S 2079 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE I I
BUILDING DIVISION APPLICATION/PERMIT PLumnINCMECUANICAL No 2079
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUIfMITTAI.DATE
ONNtiR'S NAME'. ♦ PHONE: CONTRACTORS IlPALl / A LIC NO:
'ylI'/1` I/e`�e%'L/-e N/C CONTROL#
ARCHITECUENGINNFER: LIC NO ADORES,'�S:- . ❑
CON'T'ACT PHONE, BUILDING PERMIT INFO
--(\(Vi &&0_969,.(IQO ❑ Consultant Fees Paid by Applicant Qnitiap BLDG ELECT PLUMB MECH
l ❑ ❑ luii-, ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FLE
I hereby affirm Ili.(i am licensed under paws ons of Chapter (commencing JOB DESCRIPTION
�XZ m5eaien9wn)ofDivision3 ohne euamcsa anA Pn,fesinna COU'lndmylicellae i, PERMIT ISSUANCE RESIDENTIAL
I E„�Oti ntfull Ili it a a, Z ❑SPDWL ❑KITCHI?N REMODEL
ItUU Licer", lass o lie.# S 22
It U'U A77Z Gcyylr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F d VI Delc Gmwmor/f
N5N ARCHITECTS DECLARA'l1ON PANIiIS ❑MULTI-UNIT []STRUCTURAL
Z O m Z I understand my plans shall he used as public records MODIFICATION
to UP TO 200 AMPS
OZ-�� [I INTERIOR ❑SWCHIMNEY
MING POOLSREPAIR
rr•,we�l Licensed Pon fmsional 2111-10(Lf1AMPS IMPROVEMENT E]SWIMMING POOLS
^� OWNER-BUILDER mDECLARNI Contractor's
OVIiR 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
ed PSS a 1 hereby n[fimt that I ran exempt from Lha Comramor'a Lienee Law for the
x3LU fall g (Section 96115 Barrels dP f i e,Cd'A y 'tyor wumy SIGNS F.LF.CTRLCAL ❑OfHER
W W N Wh 1 y pe I I .. 1 II 'np d oli h p' any x.maere
F-.Od
prior its issuance.also requlrcx lM1e ppl wolf hp mI. fl '.g d,mm Dent SPFCIALCIRCUIT/MISC.
W teat he is licensed pursuanno the pmm
vininnsoflie OaneadoW,Licema Law(Contact 9
WXO0 (commcncingwith$eclion9000)ef Division 3 of We Business and Professions Code)or TFMR.MET ER OR POLE INST. COMMERCIAL:
Ibut Ito is exempt thaefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Semina 9131.5 by any applicant for a permit subject,the opplucart to a civil penally of POWER DEVILS ❑TENANT ❑FOOD S17RVICE
nal mote Than Eva Imndred dollars($5A)).
IMPROVEMENT
�d0 ❑ I,nsawneroflhe pmpany,ormy employees With wagcsne theinnlemmpcnsmion, SWIMMING POOL ELEC'T'RIC
will do(rework.and lhesloolore is nmin.endedo,iAlared fasnle(Sec.90mLBusinas.s ❑OTHER
LR es and PrnTax,inm Cuda:The Conal Lia,c Law encs nnl apply ,,an owner of OUTLETS-SW ITCHES-FIXTURES
6 property who builds or improve,happen,and who does such work himself or Through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'.
,at,.If.howevegthe building orimpmvement is sold within one yearofmmplction,the / SQ.FI'.FLUOR AREA $/SQ.I*I'.
mwerabaildec Will have the burden of proving That he did not build ne improve for pur-
po�e of sale.).
El 1,as owner of the property,nm excluei ely contracting with licensed cnmmcmrs to TOTAL.
omtruci the pmjed(Sac.9144,Business and Prolfixonas Cale:)The Contractors Li-
elawdoeslolapplytoanownerofpropertywhobuildsorim,roves thereom and OTY. PLUMBING PERMIT FEE
wli
i o contract,for such Proper,with a mmmnarb)licensed pnrruannn the Cenlmemr's
Ise Law, Z PERMIT ISSUANCE r
am wicalrode,SIL, .- - -- E R P C for'his moron
—+r9-YlOY ALTFR-DRAIN Re VENT-WATER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby effort under penally of perryry one of the fallowing declarations'.
