S 1778 (2) APP1-Jr,1k TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICAL PEt IT No
BUII'DING DIVISION APPLICATIONA ERMIT PLUMBING MECHANICAL 1778
BUILDING PROJECT IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMD-I'AL DATE
OWNERA iii PHONE 'S
CONTRAC�1 ::, /vo hICN :
fflLlL NAMIM NIC CONRtlLk
dCHITECDENGINEER: LIC NO: A ESS: ❑
CONTACT: PHONE isBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG +LECT PLUMB MECH
W/1' 4 /1r/y8 y9oy ❑ ❑ ❑ ❑
I.ICHNSIID CON TRACT ORS DECLARATION Q'PY. ELECTRIC PERMIT PEIi
I hereby amrm that I am licensed under Pockialu of chance,9(cam:uorins - JOE DESCRIPTION
0
Z wim Seaicn]000)af Division 3ofine Rosiness and PrIeVions Cale,and my license is -� RESIDENTIAL:O p PERM!I'ISSUANCIi
F1— in full force and effect ❑$FOWL ❑KITCIIIiN REMODEL
aU .icenw la. Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FZ ac Cnmmcna r,ti AllAila I
an sit All,CTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL.
F)o z I understand by plain shall be rowd as puhlis record., PANELS MOGRICATION
OZ`3� I1P'TO 21X)AMI'S []INTERIOR ❑CHIMNEY REPAIR
C-4„tw J,eccd Pm lexdooal ,201-11100AMPS IMPROVEMENT E]SWIMMING POOLS
,..I (1WNHR-HUIIAPJ2 DECLAItA'I'ION OVER 1000AMPS El BATH REMODHIJRIIPAIR ❑DEMOLITION
E5 o 9y w+gj�ow¢ 1 hereby aff rat.On 1 nm es ants from,he Contrue v Liceme Law for the
X 3 LL U Inllnwing reason.(Section 91111 5,Business and Pndesxlans Gyle:Any city or conmY SIGNS ELECTRICAL ❑OTHER
y which requires a permit m amstrvm,alcor,,mpove.Jnnnlixh,ar«pair my umewre //zi+� C'
F-11'�sle prior to its issuance,abar Inquire.,the applicant for such nemrino file a signed.mtement SPECIAL CIRCUIT/MIS
that he is licensed pursuanrto the provisions of the Contactors License Law(Chapter 9
�yQC (commencing with Seclan]IXX11 of Division J of the Businessland Professions Gxic)nr TESIRMIi ERORPOLE ST. COMMERCIAL:
that he In exempt domfrnm and the bask for the vllcscd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W..y Sconou7031.5 by anyapplican for a Permit subjects the applicant of a civil Penalty of POWIiIt DEVICES ❑TENANT ❑1,000 SERVICIi
not mom than Bva vol ]altars(5500).F�zd ❑ I,mnwne,nf Je arlwny,or oY cmwith wabres as their aolcssaPnls,ion, SWIMMING '(10FLECTRI
'
IMPROV!:M?N'
FQ will do,hew.rLand mcsaonat intended or offered forsale(See.]fllq Business El OTHER
mum is
ad 3 m and Pmfmsiom Cade:The Contredm's License Luw,does not apply h,an owner of DO['LIOS-SWITCHES-FIXTURES
property who builds or Improves theteon,and who does such work himself or though
his own employees,provided that such improvements am net intended or offered for NEW RESIDI N'I'LM.ELECfR SQ f4.
sale.If,howevrce the building car improvement is sold within one year ofcompledan,d¢ SR FII FLOOR AREA $/SQ.PT.
poer-hi ildef win have IIs harden of proving mat he throw build or impr:we for pitr-
sof cele.).
[:1 ],uv owner of the property, all exclusivaly eontrraminR will,licensed mnumrsacIII
TOTAL
manacl the project(Sm.71144.Business and Profession,C'odc,)'I'he Cal,I,,-
cruse Law dres avapply trial owner of partially whii builds or improves themon.and QTY. PLUMBING PER -.FEE
who coutmcty fnrsuch pnjects with a commnnr(s)IlcemxA pnwuum w the Cnmruanr'eIs
License Law. PERMIT ISSUANCE
plat ctjno;�,Ie,Sec. .B&P C Tobi,pawn
ALTER-DRAIN M VENT A'1'. 'A) - VAIDATION
wit Date U G
WORKERSandarCOMPENSATIUN DECLARATION BACK Iq,OW PROTECT'.DHVICIi
1 hereby off nn undtt Iw'nalty of perjury ane of the following daalnratim... �(�
❑ Ihava andwic mei by Section
37M afR,Labor self-inIn,the Worker's v,of Iry DRAINS-PIAf1R,ROOF,AREA,17GND' SIT)121115 TYPE CONSI'Itl1CTION
work f r provided car o Semite,3]W of the Labor eons.li,r the ferfnmmnca nl the
work for which this pconi:Is tarred FIXTURES-PER TRAP
FJ 1 have and will Coca
ton he perfs Comcoftte w rk(,I,e,ac required by Section
37011 Luhnr Gvde,fnnhe performance of me work lar which this permit is issued, GAS-IiA.SYSTIiM-I INC.40U1'LIffS OCC GROUT' AI'N
Ca Workers Compensation Insurance carticrand olicy or:number are: GAS-HA.SYSTEM OVER 4(EA) � Q
Carries Policy Nn:
CL•R'1'IIICATE OFCOMPE COMPENSATION
FROM WORKERS' GREASHIINDUSTRL I STE INTERCEPTOR
Q)MPIiNSAT'IQN INSURANCE ih VISION FEES
Ohisai Irecn nm be,or land ifmaper ix fonmc handreJdollon(SAXI) -
orlcnx.) GRBA5i?'!'RAI' P CK PI„
1 1 certlfy Ihm in the lwrfonaturee of mework fin or which this pormi,is ivsucat.l shall �7 e
not employ any person in anylnannerso uv to born SHWI3R-SANITARY-ST MEA.21X1 PI'.
