S3918 APPLICANITTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECDANIL'AL (+ �]
BUILDING PROJECTIDENTIFICAl1S ON J
918
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
NL:R"N F1 E: PHONE: CO CIO '�NAMEi s� NhC
r� � CpNIROLN
�N �0 I
ARCHITECT/ENGINEER: LIC NO: AD RCSS' Li
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGr BLLE PLUKtq� MEC
Irl/
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE .
I hereby.Rrm real I.m Hansell under pmi'ian of Chaper 9lrnwercNe JOB DESCRIPTION
DXZ tin Section]O01B of Divisianl Mth Buxirea ad ProfcsnkmsC ylittna is R SID�AL
woo v� ll PERMIT ISSUANCE
FWD inn full lincc and cnalyZ r ❑SFUWL C1 KITCHEN REMODEL
�U� Lice.Clan" Iic.N APPLIANCIS-RESIDEYI'IAL ❑ADDITION ❑PLUMBINGRE-PIPE
QW Dne Contr.ctm - STRUCTURAL_
,],� ARCHDECTS DECLAR PANELS ❑MULTI-UNIT MODIFICATION
ON
Z C)�z 1 unAiaaml my plan.shall be u:i r,public records
OZ UI.1020IAMPS El INTERIOR []CHIMNEY REPAIR
K!:7W Iicenuxl Pmfewereal 2(11-I"AMPS IMPROVEMENT C]SWIMMING POOLS
5 C C 6 I hereby.0irm OWNER-BUILDER DECLARATION I am exempt from Ae r'.License I..w f«the OVER IoW AMPS ❑BATH REMODEURFPAIR ❑DEMOLITION
k d U following Tenon.(.Section 7031.5.Husirew and Er,resoo,Code:Any elly a cwmy SIGNS ELECTRICAL. ❑OTHP.R �5
uu11 ry
u O which rrymrec a pcmtit m mnstrucl,nod,improve Jcnwli.h,rc rtivu any swewre C �(
F'-yg prim to iu isawre,imo rtqui,e,the applicant for vein remlit w rk a signed statement SPECIAL CIRCLUTIMISC. �.
f Y that h it Iicrnudputuantm th pnvisiau n!the Connru�ra Lwrn+c Lew ICh.pter9
WC�p Icomttxreing with Sttdon]WI)nf dvisimJnfthc Baxirexxmtd Profexninns Codc)ur TEMP METE LE INST COMMERCIAL
dp,eC then b,is excmp mem oro ad the basis for the allegd conniption.Any violalion of ❑NEW BLDGIADDITION []DEMOLITION
W N Section 7031S by any applicant fora ps ontsubjectsmeapplicant toacivil'nalty of POWER E)TFNAN7 ❑FOOD SERVICE
FZT that nine than five hudnd dollars(S50% IMPROVEMENT
_Q 01.ax owner oDh pWertY.amy cmpbyeen wN waeen.sth'v utile compenation, SWIMMING POO IC
SSG will du the wink tint the suumumisnor imededorolfe�fawk(Ser.J(ILL B.,mc,s ❑OTHPR
iand Profo moria Cork'.The Contnhctocs Liccnxe Lw Nine"nor apply it)an ou.nf of OUTLETS-SWITCHES RES Q
pmpeny%bo builds or imposers Uneven,ud wlw docs ouch work himself or tuough
his awn empb)ecs,Provided it.....h imperometua are not intended or Mrcrtd for NEW RES!;!Tjx,��GCTR SQ FT.
aka IL lwrcd.the building or in,imvemmt i,wild within I.Year nfmmpleton,the SQ.IT,FLOOR AREA SlSQ.ET.
mr-M1uilder will haw the b.,&n of proving,1.L he did nun emild a Impose ra
poseof sale.).
❑1,as ownef of the property,oro r.elhrvvely crwtrectin,with he ni awreco.no AL:
continues to Project Pke.71w.Business and Pinfevnom Code)The Contwtoef Li- -
anrelyw does not apply to on owner or moreny who but Ids or imausce,tmobm.and QT'Y. PLUMBING ER IT FEE .
