S 1055 (2) N APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I I'I?RM IT NO,
I
CITY OF CUPERTINO LUO IMEN;-NIEC ANICICA L
BUILDING DIVISION APPLICATION/PERMIT PING PRNG-MEDEN)[FIC S 1055
BUILDING PROJECT IU�EN'1'IpF'll'AT'ION
BUILDING ADDRESS: C(JPM-rlk0 SANITARY NO. APPLICATION SUBMITTAL HATE
log-357 � h/atLpE- ROAD Sul-T& - 20 V LL_JA0f b'u
OWN • _ , 1 w_ - PIIU I � • CONTRACTORS NAME LIC NO. CONO
f/TGWIvIv NIC l/k
111" A/�IRCIIITELTOiNGINT:ER: � LIC NO: AUURF_SS: ❑ •�_�1•••(rJJJ'J16(v'
Iz z 2 �,n.cA.9�o1
CONTACT: PH Nli: Z BUILDING PERMIT INFO
PNS 1 1 /1 WOKE.)
O E. Z'7j��ZZ'7S 9T ❑ Consultant Fees Paid by Applicant(Initial) l D P� MECH
L T ttNnM17 O
LICF.N,IiDC( RACI'(1R:5 ECU ATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed uader provisions of Chaper 9(commencing
MWCZ with Seution100(Oof Divicinnlnflhe 9usiri and PrfiessionsCadc.ad mylicenseis RESIDENTIAL'
PERMIT ISSUANCE:
�W� in full force and effect. ❑SPUWL CI KITCHEN REMODEL
Q L License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING REPIPE
+FZ Dare Contractor [I MULTI-UNIT []STRUCTURAL
aot ARCHITECTS DECLARATION PANELS MODIFICATION
Z O y Z ]understand my plans shall W anal as public records
OZ-M 12 UP TO 200 AMPS ❑INTERIOR (]CI{Ih1NEY REPAIR
W Licensed Professional 201-10MAMPS IMPROVEMENT C:)SWIMMING POOLS
C C Q 1 hereby affirm nw Nlum NxemPtl Rom dm Commence,License Law for the OVER IOW AMPS ❑HAT RIiMODIiI/REPAIR �DEMOLITION
X a U following rectors,Section 703I.5,Bunions and Professions Cada Any city or ammY SIGNS ELECTRICAL ❑OILIER
W 3 LL y which requires a Permit to consumer.aper,improve,demolish.or repair any structure
I-'u'OQ print,)its mmaimsthe ppl t for suchpermit III file a.'gcd statement SPECIAL CIRCUTUMISC.
that he -1'licensed ti thcp fth Contractor's 1 L wtcbaptar9 COMMMU
�ap0 (commencing so Suction 7U(MBof Divi a of Business dl f..'om Code)or TEM B METER OR POLE INST.
Q.X e c That he is exempt lhcrclinm and the basis for the alleged exciume n.Any violation mf ❑NEW BLDG/ADUI"f[ON ❑DEMOLITION
-fay Section 7031.5 by any applicant far a permit subjects the applicant to a civil pily of y POWER DEVICE
aS 7'I7 ANT C1 TODD SERVICE
not mom than Else hundred 11111110110500). sROVEMENT
2G ❑ 1,n owner al the propcny,or lny employees wile wagesns hnei r dale cnmpenmtion, SWIMMING POOL ELECT ,UIFR
will Ao the work send the slmclure ie nut innn11eJ nr nlTercJ tarsale(See.70.14,Businnv
IYHa -SWITCHES-PI%
L
(D 3 m A Prnl'ceninnl CrvlCod,The Common,License Low Anes sol applyw sea owner of OU'T'LETSTURES
and
CC properly who bu1111s or improve Ihercnn.and who dues such work hi oil or Ihmugh
his own employee,,provi11W in m four such i +rnvctnems am nImm�dcd ser 11U8red Int NEW RESIDEN'fIAI.GLGC'I'R SQ Irl'.
vale.If,however,the building or lmprvvamonyea
lit ix odd within o ycat completion,the $Q.r.'1'.FLOOR AREA SISQ.FT.
