S 2331 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICA7•ION/19?RMIT I'I,CMBING-MECIIANICAI, S 233
BUILDING PROJRC'1'I..6R,IFICA'TION
BUILDING ADDRESS f Prior-1
/ SANITARY NO. APPLICATION SUI1 h111TA1,DATE
S-OJi IV /V
OWNI3ItR ry e p Cae� ,}'ll l li: ,5�tr� INIC CON'fHOl.p
ARCIUTECf/ENGINEER: PLIC NO: ADI•JI�C1yiJy}/�- T-e&00 IQ
CONTACT PHONE: / � "�ClA/� X/IL BUILDING PERMITINFO
/ /�D ,r ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PER cu
/7 ( (7 N El ❑1
LICE SED CON'I'RAC 1014-S DECLARNI'ION
p Cry ELECTRIC PERMIT FI7E
1 hereby:drfm that 1 apmvlsmmnm Rcensed under t Cha ter 9(commerams JOB UNSCRIPTION
D�'Z 'th Section 2UXp of Sof the HuseanJ l'm'ession. d d sy.La� RESIDENTIAL:
InOX mad �a( PERMITISSUANCE
F Iy.. mfull force am - C�`D 5 7v sw is ❑SFDWL ❑MI'CHENREMODE1.
�UU Licenw Class `^fclf AI'I'hIANCGS-1t13SIDIiNt'IAh []ADDITION ❑PhUMHING RLI'll'li
yZ W Dane Commet-
aARCIdUiCTSD1E. 1[ ❑MULAI-UNIT ❑SIR UCTURAL
p•D vs PANELS
zo,'K l understand my plans shall is used as public records MODIFICATION
O-t,-0 UP TO 2011 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fo,.,~; Licensed Prof..imed 201-1000AMPS IMPROVEMENT El SWIMMING POOLS.]
OWNER BUILDER DI?CLARATIDN OVI3k 1030AMPS El BATH Itl3MODP.IJRI:PAIk ]DEMOLITION
C Q 1 hereby attinn thin 1 ant exempt from the Contractor'•License Low for the
xoaU following reasea Section 9031.5,Business and Professions Code:Any city or county SIG NS ELECTRICAL ❑OTHER
W 1+y which requires a Permit to construct,alter,improve,demolish,or repair any swcmre
prior to its i......c.nl.o mouircm'om epPlicmn fnf inch Permit no file esigned indenter, SPECIAt,CIRCUII'/MISC.
�N`a mm hn i,Imemne ptlrsnamm tan vrov¢ionannhe commemr,License how febapterg
CLQ (commencing with Section IIXXDof Dlvisioe301 the Businessnnd ProfessionsCode)air TEMR METER OR POLE I MP
a a c C that he i,exempt therefrom and the Was for the alleged esanption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
et.
Section 7031,5 by any applicant for a permit subjects thenpplicam to a civil penalty of POWER DEVICES ❑'TENANT [I FOOD SERVICIi
tiiynounnre than five Inndred dollars($511fp.
❑1 ,os owntrol'aw property,nnny employees with wages us theirsolccrmtpeoation, SWIMMING PO L13 :C' IMPROVI3MI?NT
.XD will do the work,and the strucmtc is not imendedomfierod fill made(Sao.JOJJ,6uainesa ❑OT'HER
Wm and Profesinns C de:The Contractors License law does Inst apply m an owner of OUTLI:L:S-SWI'I CIi[S-FI%TUR
property who builds or improves thereon,and who dors.such work himself or through
his own employees,provided tont such impmvc"wer,amsol imm�dcJ nI'offered for
r NIiW ItIiSIDENTI A I.ELECfR SO PT
sele.11;however the building or improvement is sold within nuc yevrot camplclion the SQ.FI:pI.00RAREA $/SQ.EL
owner-builder will have the huNcn of proving that he did not build of improve for fm-
pose
ur- /t O
poseofrwlc"f
I,as owner of the property,.am extlusively common with licensed foolm lens In TOTAL: A
mslruet the project(See.7044,if Baines,and To cession,Comm—9Le Cunt.......Li- r
ate Law does not apply to an owner of property who builds of improves thereon.and QTY. PLUMBING PERMIT FETE ,IAN 8 RECRI
who contracts for.such projccu with a monercte(s)licensed pursuant to the Contmcmrs
License Use PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C far this renter
Owner Do¢ ALI'17R-DRAIN&VENT-WSJ ER(EA) VALUATION
+' WORKER'S COMPENSATION DECLARATION BACK FLOW PRICT ECT.DEVICE
/A
n hereby affirm under peeulty of per)ury ore of the following dechouirre:if I'avcond w........main.Qntifculo of Concent msnlf-insure outwork Compen- DRAINS-FLOOR,ROOF,AREA,CONE. S'T'ORIES 1'YI'I:CONSTRUC'IION
ulL
epmvidealliebySerbon 9903 or due Lahor Cole,l iethe perf.... neeofthe
work for which this Fount is issued. FIX'I'LRES-PER'I'RAP
❑1 have and will maintain Wmkers Compensation Insurance.am required by Section
3700of Ne Ldxm Code,her the mrmanceofthe work for which this mdit is issued. GAS-HA.SYSTEM-1 INC.a OUTLETS
per pe OCC.GROUP APN
My Wnrkcr' npcnwtinn Insun ce carrier and Policy null n,
Grrim',' ILilicy GAS-13A SVSTIiM.OVERd(HN
CLR'PIIICATE 017EXEMPfION FROM )RKP.RS'
COMPENSATION INSURANCE GRI:ASI%INDUS 1'RL WASTE INI INCEPTOR
BUILDING DIVISION I�IRaS
(Thisscaion need sol lsunupletedlfmc lwnnd is forone hundred dullnn(511XB GREASETRAP
or less.) I'LANCHF.CK ITE
Icnnlfythat inlhe Park m to re ofthewmk l'eabIh this farmit is Issued.l shall SEWER-SANfLARY-STORM PA.203 FI.
