPllcutinn and once that the above ialbrmaunn is
rF.In cooter.I agree to comply with all city and county ordinances and nate laws mating it) QTY. MECHAN ICAL PERMIT FEE SEISMIC FEE
OZ building construction.and hereby mahorme representatives ill disdtytncme.alwn lea
Ti above-mentioned pmpny for inspetinn purposes, PERMIT ISSUANCE ELECTRIC FEE
(We)agree ut save,indemnity and keep harmless the City u1"Cupertino against
liroluies.judgmers,costs and ex,enses which may in any way acerae against said City ALTER OR ADD TO MECH, PLUMBING IEE
in onsequence of the gmn'fig of this permit.
APPLICANT 'VDERS's DS AN WILL COMPLY WITH ALL NON-P INT AIR HANDLING UNIT(TO It3,gIB CFM) MECHANICAL IEE
SOURC J N e 1
s AIR HANDLING UNI'f(OVER H).qX)CFM) CONSI'RUCGON TAX
S' co pplicantlC n tar / at EXHAUST HOOD(W/DUCI) HOUSING MITIGATION IEE
HAZARDOUS MATF,R PALS DISCLOSURE
d,the applicam or fuer,building«cu.am stare or handle hvallous material HITAI ING UNH TO HNIJNN)RTU)
as defined by the Cupertino Municipal Ctde,Chat o.12,and the[Wellb and Safety HEATING UNIT(OVER BN)gN)B'I U)
Code,Section 25532(u)1
El Yet, C]No MI!
N(SINGLE RESID) PAID
_Dmm Rocciptp
Will the applicant or future Wilding occupant use equipment or devices which (3111'OR IW.(Ma BTU)
nit hazardous air ondantinavls as defined by tire any Arca Air Qua11,y Manugcmcnt TOTAL:
fishiat? COMP IOMIJXIO BTU)
.Yes ❑Nn
I have and site levadous materials tequimmcals under Clmpler 6.95 of the Cilli- ER [$NUANCE DATE
li+miu Hullh Ye S:dcty CttJc.Stctinns 25505.255.JJ nnA 25514.1 undemxnJ Ihm if the Ad.MIiCH. SQ.ET.
i holding does na,currently have a moan,seas;,is my responsibilisy m notify the newlevet
of the"i itemtual which muss M met prior m Issuance of o Ceniltcute of Occupancy.
Osonw.routhnrixcd agent Date "}� / ISSUED BY.
OFFICE 1