S 0148 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CFPY OF CUPERTINO NUI LOING-ELECT'RIC'AL PERM F NO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0148
BUILDING PROJECT IVEN'FIF'ICATIOM1'
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMITIAL DAT I:
/oto Np D77-iS S Q uA
P40 N IAvg
v RS &G -LiC
O777d—+
�4������ � Xi 1 Xy/_- 57� NIC CON'I'HOI.
ARCf11TECi'IF.NGINIiIiN: LIC NTTfII)�O T S -rN wr +S✓ ❑
" C NES 5T-
CONTACT. PHONE: BUILDING PERMFF INFO
❑ COngU11aM Fees Paid by Applicant(Initial) HLDG ELEG' I'LUp MHC11
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I heteby affirm mat I an licensed under provisions of Chapter 9(Commencing JOB DFS R PPION
�aZ NScdinn](XXq ofUivisinnJofthe Business vnd Pmfessinnx Cmdc.undtnylic se" RESIDENTIAL,
WOO wt w O I'IiHMI'1'ISSUANCE.
Fly r- mfull force and effect s ❑$Il)WI. ❑KITCHI3N REMOUI31.
�UU license Clu Lich APPLIANCES-RESIDENTIAL. ❑ADDITION ❑1'I.UMHING HE[']PIT,
N Z W Dam _TS DECLARATION
rn¢a
R 111'1'ECPS DECLARATION INNEI S ❑MULTI UNIT ❑STRUCTURAL
Z~O Z 1 understand my plans shall be used as public record. MODIFICATION
OZ_� - UP TO 210 AMPS [I INTERIOR [I CHIMNEY REPAIR
I:•�Fw Formed Professional 201-IIX0AMP5 IMPROVEMENT [3 SWIMMING POOIti
OWNER-BUILDER DECLARATION OVER 11X0AMPS O BATH REh1(LIlII�' li DE I
CYC,
C Q I hereby affirm that 1 am exempt from the Comrxmrs License Law for the ❑OTHER
X 3 G UF. following mason.(Section 7031.5.Business and Profen,xmw Code:Any city or county SIGNS ELECTRICAL
W LL N which term.,a permit to construct,ole%,improve,de rales,or end,uny tructute
1- O.a] prima,itsissuance also 4 rethe pplt 1f h ,,,to fileasagredstateroom SPCCIALCIRCUIT(MISC.
,F, y
but he s licensedpursuant tthe provisions color,C t' t License I (Clapter9 COMMERCIAL:
(,o gwith Strome? p0)ut'U'v'xi 3ofihe Bevies JI death is Coda)or 'T CMP ME I ER OR POLE
G L e C mut he is exempt therefrom auto the basis for the alleged exemption.Any violation of ❑NE 131.UG/ADDITION ❑DEMOLITION
WimSection 911315 by any applicant for u pemslt subjec6 the applicantto a civil penalty of I'UWIiR DEV ❑'TENANT ❑FOOD SERVICE
m more than five hundred dollars IS50X0. IMPROVEMENT
fSC ❑ I.as uwnerofthe property.or my employees with wages as their sole aompensation. M�LE=RICLEECIRIC []OTHER
F. will do the work.aM the sruaurc is not intended oroRctwl for sale(Sm.]Obf.Business
Wand Notes ions Cale:The Contractor's License law does oat apply to an owner ofITCHES-FIXTURESproperty who builds or improves thereon,and who does such work himself or throughIAL ELECfR SQhis own employees,provided that such improvntams ate not intended or offered forSQ.FT.FLOOR ARBA SSQ.FF.sale.ll:Ivswcver,the building or improvement is sold within one year ofcompletion,the
sunsrhuildef will have the burden of proving that he did not huild or Improve for par-
pmn I ) 'rOTAI:P41
ap pa ty ly tai i 6 lb l J lot mcon,t t th p o t IS ]1}14 13 d P fC J )Il C t t '.Li-c 1 J tapplyt ff party h h'IJ p :th a nd MBING PERMIT FEF�� .who contracts for such projectswth a commalar(s)licensed pursuantt theC nt t rsLicense Law. CE HLU s '4C�
I am esempt under Sas . &P C for this reason
ALTER-DRAIN&VENT-WATER IRA) 7 VALUATION
owner nam //y`
WORKERS COMPENSATION DECLARATION BACK PLOW PROTEGE DEVICE
1 hereby notion under pcnuhy of perjury one of the following decimations;
t] Ihave and will maintain aCcaracataof Consenttoself-insure for Worker's Compcn- DRAINS-FLUOR,ROOF.AREA,COND. STORIES 'TYPE CONSTRUC TION