not nnploy any fervor in any manner so as m become subject to the Workers'Cumpen. ENERGY FEE
ZZ satlon Laws of California.Dom WATER HEATER W/VENT/ELEC'TR
O Applicant GRADING IEE
.-s NOT ICE TO APPLICANT:IT alternating this Certificarrod zmaindion,you should WA'I'EIt SYSTEM/TREATING
a ; become subject to the Worker's Compensation provisions(it the Labor Cole,you must SOILS FEE
forthwith comply withsuch provisions of this permit shall he deemedrevoked. WATER SERVICE
0. n
UO CONST RUCTION LEN DING AGENCY NEW RESIDENTIAL PLMB. SQ.PT, PAID pate 14¢ciptk
I herebyaRnn rela ohm theucmaracno lendinghgcne,forthe prd aruvm
nof
the w (Se1X)
work for which this permit is issued e.3 ],Civ.C.)
0 (~ Lender's Name TOTAL.:
U
Lender's Address TOTAL: BUILDING ITC
f� I certify that I have rend thio applicvan
ton d sate thin the above indentation Is
F-I rp enrrcct.I agree in mnoply withdl a ay and ennntynrdira a,enal slatelowereheln,no QTY. MECI IANICAL PERMIT FEE '
UZ building construction,and hereby outhorre,representatives tears city it)cater upnnthc SEISMIC FEE
above-mentioned property for inspection purfnses' PERMIT ISSUANCE
(We)agree It,save,indenmify and keep harmless the City of Culsninn againn ELECTRIC FIAT
IixM1ilitics,judguncnm:costs and expenses which may inany waynccmeagairel maid City ATTAR OR ADD'I'O MECH
in asequence of the grunting ol'I his pennh. PLUMBING FEE
API'. ;ANT UNDERST 1 AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONI'f(TO PAN)CFM)
S ERF.GULRI IN MIiCHANICAI.ITE
i/a/art, {�y//I AIR IIAND1.INf,11N1'f(OVI?R IO,Ip11 CFM) CONSTRUCTION TAX
u nc idYApplicllaftCCo��n�nanclou,III LLL111 ff(s� Dam EXHAUSTHOOD(W/DUCT) HOUSING MI'L'IOATION FFE.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hr7adom material HEAT]NO UNIT IT0100,000 Bt'U)
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Hcaltb and Safety
Coda Senior 25532(a)? E HEATING UNIT(OVER 100,0W)11'111)
❑Yesf7fNu VENTILAHON PAN(SINGLE RESID) PAID
Ilam Receipt If
Will it canamtimal,or c building emeby the nl use ay Aoaa impairment ordevices
Management
ROILER-COMPOHPOk IW,WD BTU)
n hneuudous uircontaminants as Defined by the Nay Arcn Air Quality Management TOTAL:
Dialud? Yes BOILER-COMI'(OVER 1001X10 BTI])
AIR CONDITIONER Ilmvo rend the hmardnusn mriels rtyuimmean under Chapter underswi of the Cali- ISSUANCE DATE
fomA& d 0th, Code,Sec s s 25511&25537 end nerd utd 6.95 of
if Cthe NEW O NDIRESIDIONNT R MECH. SQ,FT.
dy h: c aant,thrt it is myfcsrymsfulity to nutiry l baowupu�n]l
t trot ylyrhm to t rt ser C,niticat7tOac yCy-/
,Iftjl I 'J J -UI
U m awh red agent )a�'� TOTAL: ISSUED BY:
OFFICE