S 0812 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE51'r NO.
BIJII.DING DIVISION APPLICATION/PF.RMI.1• PLUMING-MECHANICAL - J 0812
-' BUILDING PROJECF IDEN'pffricA'r1ON
B ILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'PI'AL DAL
21743 ' o a.l,I Coo Cu Q ,)
OWNER'S NAME: a I10NH: CONT C'I'OR'S NAME: - LIC NO:
RAs( IN �- u 2 ) NIC CONTROL#
�ARCHITECTIHNGIN EER: IRA):): AOORESX ❑
CONTACT: PHONIi: BUILDING PERMIT INFO NYCH
❑ Consultant Fees Paid by Applicant(Initial) BLDG F,LECrrh
'I' PLUMB �.ctf
❑ ❑ ❑ yP"
LICENSED CONTRACTORS DECI.ARAGON QT'Y s ELECTRIC PERMIT" t FL^li -
q Ihereby abfirthat 1 licensedud pn i. f Chapter 9(conmene g '' JOB DESCRIPTION
WOZO wino Sect mn 90t%)d lyveion.341he nos sr, tad Pr(.:ons Corr andnoy incomers vl.l<MII ISSUANCI. RESIDENTIAL:
F-,— full force and eRecl ❑SFDWL ❑KITCHEN REMODIB.
<—U License Class Lic.p nPl'LIANCIiS-RIiSIDEMI'IAf. ❑ADDIT[ON ❑PLUMBING RI PIPE
ZZW we Comamor
F.Orn ARCHITECT"S DECLARATION - PANELS ❑MUER-UNIT' ❑S1RUICTUtAI.
ZO Z Iunderstood my,].,,bull be mcdas,,hire records MODIFICA'ITON
UP TO HXI AMPS
O Z I-Q - El INTHRIOR ❑CHIMNEY REPAIR
W Licensed Pmreslonm - 2t11-UXp AMPS IMPROVEMHNT E]SWIMMING VOOIS
,��•J
OWNER-BUILDER DECLARATION
1 hemhy afOrm'hat I ton esempt rima the Controem's License Law far the OVER 1000AMPS ❑BATH REMODEL/RIPAIR ❑DEMOLITION
i,q�j5 O a U following reason(Section 1031.5.Business and 1'rnfes,mr,Code:Any city or county SIGNS ELECTRICAL 1111:1
I�s 3(�F which reyuirtx a permit m v tor,improve,demolish,or repair n, swcuu.
,g]�f0fnn im,hei Hmersm Lim,mr,Care,orl totheapplintm lar xuchpnu's Licevslsnednmpter9 SPI?CIALCIItCOI'r/MISG
,Wy tha arrepoaascdpwuvn700(hpmvinlom ofthocBmintoorlallomeLaw(C ushoor
Ia+I�a0�0 (commencing with Section 9gXB ofDivisinnJofthe Business anA lknfesaionx Gslcpn TEM(`.h11!f13R OR POLL•INST COMMERCIAL'
dkiy5 e C oho'he is excnoq the and the basis roe oho u11c,cd exemption.Any violiainn of ❑NEW HLDNADDI'1'ION ❑[)INITIATION
-
W�rn Section 7031.5byas,applicant ferapermi'subject.,thcapplicunl ,,a civil penalty of POWER DEVICES TENT - ❑FOOD SERVICfi
hZ> not more then Five hundred union,($500), IN N OVEMIiNT
E6 D 1,as ownerofthc prnpny,or my empinyeee with wages as thea sole amspena:ninn, SWIMMING POOL HLECTRIC
of
CF'o will do the work',and instructor,is not intended oroRered Faso,(Sce:91)44,Business 'IR
aceto and Professions Cale:'fhe Con'mcmrs License Lax does not apply a an toner of 0UTTErpS-SWITCHES-Po%TUR13
- prnpcny whomilds or improves thereon,and who does such work himseltor through
his own employees,provided that such Improvements are nm intended or offered for N17W RESIDER'(IAL ELEC'I'It -
sale.If,hooves.,the hi ildingnr impoommm issold within mmyearofcnapletimn.'he SQ.PI'.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving'hat he did not build or improve for pnr-
pmofsele'). I PAID
I]I,as owner of the pmpeny,am exclusively contracting with licensed cnmaoo
ns to TOTAL:
construct the pl t(Sec.7044 Business and l fee ' .Cd )TLContractor's Li-
come Law d :n property who n ld: improve,ilwoom.and QTY. !PI;UIvHBNG PERMIT 1' FCE �Ilp y(g 8
win i lae
n 's for such with a corporations)IiceasWpursuant p rsuanthemu V
Contractor's �A4f
A.cense Law. PI RMIT ISSUANCE �1L17 V
l.,it exempt undo,Sec ,B&P C kit this retuon /" Ty C):
Owner s Da¢ AMER-DRAIN&VENT-WATER Iit) ATION
OR t':LO PINSATR)N )ECLARA'r]ON BACK FLOW PRGT@a'.DEVICE
IM1ereby affirm n 'r penalty orperjury, .(the following declaration,
❑ IM1ave amd will main vCenificate of Conan (melt-ioeare lin Worker's Comp.- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONS"IRUCI'[ON
svEnn,as provided lin b Section 3900of the L.1-t-Cid.,for Abe proornwnce of be -
week for which this aria is i,wwd: FIX'TUR IS-PER'I'RAP
I] I base and will nomomin Worker's Cmmpasmion Insurance,as reyuirts by Section '
371X1 of the Labor Code,for the perfammao of the work for whichmis,Anita,issual. GAS-EA.SYSIPM-I INC.40MLIIIS OCC.GROUP APN
My Workers Corrigan...ma In.mance mermid Policy number are:
Currier: Policy No.: GAS-EA.SYSTEM OVER 4IEA)
CERT'IFICATI:OP fix 1?MPI'ION FROM WORKERS' -
COMPENSATION INSURANCE GREASEIINDUSTRL WAS'T'E ED INCEPTOR
_ BUILDING DIVISION I'11I1ii
Glixecetion Becalm'Mecompleedifthe grit is tritium andreddollors(SHM) CREASE'I'RAP.
