S 1563 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDNG-ELECIRICAI, PE n'NO.
BUILDING DIVISION ': APPLIcxrION/PERMIT PLUMBING-MECHANICAL. � 1563
BUILDING PROJECIIDKNIDTCATIUN
BUILDING ADDRESS 44bSANITARY NO. APPLICATIONSUBMITIAL INTI:
n/ 40f�a Ni me �#A�6alz
U NER', ME: PHONE: C(l "HACTOR'S NA LI
sAt" .II ' uCI I'It .p
.� /. 'INE: : DC NO', / DRESS: `/ HL IIS❑
l/Y
C TACT: PHONE BUILDING PERMIT INFO
l-
/D `5 �(� Consultant Fees Paid By Applicant(Initial) ILLIlG HE PLUMB MH❑CI1
LICENSED CONTRACTOR'S DECLARAT )N / QTY L•I-GLTRIC PERMIT FEE1 hereby affirm that l am licensed under provisions of Cbm
apmr 9(Car. JOB DESCRIPTION
WOO wnh Section 7(0X).1 Division Sof the Business and Professions Calc.aPERMITISSOANCISSUANCEnd my license is RESIDENTIAL,
'
F- full forco aUFct. ❑SFDWI. ❑KITCHEN REMODF.1.
CIa+^�-/ —Lien APPLIANCES-RESIDENTIAL. ❑ADDIT[ON ❑PLUMBING BE PIPE
1- IQ I e [O—�Y�Cnnunanr
GG �J ARCHITECT"S DECLARATION 0MULTI-UNIT ❑tiTRUCfURAI.
z O ti z I underamnd my plans shall he used as public ccurd, PANELS MODIFICATION
OZ-O UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
72z
ficensal Professional 201-10010AMPS IMPHOVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑HATH RF.MODIT-REPAIR (D DEMOLITION
a uu]]a 1 hereby vmrm Ihm 1 nm enemm fro mraco a, e Cmu -v Liecac Law for me
O L O following (Section 90913.Basincss:cod Professions Code:An t I ❑oTHER i_.Q:» In AI
W3WF- Any or SIGNS ELECT
y wh h 1 p tt i th J I M1 p ysructlx
F'1Od psi, t its q ' .tl IPI'' If ehp tl M aged snamneu SPECIAL CIHCUI'1'IMISC.
�y-4 thnhwIfiecnndporsaammmepnv...' ..of the Councl License tr (Chvplero
(commencing with Section 7000)a]])is ixion3 of the Business and Professions Code)or TEMP.MEIVR LIR POLE INST. COMMERCIAL:
a CL e y that he is exempt therefrom and the basic for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�M LL• Section 7031.5 by any applicant for a parrait subjects the midicmtuo a Civil Penalty of POWER DEVICES
Imo, sei El TENANT ❑FOOD SERVICE
nom
t ore than Eve hundred dollars($50n.
^� QO ❑ 1,as owner of thepropany,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVF.MFiNT
a o willdome work,and theswaure is nil a mended on.trud for ade(Sm.9094.Business ❑OTHER
W m and PnrmWees Code:The Coil Licennc Law docs not apply Io an owner of DOI'[.H']'S-SWI TCHES-Fix'III,
property who builds orlmproves thereon,and who does such work himself or mom,fi
his own employers. proventcn NEW RESINES HAL ELECTR Sofc
p y.the provided thus such cot is v¢ou intended or offered Lor
sale If,however.the building nrimpmvcmenl is sold within nnc yearnRomplefionsibs SQ.ITT.BOOR ' LSQ.IT.
