S0023 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELF.CI'RICA], FRESH I'NO; n!� f]-17..,
RUu,mNC.RrvISION APPLICATION/PERMIT PLUMBING-MECIIANIC\L 6nww� �'-p-C)—G J
BUILDING PROJECTIDE.N'1'IPICATION ..3��
]all I CUING A DURESS: SANIIgkY NO. APPLICATION SI111M1'['IAL DA'1'P.
109 b er+h 5K EA S ctit.(A0 S—Z /—
OWNER'S NAME ZONE: CONTRACTOR'SN ME: LIC NO: NIC CONTROLM
hr brr�5 96- 703 " u
5 cr , M o 090
ARCHITECUENGINEER: LIC NO: ADDRESS: F-17 LJn s aw
CONTAC I': PIIONF: BUILDING PERMIT INFO
�Ve Consultant Fees Paid by Applicant(initial) HIUC 1iL14,71,
7/- /771 ❑ ❑ PGRh1ECll
Pr P
LICENSED CONTRACTORS DECLARATION . ELECTRIC PERMIT FEE JON DESCR IPTION
I hereby allira sa
that 1 um Iletnl under poo suss at Chapter 9(eo:n:nenem,
Wal. with Sell i100( nI'Division 3nl'tnc liminess and Pndcssinnx coda and n.y lirenoc is jF F T7A1'
W Q O 1'I?RMIT ISSUANCE
C W F in full force and effect. - s - tUWh ❑KI'ICIIENRECDFL
aUV License Class Lie.e APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RI:-PIPE
F Z W Date Comraetor
FC]ARCHITECTS DECLARATION PANELS ❑h1Ul.T1-UNIT STRUCTURAL
snZ I understand my plans shall he used as public records MODIFICATIONOZ= UI'T02W AMPS
❑INTERIOR ❑CHIMNI?YREPAIR
Llrcnscd FolfirWsin 1.1 201-1000AMPS IMPROVEMENTSWIMMING POOLS
OWNER,BUILDER DECLARATION OVER 10I AMPS ❑RAEH REMODEUREPAIR ❑DEMOI.1'MON
W a Q 1 hear,alar..that 1 am exempt from the Commetor's License Law for the
X 3 a V following mason.(Section 7031.5.Business and Professions Code:A,city or county SIGNS ELEMICAL ❑OTHER
W 6.rQ' which requires acaut to constrect, It P demolish,ra rep y fracture
~u'OJ
prior to itss Iso requires the rMlicandf cn permit file a signedsttement SPECIAL CIRCUITIMISC. /Js r�T
,E Nye- he,he licensedpursuant t ton of the C t t L L (Chapter9 � '
�Jy�
W dWO (c,anuient,w'h Soclum]B'H)aI D,kiim 3 dune Bmill,tud Prole:' :C,de)a, TEMP MFI'I!R OR POLE INST. COMM.RCIAL:
c.d c 'hut he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDI'HON ❑DIiMDUE ION
Xm Sec'ion]031.5 by any applicant for apennit.suhjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑F(JOD SIiRVICF:
m...,ban rise hundred dollars($5101. IMPROVEMENT
ESC ❑I.as owner(if the actuary,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
F will do the work.and the structure is not intended or offered for sale(See 7(W.Business ❑O'THIiR
3 m and Pmfcaians Calc:The Contractor's License Law does not apply m an owner..( QU'TLETS-SWITCHES-PI%TURS
property who builds or improves thereat,and who does such work hunselI or through
his awn employers,provided that such improvements arc nm intended or altered forE(QyrY.
IDENI'IA].HLECTR S
sale.IL hnses,tthe building or innprovemcn'is sold within one year afcompletion.the SQ_FT.FLOOR ARBA $ISR FT.
