B 0362 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �a. 0362
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CITY OF CUPERTINO =11GG-F.LFCfRICAL I LRMITN/� 0 3 6 2
BUILDING DIVISION APPLICATION/PERMIToj"IN ErinMFCB\NIFIC �r/'-
OdEC'f IDI?N1'IPICATIUN AM
SANITARY No APPLICATION SUI{Mll'ITL DATE
BUILDING ADDRILCS:
o (s Cic awl - S - 7-4
OWNIiR'S AME' PlIONE; LIC NO'. NIC CUNFROL#
V 3 L3'1 y C ITI7C : ,NEili i NO: Z �O J y, ❑ C 3 V
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CONTnCF: PHONii: vJ BUILDING PERMIT INFO
t6 U 7\3 ����7 I /j�/�I ❑ Consultant Fees Paid by Applicant(Initial) m.irJ� Ii[:L- PI.UMIi MGCII
(fC/IVJ\ LIC. SED C!D RACfOTE
_`I l QTY ELECTRIC PERMIT FEE° LJ JOU UL'SCRI IIT^�10—N LJy
I hereby affirm that 1 am licensed modChapter9(commencing '
�QZ wilhSmtimn]OgB of Uivisinn3of the nd mylicunu is : / F F TIAL,
O m PERMI'I'ISSUANCii ,I'DWI, ❑KI'I'CIIIiN KIiMODEI.
CSF- fulloace:mdellecl.
aUU License Cla.cs Lie# APPLIANCES-RUSE DENFIAL [I ADDITION ❑PLUMBING RIz.PIPE
NQ6 Dae Contmnor ❑MGUII-UNIT [I STRUCTURAL
ARCHITECES DECLARATION PANELS MODIFICATION
zCanNz 1undersand my plans shall he meed ax public re ob, HP TG 21XIAM1'S
❑INI'HRIOR ❑CI I VINEY REPAIR
OZ
Foaol Qn Lormead 11 fallional 201-1000AMPS IMI'ROVEMEN'f SWIMMING I'UOIS
2E,1 f; OWNER-BUILDER DECLARATION OVER 1000AMPS ❑HATE{RGMOUIiURIiPA1R ❑DIihIQLITIQN
C C Q 1 hereby affirm Ihvt I am exempt from the Coronations License Law for the ❑OTIIER
jX O a U following reason.(Section 7031.5,M%moss and Professions Code:Any city or county SIGNS ELECTRICAL
W 3 Wt- which"'nor,a permit m um.amct,nitcm improve,demolish,or repair any xirvcwrc
. Waal prior[to its issuance.don teymires the applicant,orsucb permit to Glu a signed xmtenenl SPECIALCIRC 'TDMISC.
f
.n —the pmvivionx ofthe Contmennev License Low(Chapmr9 s,• COMMERCIAL
=00 (commencing with SectionWhat of Divi%ion3ofthe Business and Prnfessions Codaton TG
1xMII METER POLE T.
a 6 C that he is exempt therefrom and the W%ix for the alleged exemption.Any violation of El NEW BLDG/ADDITION DEMOLITION
xoro Seution 9031.5M1 applicant for 't subjWx the applicant a civil It f POWER DEVICES
Wim Y+onY:SPP penal i PP Penalty � ❑'f1iNANT FOOD SERVICE
not more than five hundred dollar,($PIX). IMPROVEMENT
=Q Lae owner of the Property.or my employees with wagcxas thcinnlc compensation. SWIMMING POOL l;I.LC
will Jo the work,and the mmcturc is not intended ornRcmJ for sale(Sec.9600.Business ❑O'T'HER
F OUTLETS-SWO CliFJ IXTU
d 3 re and Pmfessintn Code:Me Centimeter Licence Law does not apply to an owner of
property who builds or improves thereon,and who does.such work himself or through NEW RESIDENTIAL 1?LECTR SQ IT.
his own cnrp]oyces,provided that such improvement,are not intended or offered fit ;Q.FC FLOOR ARE $ISQ.1'r
sale.lL luesever.the huilding or improvement is sold within one ycnr of mnq,lUinn,the n
owner-builder will have the burden at proving that he did not buil)or improve for Our- O L 7
po�xJ• fvala.).
