S0001B0397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH UING.ELECTRICAL IT, Up o.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 5000 00397
BUILDING PItOJRCT IDRM'IFICATION
SANITARY NO. API'hIG111UN SUIfMI'I'IAh DAPI
BUILDING ADDRESS:
9
OWNER'S NAME: ONE: CO RAMORS NAME: LIC NO: N/C CON'IROLN
I I�L��d� u kgk,_ 1246 J v 9uS
ARCHITECT/ENGINEER: LIC NO: ADDRIS. ,r/ ❑
p 9 7 S. >� (3
CONTACT PHONE: BUILDING PERMIT'INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB NISCH
FT4n� ZS-a-cy i e ❑ ❑ �_ Cl
LICENSED CONTRACT ORS DECLARATION QTY ELECIRICPERMiTFFEr, JOB DESCRIPTION
I hereby union frau l am licensed under provisions of Chapter 9(commencingwith Senior lIXNpd Divisinn3nf the Business and Profesxiom Code.and my license rs R SIDS ENTIAL'F�� in full ctio 700(bofand PERMITISSUANCE CSFDWI 0KI"I CHEN REMODEL
unnor Claes Lic.a APPLIANCES-RESIDENTIALCADEE I]ON ❑PLUMBING RE-11WE
NZaa pale Currenctor CMULTI-UNIT CSTRUCfURAI,
ARCHITECTS DECLARA'T'ION PANELS MODIFICATION
zOyZ [understand my prom,bull hetmodas publienec�rdo UPTO 21X1 AMPS
OZ-- EJ INTERIOR OCHIMNEY REPAIR
Mt:F4( Licensed Professional 201-1000AMPg IMI'ROVISMEN'1' OSWIh1h11NG POOLS
W W 2.j - OWNER-BUILDER DECLARATION OVER RKXAMPS C BATH RE\40DEURITAIR ❑DEMOLITION
W a a Q 1 hereby a1f nn that 1 am exempt from the Contractors License Law for the 0OTHER
X O L U Following rcnson.(Section 7031.5,Emincas and Professions Coda Any ca,nr county SIGNS ELECTRICAL
413 LL y which requite,or permit m consume,alter,improve,JenniliJn,or nyur any morlurc
01' pdmurmissuancc,also rcyvirtsrhe aPPlicam for such#crusta fleesigned srammenl SPECIALCIRCUII'/MISC.
} Ihahelsllr,rucpoverattedaprovwarrofnce Comrecurs Licence law(CTapmr9 COMMERCIAL
6�Cthmhei.seng with Sectio]INN))of Division 3 oOhe Business and Professions Cods) 'TEMP.MMER OR PILE INST.
(buthe Inc
C., xennp,therefnnn and the bssis Ibr the alleged exemption.Any vial ra Of C NEW BLDG/ADDITION C DEMOLITION
k m_LL SeOion103 LS hY any applicam fora Krmif suhjems rbc applicam,oarnil penally of POWER DEVICES []TENANT El 1700D SERVICE
ad
C' nnunom than fee hundred dollar,($500), IMPROVEMENT
E20 C Las owner of the pmpeny,or my employees with wages as theirsole compensation. SWIMMING POOL ELECTRIC OTHER
F• will do the work,and the structure is not intended orolTcmd for sale(See 1044,Holiness
Y300o and Professions Cade:The Contractor's License Use Joeal,napply to an owner of OUTLIII'S-SWI"ICHF.S-FIX TURES
property who builds or anauves fheredm.and who does such work himself or through NEW RESIDENTIAL IiLECB SQ IT.
his own employees.provided that such imprm'emenm are unintended m offend for SQ 14 FLOOR AREA $/SQ.FT.
sole IL however,the building or impmvrmenl is snlh within ane year of compininn.Ire
� cr-builder will have the burden of pawing that M Aid not build of improve Int pur-
1 putt of sale.). TOTAL:
Fl I,as.wavoid foe pm,ny am exclusively comment,with licensed contractors u
consumer the project(Sec.70,14,Business and Professions Code:)The Connector s Li- FEE
xe Law does not apply to an owner of property who bunds Or improves themen.and QTY. PLUMBING PERMIT
homnuacu fnsuchproje fowith n eonouctor(s)licensedpursued to floc Contmmor's
nuense law. ISSUANCE
,N&PC(m this..,an PERM1IIT'
I am exemm malar Sec.
