S 0890 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pljly\11T NO,
PLUMBING.MECHANICAL J O H J O
BUILDING DIVISION APPLICATION/PERMI'F
BUILDING:PROJECT IDKN'I IF'ICAI'EON
SANITARY NII. APPLICAI'IIIN SUBMII'IAI.UA'1"1
BUILDING ADDRESS
OW sR'S NA E: HONE: CON'TRACTOR'S NAMI;: LIC NU:
a NIC ( CONTROhM
LONST 3'-110 L1IFjL7 AC keg- c 2o'S4L ❑ W
•I ARfj4THCI/ENGINEI!R: y1—N(l: ODRIi11 —
nJ C.o n 8 4'1 A j raN,o nA Z44,0 Mery
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) pLD(i HLECT PLUMB MECH
'jAJ CJ( AR,11 -b 621 CT{(
LICENSED CONTRACIOR'S DECLAKAHON QTY. ELECTRIC PERMIT' FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provision.of Chapter 9(commencing
�0z with Sector.i000Eof Division 3ofthe Bmsi.c,sard Profcssm-Cade.and my license is RFSIDFNTIAI'
F�-�� full force and elle YI!RMI'I'ISSUANCIi 0SFOW'L ❑KITCHEN REMODEL
4�F to
aUZU License CPs - LIc.N APPLIANCES-RESIDENTIAL []ADDITION ❑I`IAMRING RIiI'IPIi
NQLIlam Contruchrt
4 ARCHLECT'SDECLARATI N PANELS ❑MUhTI-UNIT MODIFI URN,
F h 1 understand my plans shall be used as public records MODIFICATION
zzo4z UPT02MAMPS ❑INTERIOR CHIMNEY REPAIR
f-4 t:"i Licensed l'mm"imad 2II-1000AMP$ INIPROVEMIiNT �SWIh1MING POLLS
6�sj ; OWNIiR-BUILDER DECLARATION OVER IIXp AMPS ❑BATH BE OBE AEPAIR ❑DI!MOLITION
C Q I hereby of im,mm mit attempt Rom the Contractor's License La tin Bra ❑O'T'HER
3 rnllowing mason.(Section 91191$,Business and 1'ndessi I G.lu:Any col n....my SIGNS ELECTRICAL -`
a which requires permit tConstruct. Uteimprove,d lish p Y swuum
O, prior I ite
calr "luma,thr applicant fch Permit ifile 6 edstatemert SI`LCIAL CIRCUIT/MISC. '
flyded he is licensed mett.he p ... ftheCingrachas ro W (Cle,par9 COMMF � ^
��DO (cam n 6 +tit Secl III(Itp fill iso t fth Il : e- JI f.. nsCdepa TEMP.METER OR LOCH INST. -
ty%o y that he is exempt therefrom and the basis lin the allelic xcropwmio
m.Any violn of NEW NLDG/AUDITION C]DEMOLITION
rn Section 9031.5 by any applicant Err a permit xnM1,iCCs' Cap, hi u civil Panully of I`OW ITR DEVICES ❑TENANT ❑FOODSERVICE
ram more than live hundred dell...($NN)). IMPROVEMh/'"'
f=C 0 L as owner of the property.or my employe ith wages as their sole compensation, SWIMMING POOL ELECTRIC 11 OTHER
^ —
F will der the work,and thammcmm is not inte edoruRelcdforwle(Sm.ODW.Business
L 3 m and Pose,,ions CMR:Thc Commerce. mens,U.does not apply to an owner rr OIfrLLTS-SWII'CHPS-FIhTURES
,o,arr,who build,or improves the, n,and who d«s such work himself rr tnnmgh NhW RI!SIDENTIAL IiLECI"R SQ FT.
his own mnployeo,Provided that ch improvements are not intended or offered lin SQ.FI'.ITLOOR AREA $/SQ.IM
sale.ILhowever,the Buildinger' tpowmacmi.soldwithin Ineyn,r of c0m...... ,the
owner-builder will have the en of proving that he did not 1miIJ nr impmvc for par- A I D
pure or..lc)f TOTAL:
0 L as owner of the p ge4ty,am exclusively concocting with licensed comeacmrs h,
Consumer me project eF.9644.Rosiness and Profeuinns Code:)The Coro-mets Li.
cc .e how does. apply lr an ownernr pmpcnY woo hoods or in,prnvcs mern,n,and QTY. PhUMHING PERMIT FEE VL
whenntmns� such po!icsys witho contractor(,)li,Croed Pursmmrto the Comruumr's 7cj�!R
t ANSp
Licence Dow. YI!RMIT ISSUANCIi
0 I am cxempl under See. .if&P C for this reason
ALTER-DRAIN A VENT-WATER IiA) Ir N
Owner Duro
fM
WORKER'S COMPENSAIION DECLAR51"ION BACK FLOW PRUI'ECI'.DEVICE oO�
I hereby ofirn under Innalty A Pcrj.D Inc of the following derh mtienr �
O l have and will maintain a Cenificnm of Convent to self-inmrc for Workers Crmpen- DRAINS-FLOOR,ROOF,AREA,COND. S'rORll!S 'TYPE CONSI'kUCI'10'.