E ax owner of the papery,am exclusively contracting witM1 licensed contractors no
instruct the project(See nW,Buri nevx and Professions Cada)The Careanor's Li- O O
xe Law docs not apply to an cover,ol'papery wihale'e'or improve,lhencon.:rod QTY. PLUMBING PERMIT PEE `-r
who railroads for such projects with it coulenctorls)licensed pmswmnn the Contractor',
License Inw. PERMIT ISSUANCE
limn exempt fide'Se_. .B&I'C for this mason
_ ALUM-DRAIN&VENT-WATER(EA) VALUATION
woull Data �j A
WOEt fS COMPPNSATION DECLARATION BACK FLOW PRIYI'i!CT.DEVICE Z J V l�
I hereby affiml�I at Penalty of Perjury one of the following declinations:
,-j l havcand will nal t nn a Crnificme of Consent In self-iti for Workcis Camper- DRAINS-FLOOR.ROOF.AREA.COND. STORIES 'TYPE CONS FRUCTION
nation,as provided for by Section 3700 of the Labor Code.for the performance of the (,IA-,)
irk for which this permit is issued FIXTURES-PER TRAP
1 loop and will trainmen Wnrkcn'x Comprn,ntion nsuana,is r.,dor l by spelinn
J]Ull of the LaMu Cedc.for tis pedarmm�ce of the work for which this permit is issued. GAS-G.SYS]'1iM-I INC.xDUE'LEIS OCC.GROIIi' 7S✓ 'ZC
My Workers Compensation Insurance carrier add Policy number an: GAS' E&SYSTEM-OVER4 BbG ,Q� J b.]�
Carrier: Policy Na: 1
CERTT I FICATE OF EXEMPfION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMPI?NSATION INSURANCE NUILUING DIVISION FEES
(TLisecUionoed not becomplcnd lfthcpeo...is fnerelandrWJullars($11X1) GREoiSE TRAP PLANCH- I ' 3 2�
or Eco".)
Toy anythan"in any manner ofsn Bee for which this the W,kers' d.Isball SIiWER-SANITARY-STORM EA.21X1 FT' ENER( tF.
m r L,po any Caron in any manner no as m bcttrme auhleet to the Workers'Compen-
z xutian Law,of Calilirmia.Data WATER BEATER W/VF,NT/IiLiiLTR GR Ne 'E
zO Applicant 1
z NIYI'ICIi TO APPLICANT:If,after muking this Cmificme of Excmptiun.Yon should WATER SYSTEM/FREATING SOl1 S .
f"' became subject to the Workers Comrynmtion provi.xions of the L albs Code.you must
forthwith comply withsuch pmvisionsor this permit shall lx deemal reroked. WATER SERVICE?
QaPAID o CONSTRUCI[ON LENDING AGENCY NEW RESIDENT 1AL PLMB. SQ.Ff.
Doc Rmcipl p
U O Ibcrthy allirm that there i.xuconslrvction lenJin6 agency for the perlmnmance nl'
U. f-' the work for been this permit no issued(Sec.3099.Civ.C.) 'IRT I,
p ULender'%Name
U Lender's Address BUILDING FEF. /
I verify that 1 have orad this n,dication and'late that the abuve iofotmainn ix ! e
.. fn c rzut.l agnc�mcmnply with all city and county nNlnan«s
and%unNows arming In QTY. ML'CHANICAI.PL'RMIT PP,I; SEISMIC .
U Z building consumption,and hereby an harbor aprcamatives of this city m enter upon the
nNve-mentioned property for inspection puryams. PERMIT ISSUANCE ELECT 'F-E
(We)agree m save,indemnify sand keep hatmlesx the City of CuNdiao against
Iiabfinics.judgmenu,costs and expenses which may in anywayacerue ugainstmioiCity ALTER OR ADD TO MECIL --'" I PI. MBIN FEE
, wnII gamingoflhi'permlt.
eery t
AYPLICAN UNDEH'FANDS AND WILL COMI'LV WI'I'll AL1.NON-1'OIN'F AIR HANDLING l ty'IT,(TO 111,1X%)CPM) 1 MH'I ICA].FEE
SOURCE RI sULAI'IO) S, '
q AIR HANDLINGUNIT(OVER10.000 CFM) CON. "RUCf10NTAX
GG to O
Sigoammof Applic nV ntraclor Date EXHAUST HOOD( CD (,1 DO INGMITIGA'1'ION FEE
II ,ARDOUS MATERIALS DISCLOSURE
Wlltieapplin for future Wilding occupant mom or handle hevmdous mamnal I{EATINGUNIT(TO ,000BUB
as defined by the a sono Municipal Cole.Chapter 9.12,and the Eicalm and Safety HEATING UNIT((IV 1(N),(XXI BTU)
Conic.Section 2559-ul"
❑Yes El No VE TILATIONFAN(, lJ R15i0p" PAID
Date Rettlpt#
Will the applicant or future building occupant sea acuipmcm or devices which BOILER_COMP CHP OR I(X).(XXI BTU)
'hardoms air contaminants m defined by the Bay Area Air Quality Management 'TO'I'AD.
m
1 Atncft BOILER-COMP(OVER 100,000 BTU) _
/ Lbmidia,doic
❑Ycs ❑No
hath read the b one.S nsand:dx m.25533 a under .I car onat nl the if the
AIR CONDITIONER ISSIJ CIi UATP.
Health&Salcuy Cesde.Seauinn'25005,2553]and 2553x.1 unJeamnJ IM1m if the NEW RESIDENTIAL MECH. SQ.PL ^^
nmcmrantly havev rias my nsponzibilirymnnfify due eccurym �- 7 0 ccfo
ty it n which mobs ofaCenihcae of Occupancy, r / Q [!'
amhorimd 'gal
Date TOTAL: ISSUED BY: l^ /
OFFICE