-
owner-Wilder will have the Wotan of proving that he did not III improve for par-
",vol ��
. L:
). TOTA
E]1, fth propeny.one isel-livel,eachellual withI : I cotimmours 1
em,loaato project(S71410 B dl fic,00n,Cole:)TC I ree I,
cause Law does not apply no an owner of property l es Id improves thconan.and QTY. PLUMBING PERMIT FEE ^ p A 1
who contracts for 'hl nt lctswith a counN
vlcensWp am to the Cnmmemrs r D
Ciccone law. PERMIT ISSUANCE,
I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN A,VENT-WATER IIiAI '(�]Lly3'/(.lp)_
Owner Dee r,7 /V�J��)
WORKER'S COMPENSATION,,rju one of the
BACK FLON'PROfECT DEVICE /s
haOD
ve
and will
under pe rti fi of of Corwin
one the inwore for dedam'Co C1
❑Ihave and will mvimain uCenihcmeol ConsenuosdGinsure for Worker's Cnmpen- DRAINS-FLOOR,Rll(IP.AHFA.COND. STORI UCtttt ;hYPLCONSTRULTION
sation,as provided for by Section 3700 of the labor C A,for the perfomunce of the
work for which this Permit is issued. Q FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section GAS-EA.SYSTEM-I INC.a OUI'LEIS / ^`
37M of the Lahr Cade.for the performance of the work for which this parrol is issued. OCC. APN
My Worker's Compensation Insurance carrier and Policy number am: O GAS-EA.SYSTEM-OVER nicer. Policy No.: -0A—
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
DIVISION PEES
(This section need not brinmplecd ifthe Permit is for one hundred dollars(SIM) GREASETRAP I LANCHECK FEE
odes.)
Loy any theinthe any
sit lhewnrk for onswbjeeL to Permitisers'Cossued.I shall SEWER-SANITARY-STORM EA.?(NI FT. ENERGY IEE
not employ any porton in any manner m 101 m hcnme subjcn m the Worker'Cumpen-
z satimn Laws of Califnmiv.Date WATER HEATER WNENTMLECfR GRADING PEE
ZO Applicata
4 NOTICE TO APPLICANT:11,after making this Cenificee of Excmpfion,you should NATER SYSTEM/1'REATISG SOUS FEE
I•' hmme subject to the Workch Compensation provisioLaborofthe Lan Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
YJ
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ.17, PAID z Uma
U O I I,),w affirm thatPermit iix,ml(See 30lcnCis.agency for the perfomtance of
W F.t thuwork fol which this permit is isxunl lSec.9W],Civ.C.) TOTAL:
O U 1,orkes Name TOI'A I:
>, IsnJcrI ecibt, BUILDING it
1 I cen'dy that 1 hove read this nPPlkwlon and stoic the the uM+vc inlimnhahnn is
.F..t to cone" lugrcuto"noply with all city and county ordimmcev and slate laws Waling to QTY. MECHANICAL PER MIT Fhb SEISMIC FEH
U Z bmldins cons..nim,,and hereby mahon,re,co,tonvcs 111this city rah enter upon Ilio
abovomm...ionad pnmcdy In,uspuulion Purposua, PERMIT ISSUANCE IH.ECI'RIC PHI?
(Wel arra:to save,indemnify and keep harndcss the City 11f Cnpcnino ugainnl
IiuM1ilitics.luJgmcros,conLs nnJ cxpcnnns which inuy'm lmywa memeagxin.a said City ALTERORADDTO MECH. PLUMBING THE
in n,e,.cnee of tbe gnat 11f 11111 Permit. _�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI I(TO l0Jb0CFM MECHANICAL,J711111SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IU.INIIl CIM) CONS'IRUC'I'ION TAX
Sig a lure of ApplicanVContmeor Date EXHAUST HOLD(W/DUCT) TIpUSINGMI'IIGATIONF
IIAZARDOUS MATERIALS IIISCI.OSURTi
Wilhnc apPlicum or l'uwrc huilAing hwcnpum store or hvnJlc hvvrdnus mvtmiel BEATINGUNITfTO100,00013 U)
as delinW b,the Cupenim,Municipal Calc,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 1,00,00)BTU)
Code,Section 25512(a)?
O Yea 0N VENTILATION FAN(SINGLE RESID) PAID
Dec Hamipl p
Will the applicant or future Wilding occupant use equipment or devices which� BOILER-COMP PHP OR I(p.(NN)BTU)�nit hamrdous air coneminces as defined by hie Bay Arca Air Quality Manasemcnt TOTAL:
Dislnc,? BOILER-COMP(OVER 101LINp BTU)
0Ye1 C]No
AIR CONDITIONER ISSUANCE DATE
1 have teel the h ode Sections s mvmridx 5,Z53 an under .1 mucr 6.95 of tbe Cali-
fnmla Health&Safety Cade. am ,thin i 25531 and 255310.1 t onemmd Inst if the NEW RESIDENTIAL MECH. S
building tar ton c,mallywhich have a,hanPthe it am ec of
coo asnotify thepancy.m
of the rcyuirthhhcnts which must be ma prim n,issuance of a Ccnifica¢of Occupancy.
Owner mr truth orieend agcm
Date TOTAL: ISSUED BY:
OFFICE