station,as provided for by Section 37M of the Lahr Code.for the performance of the
work fur which this Permit is iweFI%TURFS-PER TRAP
d
r 1 have and will maintain Worker's Cmin,om
tion Insurance,a,required by Section GAS-IiA.SYSTIiM-I INC.J OUTl.lip5
I0Il of the Labor Code,for the parformanecof the work for whichmis permit is issued. OCC GROUP MINE
My Wmkcr' ompcn.mum lnsnrnncc cvrzicr and Policy�,f�}h
Carrier: (�/IL [p QOF1'olicY GAS-EA.SYS'1'I!MOVFR 41
CERTIPICAT' EXEMPT ION FROM WORKERS' GREASUINDUSTRLW'AST. N R
COMPENSATION INSURANCE: fU DN, ISION PEES
(This section need not be,completed tithe permit is(Drone hundrNdollars($1W) GREASETRAP PLANCHEC FEE
(certify matin the pertnrm:mcenfthework lot which this Ile,W rke,unl,l>hdl SIiW I!R-SANI''Ally-BYOB E NII• IiNIiRGYI'lil.
not employ Any Person In Any manner so trial hccnma subject m me Wnrkcrd Cnnq,em
Z ..tion Laws of Calidemia.Dam WATER HEATER WIVENT/ELE GRADING FEE
C) C) Applicant
z NOTICE TO APPLICANT:If,after making this Certificate or Esemption,you should WATER SYSTEM/TREATING SOILS FEE
F ^ become mbjea Edda,Worker's Comgen n pmvisionz of the Labor CNe,you must
forthwith Comply with such Pnwisio nr this N..r,t shall rte deemed revoked. WATER SERVICE!
p" CONS ULTIONLENDINGAGF,NCy NEW
RESIDENT I'IAI,PLMB, SQ. 'r.
PAID
7 z Date Receipt
U O IM1ercny aflirm the an lending agency for performance of
the work rot which thi omit is issued(Ser-1047.civ.C.1 T(TI'AL:
O Lender's Name TOTAL
U
W Lender's Address BUILDING FII" �t,�
a I comfy that I have rued this appli[utien int elate that the above into...andon is FEF.
FV) comer.l agree m comply with all city and county ordinances and NlmR laws relining to QTY, MECHANICAL PERMIT SEISMIC F.
V ,Z building construction.and hereby ammmue mpremnmovesrfthis city mentor open the
above-mentioned poll for inspection purl sets. PERMIT ISSUANCE ELECTRIC FFP.
(We)agrec m mss,indemnify and keep hature's theCity of Cupertino against
Iiahilities.judgmenl......is and CM,Cmsos which may in any way C,.0 against said City ALTER OR ADD Is MECH. PLUMBING :L!
SOURCEuNT NCERSIAN SAiNPcmtil.
APPLICANT )8k51'ANU WILL.COMPLY WITIIALL
7-?7 AIR HANDLING UNI'I'(TO
OVER W.0000 MECHANICAL F.'
pA�'I'ss(A(ry��''AA ll CC AIR HANDLING UNIT(OVER IILUXICPM) CONSTHUCfION'1'A
SigrourcfAppl�ucontmmrr Umc EXHAUST HOOD IW/DUCT) HOUSING MEI IGATION TH
HAZARDOUS MAICRIALS DISCLOSURE
Will the applicant or l alum mildlneoccupmm swrcor handle hazardous material it17NrI NO UNIT('TI)11XI.(XX)B'IUI
as defined by the CoNnino Municipal CN,Chapter 9.12.and the Health and Safety HEATING UNI"L'(OVER 100.61X)BTU)
Code.Section 5532002
0 Yes k�l o V12WILATION FAN SINGLE RESIDE PAID
Dau Ker ipl p
Will me.pplicunt or future building onmpant use C,mpmmd or device,which BOILER 13111`OR 1441,144X1 If III)
mit h...olovs dr ennwmint is as defined by the Boy Arca Air Quuliry Management 'I O'TAI
Umhicfl BOILER-COME'(OVER OR)I NX)BI U)
0Yes
1 AIR CONDITIONER ISSUANCE DATE
I have mad the M1 ode Se m ns 255 5,25533 i under Chapter 6.95 of the Cdi-
h,mia llaahh&Safety Code Saviors 255.5,25533 and 25530.I undemund mal it the NEW RESIDEN'I'IAI.MECH. SQ.171
Build v 1,wCynavcareneplioraillums_IsoCll'uymmnlry lhc,ncnpnnt VY/��\'/
of lh n 'mc Isw ich mmtMmc Prior e,issuunw ufu Ccnifienm nr(xan ancy.
Owner rant dredagent Dam TOTAL: ISSUED BY:
OFFICE