whe commit,for such pojceu with a umtracn,r(xl Geta cd puouanno line Contractor's T
Lieen.a law. / PERMIT ISSUANCE 3 • n� Q
❑I am exert under See. .B C P C for this tenser
ALTER-DRAIN R VENT-WATER(LA) VALUATION
Owner I}ter
W'ORKERSCOMPENSPTION DECIARATION BACK FLOW PROTECT.DEVICE ^
I hereby affirm under Penally of perjury one of to following declaration: e/ '/
❑Ih.ve uilln.InWna Cmifc cof Consentoal6lnsumfm WS er'i Com - DRAINS-FLOOR.ROOF,AREA.GOND. STDRI1iSTYPE COR ULTION
sauon,a provided fur by Section 37M of the labor Cork,for the penihmharce of IM1e
work for win lch this pooh is il,oin Pus:I'U RES-PER TRAP
❑ I have and will maintain W'orkee,Com,ea anion netir.rcc ax required by Seeiah /�
37W of the l�Cole.for the perfrmuae of the work fawtich min permit is isxud. GAS-EA.SYSTEM-I INC.4 OUTLETS D OCC.GROUP Y
My worker.Cnmpemahion lnwaathre carrier and Polity m.hnnd aa: 3-7$ )?v
Cra cc Policy No.: GAS-FA.SYSTEM OVER 4(EA)
CERI'119CATE OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INT'ERCEPIOR BUILDING DIVISION FT!FS
an recall he compktd rm
ifthepeit u fawn �
hucd dollarx(SIM) GREASETRAP
or kis.)(Rha sedd twit PLANCIIECK FFk
I,ce bellit intoe cdoamtirc Ifni,work orwhich rN,croo I, ,oed,Ishn11 SEW17R-SANITARY-STORM anEA.2n)FT,
not employ y pcnnn inn mhcnra subject m the Worker,Compen. ENERGY IEE
pZ anion L.ws o`YYC�hhilifornu �n WATER HEATER WNENIUPLECTR GRADING
z� AD lboarm�p, .
T`f) NOTICE TO1IAPI'LIC :If,after a:mg mo Plate of Excmpican you."bald WATER SYS'TEMaREAHNG
income suhjm m nh Workers Cmnpnat mvmion of Ilhe Izbor Cud",you ronin SOILS FP:
forthwith comply wiNnxt ptovin.or Nix p.I,shall be,ectal revoke. WATER SERVICE
0
� Z GONSre,ac DN "lion LENDINGAGENCYNEW RESIDISlTIAL PLMB. SQ.FL PAID ac Re,ci,t
I hereby,h Thi that there Is o um(S elIno IUMng ugcn y fa Ila Nnihmharcn of
ILO tine work for wnicM1 Nix permit is loud(Se.3097.Civ.CJ TOTAL
UIcdv'r Name
V Lender's Address 1A1:
2. 1 emify tical I have red thin aplNicnnion ad state that the above infommtnn is BUILDIN' FEE
aVi timet.1.gine m comply with at city and county oNirhances"mane law,relaing uh QTY. MECHANICAL PERMIT' FEE
C.) Z buildin,,merrection.ndhcreby a.mtidee rep«nadoa.fthlscity In entdupon th SEISMIC
` above-mania i p�o eriv for in menton pupma. PERMIT ISSUANCE
(Wer)agree m save,indemnify and keep Mrmlda the City M Cu,semro against EIPCTRIC f
habilit,".judgments,cram and cx,iraws which may in any way wenn against xakl City AI21'12R OR At)[)10 MECILPLUMtlING O
in nscyvenanfth ,marring efta,permit.
APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CEM) MECHANICAL ME
SOU - REGULATIONS.
` 710.00010.0000:10)�-9-?17Q17 AIR HANDLING UNIT(OVER 10.0000:10) CONSTRUCTION TAR
en
\�S t c ol'Applanim"Con 1). EKIIAGST HOOD(WIDUCD HOUSING MITIGATION FF.E
If DOU5 hIAT15i DISCLOSURE
Will Inc appi mftnurt huildingmccupant sure nr hadklhvanbua mntcrW HEATING UNIT ffO I00.00)BTU)
eo&-find by the Cup imo Municipal Cork,Chapter 212,ad me HcWih and Safety
Cork,Section 25592(.)! / HUNTING UND(OVER I(10,00f)PTU)
❑Yes PAID
VINIl1AT10N PAN(SINGIE RFSID) Date Rec'Pi
I'� - Wil
I du applican a futon:building occupant u,e equipment ak+ices twhich
If OILER-
mit lica-buus wrnmmnnocan :,&F—d by he Hay Aroa Air Quality Mnnugemcnl -COMP(311P OR IW,
11 OW BTUI
j'>T11i L.
District(!(DYen [1f Nu ' BOILER-COMP MOV ER 1010.000 BTU)
AIR CONDITIONER
I Moe read the Code,S amt 2!ls 3.2i53 tum anl,r Chapter bla d(the Calle ISSUANCE DATE
Tench Ic m&sateny Code,a WQo 25503.2 my ant i5 lit4.1 ctrl fy Thal if the NEW RESNEM'IAI.g1HCH. SQ.Ff. G
bwldin 'have Ic�W.IhL it'n hay taphu"ibilitymnwufYth oavpwu Q l
of ' In m-tp;ami.x,hana a.cenrmte udfxapan-y.
11
utedscr al ugcn Dat, 9(1'TAL: ISSUED BY:
OFFICE