or less) PLANCI IECK THE
I comfy that in Ne performance ofthework!orwhich this permit is issued,I slmll SEWER-SANITARY-S'FORM EA,200F'p..
no'employ any person in any manna sn as to become subject m the Workers'Compn- L'NP.RGY FEE,7, smi n i Laws of Calilbrnia.Date WATER HExTER W/VENT/HI.ECTR
ZApplicant { GRADING FIi1i
y NOTICE TO APPLICANT':If.after making mr,Ceni irme of lixnmpunn,you should WATER SYSTENIGREATINC I
abecnow suhN,r m the Worker's Compensation pravisin i Aline LnMrr Code,you true' SOILS 9SF.
LkJ forthwith comply with such provisions crfhis prit shall he deemed revoked. WATER SERVICE -
Q
:Dz CONS TRUGI]ON LENDING AGENCY NEW RESIDENTIALPLMI SQ.FL PAID
U C) I hereby olRr that them is a construction lending agency for the performance of Dae Rcccipte
the work for which this peri'is issuul(Sec.3097.Cry.CJ
O Lender's Nmne '10'1'AL:
fenders Authors, TOTAL:
s�•r 4 I cemify ohm I have road this applicminn and stme'hin the dnwe information is / - . _ BUILDING Bili
V) correct.Iagree a comply withnll cryurd c.svntrordinnnces and nwro lows relating n' QTY.' " 1( M EGI IANICAL PERM IT FHH
U Z huilJingenn.awminn.andherebyamhnrizerepresenmtivesoflhisciDmvmerupntbe - SEISMIC FEE
aMsve-mentioned porosity for inspection prase., \
(We)agree m sane,'adcrmiby and keep harmless the City of Colmnlno agalnxt PERMIT ISSUANCIi HLECI'RIC FEE
liabilitics.judgmenu,cnstx end capen.wa whichmay imm,paryacnue ogains'eaid City ATTER OR ADDTO MECH.
in consequence of the granting of this peril PLUA113INC itleli
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT ABR HANDLING UNIT Or)IIIJIBB CPM)
SOURCE REGULATIONS. MECHANICAL FEE
-0 1 �, ',� / AIR HANDLING UNIT IOVliR 10,(X1(1 CPM) CONS'I'RUCTION TAX
Signmu AppV12(lal
/Comrvclet Da'u F.XHAUS'I'H60D(W/DUCT) HOUSING MITIGATION FEE
AZAk0005 MATE LS DISCLOSURE
Willtheam nr homrc buildia,il'om smrmorhi lie Mardon,mumrial HEATING UNITfTO 11,0X0 BTU)
rims Municipal Code.Chapter 9.12,and the Health andSafmy
]? BRAYING UNIT(OVER I R X)BTU)
E)Yes 0 N - I'AIU _
V AIN'I'ILA'I[ON FAN(SING LH RES I D) Dam Rea'ipta
Will the applicant or furore building occupant use equipment or devices which-
eBOILER-COMP 13HP Ok IIN),OW RTU)
emir. air contaminants as dcli'ned by the Bay Arca Air Quality Manogssrent 'TOT'AI_Diane' BOILER-COMP(OVER 100.[)00 BlU)
(].Yes [-I No -
si• -
ihavcrealthehazurdousmvmnatsreyuimment.under Charter R.'JS ofhe Culi- AIRCONDI'GONER ISSUANCF DATE
basic Heahh&Safety Code,Sectiom 25505,25533 and 25534.1 undor mnd'ha if the NEW RESWENT'IAL MECII. SQ.FT.
building doe no'earn.•ndy have a moan,that i'Is my rcepnnsFility to omify nhe,ncmpan' V
.(the o«4uirement,which most he me' our m issuance of v Certificate M Occupawy.
Owner nr uuthanzed Agent - Date "' IOTAL'. - ISSUED BY: ���� • r
OFFICE