owner-builder will have the MuNen of proving that be did not build or improve for pur-
C] 1.as
APR
L as owner of me property.trot exclusively ly 11revcting with t I heeCommmaors i T sats 7
cause1, the prnj,ta(See s,,m welluxs 3131,01'ndesit to Gldea The C,drier,Li ao
cause own arofpropany whored pursuant
rant to
o the Coca,and QTY. PLUMBING PERMIT Flili
ens b
whe contracts for wch projects with nunnructor(s)Iicense0 punuaan Wihe Contrannr's I'I (Jf-
Licaric 1-w. PERMIT ISSUANCE
❑1 am exempt under Sec. .Ir&P C form,reason
Owner Dare ALTER-DRAIN&VENT-WATER Q'.A) VALUATION
WORKER'S COMPI'.NSAI[ON DECLARATION BACK FLOW PRO9FCT.DEVICE
I herehy dl lar under penalty of EcrijnD one of the following declaration'
� Ihavemed will nm arcur a CeniOc'mul( atloaclf-inswe for Worker,Content- DRAINS-FLUOR,ROOF,AREA.C(lN0' S'TOItIf3S 'I'YVE CONSTIIUC'I DON
inion,as provided for by Section 37(m al tire Labor Cole,for mt
me pe,foanca of the
work for which this permit is is,nod FIXTURES-PER TRAP
❑ 1 have and will ntalmam Wakeek Compen.mtion Insurance,as reyuireJ by Section
lIIp of rhe laMm Gratia,for rhe pedormantt of the xork for which
111hpem,i1 fit 'e`I. GAS-I;A.SYS'rE;M-I INCAOV1'LMS OCC.GROUP APN
My Worker's Compensation Insurance Cartier and Policy number /`^7-1_ hA�d�!_J/-1 O
alines. 11 Ley Ne.: 'AS-EA.SYSTEM-OVER 4(HA)
CERT IPICA'fE OF EXEMPT FRO GINS'
COMP17NSAI'ION INSURANCE GHEASEANO1 IS'I'Rl.WASTE IN'I IiRCiil'IOR
BUILDING DIVISION RHES _
Olik,relnn Cecil nil be complcmd it In,permit is for one....dreddollarn(S10k) GREASE,RAI'or let,) PLANCIIECK FEE
Icenifytha imhe performance ofthework forwhichrhispennil is iasued,lsbnll SEWER-SANITARY-STORM E\.list FE
oat employ any perm in any manner so as Er Footnotesubject unhe Workeri Compere ENERGY PER
0 Z •inion Laws of California.Date WATER HEATER WNENT/ELECIH FEE
Applicant GRADING I
NOI'ICH'f0 APPLICANT:If,afmrmaking this Cereficate of Hxcmptioo.you Whoa lel WAIHR SYSTEMfI REAPING
hccome sab,iecl Io me workers Cantpac ial"a provisions of that I.al Cade,you ams. SOILS PEE .
0mhwim comply wim Irish previsions or this, an shall be donnedrevoked. WATER SERVICE
a0
Z) Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
G0 I herebyaffum that there is a Construction lending agency for the performance of flare Receipt#
the work for which this permit is issued(Sec.3197.Civ.C.)
Ol'" Lender§Nome 'IOTA[.:
{U Lender's AJdrecs TOTAL:
1 Certify than I have revel this appllc:nlon and stem Ibm the above Intoonminn Ix BUILOINO ITA
tai] correct.lagree nicoetplywhn all city and county orJinnnces cold sat:am laws mlaunS la' QTY. - MECIIANICALPHRMIT FEE
U '7J. building wnnrualnn,unJ Hereby aumnriec rvprescnmtives of thin city ni color upon rbc SEISMIC FEE
aMwumcntioned,al for inspection pnposes' PERMIT ISSUANCE(We)ago¢m wve,indemnify and keep costive City of Cupcnino aguiml ELECTRIC FEE
liahiliries
Vdgmemstsandexpenses is a inany way accrue against said City ALTER OR ADD'1O MECILmnvueumingof nitPLUMIIWG FEF.NTAN AN WIl. OMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 1(1,00X1 CFM)
NS. MECHANICAL FEE
AIR HANDLING UNI'P(OVRR 10,I0)CFM) CONST RUCI ION TAX
Sign r d AppliGnVConuacmr Data F.XHAUS'T HOOD DODUCT) HOUSING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi11 the applicant nr fumrc buLlding rwcupam store or handle hermdous material ((EATING ON]'PTO 100.000 BTU)
as defined by the Cupention Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25592(0)! HEATING UNIT(OVER 100,000 H'I'U)
E-]Ye., L]No PAID
VENTIhAI'IIIN PAN(SINGLE IIL'SID) Dam Rocciplq
Will d Inc oepllc ec m Tama,building occupant use.Air she or Cicalas which
emit hvmdnm air cumvminent.m JethmA by the Ray Ana Air Quality Management ROILEk-GGMP(741P OR 100,IM0111'ID)
District? 'IY)TA L:
El Yee C]No BOILER-GGMP(OYER IW,IXX)B'ITE
I havemad rbc horooll Orinnal,re,moreents under Chapter 6.95(if lhe Cnll- AIR CONAL"I IONHR ISSUANCE DATE
firma Health&Safvty Gale See, 25505,25533 and 25534,1 understand Ihat if me NEW RrSIDEN'I]At,MECH. SQ.FT.
building docs nil Corn allylaveaHnnl,min itn aryr.Pnsihiliry lousely the r r puna
ul me requlremenl,which mml be met prior m Isodose via Cenilicu m of Orc puney.
Owner m authadxed agent Data TOTAL: ISSUED BY:
OFFICE