ter-builder will have the burden of proving aha he did oat build or improve for pur-
ptrtc of rola). T
Fl Las owner of the property,am exclusively contracting with licensed contracmn to
msamn'he project(See.10.,Ituxiness and nou..arts Cod a,Contact....Li-
stLawdsecsnon upplymanawneofpropeny who mold-,improves bacon.and PI.UMBING PF,RMITFEEwhoeantrm6 or,mhLicense Ise. SSUANC17
I am exempt unit,,See ,B&P C far this reason
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
Owner Date
Adaki WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I berchy nflirm under penalty of peajury-a'')I the follnwiag declam'ians:
�Ihavc and will nmiaaim ICerlfi.amof Consent m,set I�mere for Worker's C...own- DRAINS-FLOOR,ROOF.AREA,COND' STORIL*$ TY PI?CONST RUCTION
sating as p..mided Ra by Section 3700 of the Labor Cede,for the performance of the
ark far which this pe.it is issued. FIXTURES-PER'ERAP
dJ I have and will maintain Workers Compensation Insurance,as required by Section
3700offle Labor Cede,Entire performance nfdre walk for which Nis pe arm is issued. (IAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUT' APN
M Wnr 's Co ..-tion � ' rand Policy nu
Ak- ff
Cortico l�OML11r/:�A mM�rlol(c Policy N^�: 1 A7J GAS-EA.SYSTIiM-OVERJ(EN
CERTI� PICATEor r, MPTION PROM WORKERS' GREASE/INDUS'1'RI.WASTE IN'I ERCFIVIOR
COMPENSATION INSURANCE BUILDING DIVISION ITE i
(Thissaaiou need net h.......tried it the Permit is for me,hundred dollars($300) GREASETRAP
or less.) PI,ANCHECK
I ttnify has in'Ieperfnmtancc nDM1e work 6nwhich'his permit is issued.Ishall SEWER-SANITARY-STORM EA.20114.
moa employ any y mann o to h me subjcn m the Worker'Cumpcn-
nn into
Oz xation Luwrof:a, Duro rsr, NATER HEATER W/VENT/ELCCI'R GRADING 1�li�T\111
z Appliront VY� -
NQI'ICE ) I'I'LICANT:Il:user mukinb'hu Crmfcate of Exemption,You sbaW WATER SY5'IEMII'RIiATING
f-' ; Mcnm sub'ant the Workers Compensation provisions'If the Later Code,you must 11 SUIT i I:EIi
forth M reply witnsuch provisions as his pcnmia shall he devoted residual. WATER SERVICE
W Q
0.
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET PAID
D Z the n Ilirm that thre,,a construction lending agency Rath performance of Dae Rtceiptp
U O re Fn
W [:.t the work En which this.crmit is unwed(Sec.3097,Civ.C.)
Q Lender's Name VTJ))IALV LenddsAddress TOTAL:1 certify that I have readthisapplication and slam Ira Ne uhcor information isOn correct.)agree a.comply with all city and county orinances and sate laws relating m QTY. MECHANICAL PERMIT FEE z building conswction,and hereby athorize representatives offluscity v,enter upon theabrvcmentioned pro,eny for Inspection purposes. PI?RMIT ISSUANCE(We),,,.to save.mdvaou0y and keep hum le"No City of Captation against D' Iiabilities.judgmmntx,.nsta and ex,mr,,hich may our,way attmrapaingmid City AEI FEE OR ADD'IO MECH. :in asequence of the gaming of this Permit.
APPLICANT'UNDERSLWDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLING UNIF(TO Blak CFMI IEF.
I
SOURCE RRGULAA IONS.
AIH HANDLING UNIT(OVER I0.100CFM) CONS'1'RUCTION TAX
Sigmdad ol'APPlicum/Cnntmeon Dam EXHAUST It()()])OVIDUCT) I IOUSING MITIGATION Iqnt,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant a,future building aceupan.Bon ar handle notorious material BEATING UNIT('101On"H'IC
as defined by.he Catalina Municipal Cade,Chapter,9.12,and the HMO send Safety HEATING UNIT(OVER 100.000 HTIJ)
Cale,Section 25532ho?
Yea ❑No VENTILATION PAN(SINGLE RESID) PAID
Daae Receipt#
Will laoapphrand or inter,building oreapnmt rise egt iprem ,,devices when BOILER-COMP OHP OR 100,004)it'I U)
mit hazardous air ens airman m as dclimed byre Bay Area Air Quality Management 'I OI'nl.:
Doane,- BOILER-COMP(OVER 100.000 BTU)
❑Yes No
I have read the hvnrdous mAtnab requirements under Chapter 6.95 of are Cali- AIR CONDITIONER ISSUANCE DATE
forma Heuhn&Safety Cala Sections 25505,25533 and 25534.1 understand that if the NI?W RESNENTIAI.MECIi. SQ.ET, d. �T I' ,-.��
building does tonrmrcftly haveatemtm,that it isni,orI...tsibility to not Ey tneoe,,am J f��f
lithe,equircroure,whim most Intel priors,issuance ofa Ceniicme of Occupancy, /T
Owner or uncultured!agent Date Lo ISSUED HY: � �/ l , v
OFFICE