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owner Date
WORKERS COMPENSATION DI!CLARAI']ON BACK FLAW PROI'PC I'.DEVICE
IIsby anion venter penally of perjury Uncof Ire following Jttlmsumax:
I have unit wit l mainmr.Cenificatcof Consem mself-insure for Waders Cominn- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSIRUCTIO
,moon,us pmvidla for by scene.3100 uT the Labor Code,for the perfarmsnec of the FIXTUR BS-PER'IRAP
work far which this#emit is issued.
1 have unit will maintain Worker's Compensation Insurance.as required by Section GAS-IiA.SYSTEM-]INCA OU'1'hETS
J1(M ofthe Labor Cede,for the Performance ofthe work for which this permit i,issued ICC.GROUT' AI'N
My Wor C.
F pensmi L#, cp Tier and Policy nu a¢: GAS-F,A.SYSTEM-OVER 4(EA)
Carrier: � Policy ROM
CERI'IFI ATE OF EX1i (TION FROM WDRKIiRSGREASI%INUUS'1'It I.WASTE INTERCEPIUR
COMPENSA'T'ION INSURANCE BUILDING DIVISION ITES
GIIis.section need not be completed ifthe permit is foram hundarddallars(5100) GREASETRAP :ELE�RIC
IECK FEE
or lass.)
I eenil'y that in()in Performance Offal work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FS' FEE
not employ any person in any manner u)as to become subject 1.the Workers Carolina
Z s.Iian taw,of California.Dam WAI'IiR HEATER WNENT/ELECTR G FEE
ZO Appficam f
N N(TfICE'10 APPLICAN 1:IL after nuking this Cen'IEoale of Exemption.you should WAI FR SYSTEMITREATING
a ; became,object m the Workers Com tion f the Labor Cade,yon aur IiH
#cure nnndrsmn.0 O
� > front, th comply.lin such provisions or Nis permit shall be,deemed revoked. WATER SERV ICE 1.
r,
� zCONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMIL tiQ.IT. Date clip,
GQ I hereby offnn fluuhcre is n r I,mac.inn lending agency fill'he perhantancc of
,he wad for which tom Permit is issued(Sum.5091.Civ.C.) 'TO'AL.
0 I"' 1<nder,Name
V Lender's Address r
�+ 1 ounify,het I have mad air,application and sum thuube above infonrw,ion is BUILDING FEL
FNcumor.I agree to comely with all city and countyonrnances and slate tows relating m QT'Y. MECHANICAL PERMIT FEE FEE.
U Z building construction.and hereby amrmim representatives oflhis city to enter upon the
abo ve-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE IC FEE
(Wel agree m save,indcmnily tmJ keep hamtics the Cary of Copenino regains,
l liubilo,ca,judgments.coo,unit expenses which tray In any way norms,aguin,lsald City ACI HR OR ADD'I O MECH. ING FEEin con"Nerce Uf the granting of this pc t.
APPLICANT ONDEHSTr\ S AN LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) NICAL FEE
OURCIi REGUL�� AIR IIANULING UNIT(OVIiH 10.(X)0 CPM) RUCTION'I'A%
Signor of Ap icanJContmetor /r ]] /Dme EXHAUST HOODATHOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WilltM nPPlicnm or fuwrc building rccupum sure or handle hazardous material HEATING UNIT(TO Iba.000 BTU)
as defined by the Cuperlinu mericipd Codr,Cbupmr,9.12,nn i thc Victim and Safety HIiAfING UNIT'HOVER 101,00011TU1
Code.Section 2553201"
❑Yes VENTILATION FAN(SINGLE RESID) PAIDO
Date
Will the uppliaunt nr tLmrc building occupant use equipment or devices which BOILER-COMP(3HP OR Istria)BTU)
emit hamnloo,air communicate tet defined by,he tiny Arco Air Quality Managemcn, I
�Dienia? ' BOILER-COMP'(OVER 10,000 BTU)
CYe, 7rvo
AIR CONDITIONER ISSUANCE DATE
I Lave and the haauNom mumrial,re,airemmna
es adChapter 5!15 0l the Cali"
Parent';
K Safely Cade.Sections 5,255))wd 25534.1 understand than if the Slow RESIDENTIAL MECPH. SQ.FI'. /-` 7`
buildingdoe,nour haves au11i,n,Y fmsibilitymnoli(y,hewup. l
The aCeific -flAcuPancyrah mare ,Prnr J ��
Owns faro bed a D m IOTALt ISSUED BY: A
OFFICE