❑I laic and will maintain a Certificate of Cmnenin self-insure for Worker's Gnnpen- DRAINS-FLOOR,ROOF,AREA,CONU. STORIES 'I'YPECONSTRUCfION
nadnn,as pro in thi f r by Section 39TH),(the Lnhor Cade,far the pcdarm:mce of the
work Trrwhichthispermitit orker FIXTURES-PER TRAP
❑ 1 have and w111 nmimain Workers arecidsanion work
I.,chi as squired by Section
39011 of the Labor C,de,Teethe parformanceof the work far which this pencil is is,ued, GAS-13A.SYSTEM-1 INC.40U'L'LET'S OCC CROUP APN
My Workers Compensation losnntnce wrticr and Policy nandom and
Carrier. Policy No, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORK17RS'
COMPENSATION ININSURANCEGREASFJINUUSTRL WAS'1'Ii INTERCEPTOR 177
' BUILDING DIVISIQ PCES _
(This secdonneed no,recnmplamul ifthe pert.:.is Tonne hundred dollar'($100) GREASETRAI' -
or
It,,.)(This
BBE
I ccnlfythat in the perfonnxnceofthewark for whichdis pnn il,,aIa ed,Iebull SEWER-SANITARY-STORM EA.200 fT.
not employ any person in any manure so as to became a.......Ir 0e Werian's'Core", ENERGY FEE
zzi talion Laws Df Califord.Dale WATER HEATER W/VP,NT/ELECTR
Q Applicant 1 GRADING FEE
NOTICE'r0 APPLICANT:If,after tanking this Certificate of Idw mition,you should WATER SYS FEMITREATING SBILS FEE
beeonm subject Io the Workers Compensation movi,imw of.he Labor Code,you must
LaTJQ Ta.hwiW comply with such,u,,,i.nsa this Numit,ha116o deemed revoked. WATER SERVICE -
CONS'I'RUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ,UE PAID
UO L hereby affirm Par them is a construction lending agency Pathe pedhatiot'd I Date pl#
due work for which this pamit 1,issued(Sea.3097,Civ.CJ
Leader's Name TOTAL'
U Lender's Address T
�+ a n i 1HOUSING
UILDING .E
1 ccni[y IM1m 1 htrvc orad Ibis application and xlate Ihauhe shove infonnntinn tc
�i (Z) amrer.I agree di comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT 'FE
L) z building construction,and herehymlhorize repre,emmivee ofihis city In enter upon the ISMIC 'E
albove-me.daned pmpeny for inspection purposes.
(Wq agree Io cave,indemnify and keep hurmle.+s the City of Cnpenino against PERMIT ISSUANCP.Iiubiliuesjudgmenq costs and expenses which may in any way aecma against said City ALTER OR ADD TO MECH.in oe,actenee M tiro granting of this permitUMEIN PEE
APPLICANT UNDERS'T'ANDS AND HILL COMPLY WITH ALL NONAOINT AIR HANULINO UNIT(TO III,nII CFM)SOURCEREPULATIONS. GCHA AL PEE
AIR HANDLING UNIT(OVER 10,0(0 CFM) ONEfRUC GNTAX
Signature ofApplicanVContractor Dale EXHAUST HOOD(W/DUCT) MITIIATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lhcappticantoe future bu0dingnccupint sore or handle hazardosmatet'ial HEATING ONI'IT 0100,000 BTU)
as define by the Capable.Municipal Cade,Chapin 9.12,it ],Is Health and Safely
Code Section 255321a) HEATING UNIT(OVER 1biloo0IT I'U)
El No PAID
VE'N'TILATION FAN(SINGLE RESIU) Data Receipt
Will the air containments
or mmre buildingby the nay Area ipmcnl Quality
M nagem nt BOILER (31 In 012 MILE)BTU)
emit haeaNuus air comeminants as defined by the Bay Area Air Quality Mamtgement
District?
❑Yea LIN. BOILER-COMP(OVFIt IOq(LOB BTU)
I have read.he hazardous ars is r' w under Cinque,6.95 of the Call- AIRCONDITIONER ISSUANCE DATE
25533a
fantio,diastu ctrouCnde,Sealotn25505,25533and25534.1Imdersmnd Thai if the NEW RESIDENTIAL MGCII. SQ.PI'.
build,nguiremenmremdyuns[be met prior
hat ro is ntanceof Certryrateofy Neoancy. ��- -2-
drills,
of tae requirements which mull be met prior m issuance nfa CeaiOmte of Occupancy. o
Owner-orumannoed agent Dole TOTAL ISSUED BY: �I
OFFICE