,mien,as or vided for by Section 3]19)of the Labor Cala.for he perfareman of the
m-for which this permit is Issued. Iq X'rlJRli9_PER TRAP
wi I have and will maintain Worker's Camper army Insurance,as required by Section '1'IiM-I INCA OIl'I IJdiS
170of me Labor Code,for the performance of the work far which this permit iv issued MS-IiA.SYS (CC.GROUP APN
My Werk-er's-Cpon,LsaI Incur arse earlier and Policy n GAS-13A.SYSTEM-OVER S pSA)
Cattier:LAE_(,wy �uy No.:
ttMM ERR"IRtICATE UP Ii li Pr NFROM1f OH ERS' GRPASF/INUUSTRL WASTE INTEHCEPNH
COMI'BNSATIO INSURANCE' BUILDING DIVISION FEES
Thismcdonnecd not beampletaJ if thcpermit is fur nnehindesddollan C5100) GREASE'I'RAP
I'LANCIIECK FEE
or los.)
Toy any Natinthe m anyperfortiourerol stobehe kfor whim this teethisissued,Common-
SEWER-SANITARY-STORM EA.21XII'I'.
not employ any person many ns.nncr so as booms subject to Worker.Compeo- ENERGY FL'h:
Z radon lawn of California.Date WAI ER HEATER W/VEN'l IR GRADING FEE
zO
Applicant s
y NODCH TO APPLICANT:IL aHaf nmking this Caa ificae of Hseniption,you should WATER SYSTEMITREATING SOILS PEE
F"
Income_suhject to the Worker's Compensation provisions of the Labour Code,you meso
aC ? forthwith comply with such pmvisinreorthis permit shallh deenedrevoked. WATER SERVICE
a �
=Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR, SQ.FT. PAID
I hereby affirm that hem is a construction lending agency for the Performance of Date RcceiptX
the work for Is hich this permit is issued(Sec.3097.Civ.C.)
O T(TIAI
Lenders Name .
I.1 Lender's Address TOTAL:
r LIQI certify that 1 have read thin application and stmt that the above inlormInan iv BUIhDING FEE
FZ) calear.lagree to comply with all city and county ordinances and sere a--lung to QTY. MECHANICAL PERM IT FEE SEISMIC FEE
U ,7J. huildingcongmction.and hereby authorize representatives radius city tocrier upon the
Wwry .romoomed property for in.,,rnon purport. IPERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indonmify and kap h irmlesv the City of CuPcrino.'rima
liabilities,judgments.cost%and expenses which may in my way acerae against said City AM ER OR ADD TO MECH. PLUMBING FEE
in convenience of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010.000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 111,1X0 CIM) CONSTRUCTION TAX
Signamre mApplianVConteramr Dote EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
ZlltheuppGamor linters building occupant,store or amlle hrzasJovu material H ENI INC,UNIT(TO 110,(0013'1'(D
as dcliby the Culanina Municipal Code,Chapter 9.12,and the Hallh and Safety
IIEA'I'INC,Post T'(OVER 1(/1,000 It'I U)
Code.Section 25532(o)'I ,.�,/
Yet LYVEN'TILX1'ION FAN(SINGLE R ESI DI PAID
Dam Receipt X
Will Ne applicant or forum building mxxupam uu equipment or devices which BOILER-COMP(3HP OR 11X1.1%0 BTU)
emit hazadous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
'District" / BOILER-COMP(OVER IOf1.006tt1)
❑Yes �N
I have read the hmmdom memorials a is under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
y25533a p
fomia Halm&Safety Code.Scdinn 25505,25531 and 25531 I undcolyri that'the NEW RESIDENTIAL MECH. SQ.FT
builJing does nal curcntl levee cnum.the iC ismy respmnsihilitym nnllythcoKcupvm
oft engorman ¢whle n t met pri m's oda Cenil- enl cap.
Own mrautborizW age Doc TOT'/L: ISSUED BY:
OFFICE