S 1034 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINC-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG—MECHANICALS 1034
HIIII.DIN(i PROJEC'F II)EMI'IFICAI'ION
BUILDING ADDRESS n SANITARY NO. APPLICATION SUBMITTAL DA'I'I
/037 Sri T6� kj_ Cr✓� V- 4T 1%1 o cJ �B �iti�
OW BR'S NA/.
Let PHQ/ � 76 CDNTRAGI RJB y e LIC%O:
V LL�H/.•JG / N/C �C/AO/NT///R��OI.p
ARCHITECT '[NEER: LIC NO: ADDRESS: / Y ❑ Vi
coNIACi: PHONE: BUILDING IIFRMI'I'INFO
❑ Consultant Fees Paid by Applicant(initial) n1.n EI.FC l' PLUMB MECO
LICENSIID CONTRACTOR'S DECLAMATION Q'PY ELECTRIC PERMIT FEE
I herchy affirm that I am licensed unJer provisions of Chopin,9(commencing JOB DESCRIPTION
�Oz with Section and
of Divisinn]ofth Rusinjesam Rofessiuns code,and mylicense is
ce—i- in fou Losec nnJ altar. •. �ZI PIiNMI'1'ISSUANCI; RESIDENTIAL
U License Clusx Lica�2 2 ❑SI'UWL 11 KITCHEN REMOUEI.
¢zei; Dam ( Contract., APPLIANCES-RESIDENTIAL ❑ADDITION
r�i¢4 ❑PLUMBING RE.PIPF.
ARCHITECT'S UECLARNHON PANELS ❑MUl:rl-UNIT ❑STRUC'rURAI.
z O�Z I Understand my plans shall be used c public mcmal
Oz p UP'IO2(N1AMP5 MODIFICATION
1=a•4�{y Ltttnsed l'rolesslnnul ❑IN'I'1iRIOIZ ❑CHIMN17Y REPAIR
gg2 jj OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT I]SWIMMING POOLS
y CCW 6 1 hereby affirm that I am exempt from the Contractor's License Low for the OVER 1000 AMPS ❑RA'rH REMO�DF`,L/R``EPA��IR (]DIiMOLI'I'[ON
p(O 4 U following season,(Section 7011.5.nosiness and Professions Code:Any city or county 4:7 y��
SlyI� SIGNS ELECTRICAL ""�"�' ySCJ V V Y_catSI'IiC1A1.CIRCIII'FIMISC.1` MO, (commencing with Section 7000)of Division 3 ofNe Business and Profession,Code)or TIiMP.METER ON POLH[NSI'. IAA�Ihm he Is eo,nimthcrefmm^ad the basis for the alleged exemption.Any violation of /ADDITION ❑DIiMOLITIONSection]u3 .5 by unyapplicant fore permit subjects theapplicame,a civil penallyOf IM)WER DI3VICGSnot more Nan fve hundreA dnllms(b5W). ❑FOODSERVICE❑ 1,uso,vnerofNC Proli11rmy employeeswith wages.,theirsolecoun,amatinn, SWIMMING POOL ELECTRICENT'.. will do the walk,and the suuct.re isnimendedoroffc,ed Rolonic(See 11,14.Business n41a@and Professions Code:[fie Co micalls License Law does not apply to an owner of OIITLEFS-SWITCHES-FIXTUNBSpropeny who builds or improves Hereon,and who doO,such work himself or through
his own employees,pnrvided that such improvements art not intended or Offered for NEW RESIDENTIAL ELECfR SQ .
sale ll;hawevcr,N,huildingorintpmvemem is sole within one year afc,m..el ria,the $Q.FI'.FLOOR AREA $/SQ,IIL
Owner Wild,,will have the huMen Of proving Nat he did not build a improve for par
pose of sale.).
❑ h us owner of the progeny,am exclusively contracting with limned contrachee m TOTAL:
construct the project(Sec.TMJ,Business and Professions Cowep The Comramols Li-
ase Law does not apply to an Owner of property who builds or improves thereon ane QTY. PLUMBING PERMIT FEE �q
who enmmmx for such proJam with a cnntromor(s)[sensed pursuant to the Cnntraron's O^
0 11'.nse law. PERMIT ISSUANCE V T
❑ Int.exempt under Sec. ,B&PCfnr lhi.e rcnsr'n VY
Owner ALMS-DRAIN&VENT-WATER(EA) A st'
Dale U�' �Url rrI y
• WORKER COMPENSATION DhCLARATION BACK FLOW PRDIL'C'I'.DEVICE?