nne.,nhject the Wnrkerv'Conq¢m � FF. fCl'II IIVIJ
oZ union laws of California,Date WATER IIEATEH WIVENT EL'CTR CRAVINGIEE
Applicant
4 H NOTICE TO APPLICANT:IL rafter making this Cenilicme of Exemption,you should WATER SYS'IT.M/IREATING
`K become subject to the Wori Compensation provisions of the Labor Code,you all SOILS FEE
Ruthwlm comply with such provisions or ds permit shA l he defeat remked. WATER SERVICE
a Q
CONS'I'ItUCIlON LENDING AGENCY NEW RIiRIIIIiN'I'IAL PLMB. SQ.FIT, PAID
�. � Uom ItmciplM
U O I far whit irnnl,at nom iloved(Socdan lc,Cie ugcucy fordo pa,fnrnumcmrl'
the wok for which ih.,Iermil is iswod(So'.JIM)],Cie Q)
u' h Isnder'x Name TOTAL:
U Lcnncr's Address TOTAL:
y1 certify mat I have rend this application and state that the above information is BUILDING FEE 77•
F rA coact l agree to cont ice all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PEE
UZ buildingcnmsmrction,and hembyamhurisempresenunives of cotscitymentorurynr flue SEISMIC PER
aM,ve-meminneJ prapeny lin inspection popol PERMIT'ISSUANCE
(We),gree m suvq Intlemnify and keep M1urndns rhe City of Cuvcvaa against ELECTRIC PER
Iiahilitice,judgmmtu,cop and expenses whichoi inany wayaccmea,enmoval City ALTER Oil ADD 10 MSCI I.
in wmequence nl'thgoading ading of This Permit PLUMBING FBI!
APPLICANT UNDHI STANDS AND WILL COMPLY WTTH ALL NON-POINT AIR HANDLING UNIT(TO 10,0g)CPM!
SOUL CB Rte'.ATIONS MECHANICAL 1:1717�r— AIR HANDLING UNIT(OVER 10,0g)CPM) CONSTRUCTION TAX
Sib tame of AppbaanVComemor r� DateO EXHAUST'HOOD(W/DULT)
HOUSING MI'1'IGAI'ION FIJI
HAZARDOUS MATERIALS DISCLOSURE
Will me vpplirnm nrfumre building aaupam score n,bundle hvzardous lnmeriui HEATING IINI'I'(TO 100,01114 T1
as defnal by the Cupeniao Munsolid Code,Chapter 9.12,and,he Hmlth and Std Iy
Curio,Station 25532(aC HEAPING UNIT(OVER IIXAIIlln I3' J) a�
❑Ycv C]No PAID
Will the applicant ar furore building occupant use eAiar device,which VENTIIA'I'ION PAN(SINGLE RESIT Uma Rewiptp
mit hall...air nmmminann as de0ned by me Bay Areaa Air r Quality hfnwgmnem BOILER-COhfP(111P OR I(NI,IXIO BT
TOTAL:
Di.adm! BOILER-COMP(OVER 11!,1)1(1 BTU)
❑Yes F1 No
Pry SU
AIR CON DI'I'ION ER
Ik dmcl I atrial manicured,a club,Chal ISSUANCE DA'I'�
lice' Health&S'felyC S atonal, 1525511 1255141 understand I,BI it 111c NEW RI:SIDIiN'I'IAI.MIiCII. SQ,PL
bIJ1' 6d :/Irrc Ilyl� t ,ant. 1 I Y p neiHl'tyt Il)B rocs pr I
ofm �4( wit l rI I fnce t f0 y
P�11Jl�tnf �iVa '✓ f�(Y J
Ow mar ad,o��-need agent I Lahr TOTAL: ISSUED BY:C�17 P /Qn/7JAA�f t
OFFICE