S 0793 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RGILDINC-ELF.CI'RIGU. PERMIT'NO,
BUILDING DIVISION APPLICATION/PERMIT' Y1.11MRINC MECHANICAL S 0793
BUILDING PROJECIADUNTIEICATION
SANI'fnRV NO. APFLICA'I[ON SUBMl'I'I'AL DA'I'I
BUILDING pDHfiC6:
Cl "1 e-2 7
OWN17R'.SNA '. PHONE: CONTRACTOR'S NAME: LIC NO'. NIC CON'IROL if
RCHITIICTIENGINEER: ..IC NO. ADDRLSS: ❑
Ffo,�,�,an�deffoe"',
PHONIi: BUILDING I'T;RS11T INFO
❑ Consultant Fats Paid by Applicant(Initial) BLD6 ELECT PLUMB MI!CH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE J0I3 DESCRIPTION
nn that I am licensed under provisions of Chapter 9(commancing
QOZ Section 7000)of Division 3ofthc Business and professions Code.unit my license is C RESIDENTIAL
PERMIT ISSUANCE / ❑SPDWL ❑KITCHEN REMODEL
F�OW� teet. ��Z S�2�
yGi Date-- �Contracter -LC7� AI'YLIANCLS-HLYIDEMf1Al. ❑AUDITION ❑PLUMBING L PIPE
A CHITECFSDECLARATION w.. .f [I MULTI-UNIT C1 STRUCTURAL
y
I'ANIO.S ZOOJa Iv+l"�T[ MODIFICATION
OZ~n^ dun cmvnJ my plans shall he used us punlie mmrsls V UV'IY)1(N)AMI'S LJT� ��Y. �.
�a 2-0 ❑IN'TEHIVE ❑S CHIMNEY KEPOL
F SFW Licenser Professional 3(11-IIXIBAMPS IMPROVLh1EN'1' �SWIMhfINO YOOIS
Cyd; OWNER-BUILDER DECLARATION Ov12R IB(0 nM1115 El PATH RHMODF.UREPAIR ❑DEMGI,Tf10N
CL try a 1 hereby affirm that I am exempt from the Contractors License Law for the ❑OTHER
O y O I"ullowing reason.(Section 7031 5,Business and Pn fe,ion,Code Any city or county SIGNS ELECTRICAL
Iil3 W y which reyuites n permit in.moo-It,aheq improve,demolish,or repair any onmmm
-u'0� poor Or ismance.also reyuircs the applicant for such perminn fleasigneJ swmment Sill:
CIRCUI TIMISC.
2n that he is licensed pursuant to the provisions cfthe Committer',Liceme Law(Chapmr s) COMMERCIAL
Wftp0 (camnencing with Section 7")of Division Sof lbs ltusinc'ss and l'mfession,GMq or TIiMP.METF.H ON POLE INST. C1 NEW BLDG/ADDITION ❑DEMOLITION
that he ix exunild thcra"mm and the hmis for the alleged exemption.Any viola eun of
W�y Semon 1031,5 by tory vpplieomfar apermil objects the BsPliemino n civil penally of 1'oWGR DEVICES ❑'IPNANT El FOOD SERVICE
oat nae than rise hundred dollar,($510). IMPROVI?MIiN'1'
f=� WIMMING IKK)I.ELECTRIC
I.asowner of the an,,my.or my employees with wages as their sole compensation, S ❑OTHF,R
F will Jo the work.and the structure,is not mtendeJnroRcredTor sale lSec.16k1.Business OLMEFS-SWI TERM-FIXTURES
L 3 m and Pmdc„ions Cole:Tnc Contractors License Law does am apply to an Invner of
pra,amy he band,ar balance,thact.,and enc line,such work nimsrlf nr lhrcagh NEW RESIDI!N'1'Inh B -C'I R SQ I'P.
his own employees,provided that such impmvcmcnu im nm imeroad or offered lin SR FI'.FLOOR AREA $ISG.FT.
sale.IL howcvcr,the builJinB or impmvctttcnt is told within one Yeur ur camPletionJhe
owner-builder will have the burden of proving that he did not build nr improve for pur-
,scoil,ale.). IQ, 1. O
❑ Las owner of the pre,,ny,am exclusively cnrarnning with licensed cantrnetury to
construct the Project(Sue.]OW,Bu,incss and Prole,inns Cole:)too Canlmctor,I,h e
nm Luw does not apply to an owner of progeny who builds or improves thereon.and QTY. PLUMRING PERMIT PEE
who contracts for such projects with a contractors)licensed pursuant to the Contractors
Liccnsc law. - PL'RMITISSUANCE
❑I.am exempt under Sec. .B&P C far thin reason
ALI L'It-DRAIN d1 VENT'-WAA PH(CAI VALUATION
Owncr Dal.
. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DGVICE
I hereby anion under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Workers Calliper- DRAINS-FLO()R,ROOP.ARI:A.CONI). STORIES TYPECONSTRUCI 10
,mind,ns provided for by Section 31(0 of the Lala Code,far the terminal. the
xfor wh'mh this permit is issued. FIXTURES-PERT RAP
w have and will maintain Worker's Compensation Insurance vs required by Section GAS-EA.SYS'I EM I INC.i OUTLETS OCC.GROUP APN
3700 of the labor Code,for the performance of the work for which this Permit is issued.
My WnrA 's ampm aaunn unmcc rmier and Poli.ynt01Cr GAS-C'A.SYS'IIiM-OVER4(IiA)
Carzicr:�Policy Nn:
C:RI'll'ICA'fE OF CXIiS1I'I'ION FH(IM WOHKIikS OBIiA$FIINDUSTHL WAS'TIi IN'TERCCPI'OR
COMYENSA'I'ION INSURANCE
BUILDING DIVISION PSIS
(This waian naJnotacamplacJ ifthc pcmtit is(prune hundmldollar($1,1X11 GREASE.TRAY PIANCHF,CK IPE
or Ices)
l scnifythvt inthe perfunnvncc of thewnrk forwhieh thin permil isissvcd,Inhvll SIiWCR-SANI'T'ARY-S'IORM CA.2W hI'.
ENERGY FET!
not cntploy unY pegan in any immncr.en us to hcnnnc nuhlun w the WorkcnJ Contpcn-
O Z uttinn laws of Calilnrnia.Dam WATER Hiinl'I!R W/VENT/I!LECIR GRADING FET!
0 Apphaanl
z srNs N(YI'ICI:TO APPLICANT:IL after making thin Crnifcam of Cnctnpinn,you xMmIJ WATER SYST'LM/TREAI'ING SOILS FEE
F Ixls�mc subject m the Wnrka'n Cnmpenmuon provisions of the LaMsr Code,you mull
� � funhwith comply wllh such pmvinionx nr Ilia pemtit shall he dccmud rcvokW. WA'I'F!R SERVICI3 /1 r
a pPAID 1/
CONSTRUCTION LENDING,AGENCY NEW RESIDENTIAL PLMB, SO.IT Date R c N
V Ihereby affirm thad is a construction lending agency for the perfamace of
the work fur which Ibi,gena,is ismed(See.I091,Cie Cl 'TOTAL:
O Leaders Name
'IT)1'AL:
} LTJ Lender,Address BUILDING Pili
Q. 1 ccdify that I have read this application and sate that the aMrve information i,
f N caned.l agree to comply with all city and county ordinances and%late laws ranting to QTY. MECHANICAL PERMIT FEE SEISMIC PFI?
V Z building amatmction,and hereby arthorim representatives of this city to enter open the .ten
aMoe"mcmloacd poultry fur inq,rown,ptorocs. P12RMIT ISSUANCE ELECTRIC PER (�
(We)agree to save,indemnify and keep harnduss Nit Cally at Ca'aneo against
liabilities,judgments.tamarind m
nd expense,which vY in any way accme ageitrstoid Gly ALTER OR ADDA0 MECH. PLUMBING FEE
in consequence of the granting of this pearld.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(To 10.0011 CFM) MECHANICAL 11?E
SOURC' C��{{��\TIONS
M 0- AIR HANDLING UNIT(OVHK 10AX)CFM) CONSTHUC'I'ION'TA%
..ss/�
Stg � rcof APplmenULontrsnor �O c PXHAUST HOOD(W/DUCT) HOUSING MI'T'IGATION PCF.
I IA]ARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant%,am or handle hvmdoos material HEATING UNIT(TO 100.gM)BTU)
it,dcfire d by the Colima.Municipal Code,Clugncr 9,12.and the Ilealth Lind Safety I112AI INC,UNIT(OVER I INLmSO BTU)
Calc.Saban 25532m)R PAID
❑Yes 0 N VENTILATION["AN(SINGLE RESIU) Dam Receipt
\
Will the applicant or future building Occupant use ,uipmcm or device,which
moil hvardaus air contaminants us defined by the Bay Arco Air Quality Manal eaten( HOILER-COMP(HIP OR 100.000 BTU) 'IOTAI' 1
Dourno? BOILER-COME'(OVER HiiBTU)
❑Yes No
AIH CONDITIONER ISSUANCE DATE
I have real the h udc.Se mannas requirements under Chapter h95 of the Calie
fain licahn&Sal Cadc.Semens 25505,2$533 and 2553J.1 understand that if the NEW RESIDENTIAL MEGA. SQ.F. �� A^ M(Jr 7
huddmg does imp vurrently brae a Iden,ihal a in my,1,mIibili Y m c¢up
ratify the mt F2'1
of the requitement,which must he amt pnor to issuance of a Cenifcntc of Occupancy. _ -Te
Owner or authonuvl agent
Dam 'TOTAL: ISSUED BY:
OFFICE