1 hereby affirm under penalty of perjury One of Nc following declarations:
❑ [have and will mvimvinnCenificvm of Cnnsem mselGincure for Wnrker'x Compen- DRAINS-FLOOR,RO'd AREA,CONII.
antinn,as provided far by Section 191X1 nl the Lubar Case,for the per[umenec of Ire $T(1121E5 'fYPH CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3900 of the Code,for the performance ol'the work for which 11ls peruth is issued. GAS-EA.SYS'i I'M
INC.40U'fLE'1'S OCC.GROUP
My Wodo ���yvatinyy 9F carrier and Policy number arc: APN
Cantu: ❑ H/sY�.( Policy No.: dam' f'�� GAS-EA.SYST17M�OVER 4 WA)
CERTIFICAT'12 OP EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GRP.ASEANDUS`YRL WASTE INTERCEPTOR
This section read nOl bo cnotplemd i f Ne pemtit is turns,huldreddogia,($pgp BUILDING DIVISION CS
in seal GREASE'I'RAP
PLANCHECK FEE
Iay'oil thin in Ne peaany ocame,I so,work far which Nis per Walisnme,lsholl SEWER-SANITARY-S'I ORM EA.200 IT.
sol untLew any porion in any manner so as m hanmc subject to he Wnrkcrx'Cumpcn-
,�
Applicant
of CaBfnmia.Data ENERGY ETI?
�O Applicant WAI'F.R HIiATER W/VENT/ELECTR
GRADING FEF.
V) becomeE bj APPLICANT:ll;ager tanking Ihix Ccnifil ufof Exemption,you shoal, WATER SYSTEMIIREA]ING
become t.the Worh mCompensation pmvit hal of the LaMn Cas,you mon SOILS FEE
forthwith comply with such provisions or this permit shall hL deemed rcvukal.
� Q WATER SCItVIC1?
:::) z CONSTRUCTION LENDING AGENCY NEW RESIIIENrIALPLMR. SQ.FL PAID
;JO (herchy nf0rntiler,bure inncon,maion leading agency for the performmmce of Dam Ra,iptN
LL F-r the work for which this permit is issued[Sea J
3097.Civ.C
Lendeds Name
L) Leadcde Aedrco, IOTAL:
04 TOTAL
f4 I reentry that 1 have with thirty and counand nam that the amine information is BUILDING FEIi
U �r.� fn cotrengeno,,mcomtld witha oulbons county i,sai and lawxrclmingm QTY. MECHANICAL PERMIT
allsommentionedtinn,and herchy amhmiurcprssenmlivee nfthiscitymentorupon WO FEE" EB
above�meminncJ Pmpeny for inspection pulrysws.
(We)agree msove,indemnifyand harmless the Cit fCu PERMIT ISSUANCE
a^ P " penin,adciIy ELECTRIC FEIi
tubi sel,encefnm ru and cfthi,pssvhich may in any way acrncageinst said City ALTER OR ADDI'O MECIL
in ennmquenee nfthe gmming of Ihix pemtit. PLUMBING 19iE
APPLICAN ERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'O010.(100 CFM)
SOURCE X;UL\'00,TIONS. CAI.ITE
� AIN HANDLING UNIT(OVER 19,1X10 CFM)
CTION'fAX
Sign u 'n pplican1A s minor Dote EXHAUSTHOOD(W/DUCG}
HAZARDOUS MATERIAL$DISCLOSURE 7 MITIGATION FEE
Will lire upplicum or linare huilJing,ccopam score or handle hazardous mamRul HEAPING UNIT LID W.00i B'IV)
as ectmed by the Cupeniro Muniei,i Code,Chapter 9.L2.vnd the Health and Safety
Cade.S.c�n✓io^2553200? HEATING UNIT(OVER I(st(u)BTU)
DWI ❑Nn
VP.NTILATION FAN(SINGLE RISID)
Will'he air cont^tor ntsaolume definng oce.pianby
aseea AirQntordevicesement Omc Receipt#
Will hazaNnus air contaminants as Jelined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1110,111111 RTU)
Diann? '1'OI'AL:
[11 YO, ANO BOILER-COMP(OVER I IXLooti'ru)
I have read the hazardous materials requirements larder Chapter 6.95 Or the Cali, AIR CONDITIONER
forma[]caul'&Safety Crile.Sections 25505,25533 unit 25534.1 undcrsmnJ(hot if the ISSUANCE DATE.
balldin does not cunen yhavcalenant,Nmitis my rcap,mihilirymnmi(y the occupant NEW RESIDENf1A1.MECli. 5Q.PF.
of nq mine.., it 6.1 it)i,,.alauII CmtifmtsofOwnp^ny. V I1t
td 1
,gem Dale TOTAL: ISSUED BY:
OFFICE