S1760 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELETRICAL PEIW IT NO, 1760 760
BUILDING DIVISION APPLICATION/PRRMPP PC
LUMBING-MECHANICAL \V
BUILDING PROJECT IDEN'I'MUNITION
SANITARY NO. APPLICATION SUBMI'1'1'AI.DAT
BUILDING ADDRESS
DATE
3 LpfejP Wit- C u EIL-rl Na CA qj 0l
O R:SNAME: i'HONB: CON" ACTOR'S NAMU _ LIC NO:
NE --53—L
'7 C NIC ea.-JF,•ARCHITECUENGINF.FR. - ICNO: ^ N)URESS: ❑
� 3 V%
C NTACT _ PHONE, BUILDING PERMIT INTO
Ram 4KLl4ND�.F2 �6�- X89 3 ❑ Consultant Fecs Paid by Applicant(Initial) BLD ELECT' PLUMB MFC
5 0o S
'LICENSED CONTRACTOR'S DECLARA'110N Q'I-Y ELECTRIC PERMIT FEE
I hereby alar Inas I am licensed nadef pnwixiolo of chapter 9(cmmnearins JOB DESCRIPTION
•��Z with Section]OOB ofuirisinn Sof the Buxinexsandl'mfessiu is Cale,andmy license is - RESIDENTIAL:
is100 57 ' O a PERMIT ISSUANCE
F-h2. in full force and cBert / V ❑SFDWL ❑KITCHEN REMODEL
aUU License Clan Lick APPLIANCIiS-RISIDENTIAh ❑ADDITION ❑PLUMBING RC•-PIPE
F Z til Dam Commcux
tnQC El MULTI-UNIT ❑STRUM TURAL.
Dm A CHITF:CTS DECLARATION PAN'EIS
F Ie.Z I understand my plans&hall be used as public records A10DIFIG\TION
C,z—Q UPTO200AMPS [I INTERIOR _ ❑ IMNEYREPAIR
Fyf u: Licensed Professional 201-1010AMPS IMPROVEMENT �p 4IMMING POOLS
may$- OWNER-BUILDHR DECL\RATION OVER 1000AMPS ❑BATA REMODEIIRF,PAh_Y/t0-I DEh101.ITION
5 x Q 1 hereby affirm Ihm I ma exempt from the Compact License law fur the
XO W U following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECI'RICAI, ❑OTHER
3 0� which borealis a peril to courav el.alter,improve.demolish,or repair any structure
5 prior to axalso not The pplic t for suchPermiti file a signalxtmctnent SPECIAL CIRCUITIMISC.
that he licensed ptt a the ponvionern,titth Contrai License Lt (ChapmNl COMMERCIAL:
0 (commencing n'th Section 7")of Division 3 of the Business and Pr k:: ms Code)in TEMP.METER OR PILE INST.
s e e x
and he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION Ll DEMOLITION
6!^vi Section 7031 by any applicant for a permit subjects the applicant to a civil Penalty of MWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(S50)). IMPROVEMENTSSC ❑I,as oxner of the Prnpcny.ur myempinyecswith wngcsas thcirsale rompcnvtinn, SWINIhfING POOL ELECTRIC ❑OTHER
IY F•e wiildothe work,and Ne structure isnot intended or offered for saix(Sce.9M9.Business
W ce and Profrsions Code:The Commctoe%License Law drcx not apply to an ironer of OUTLETS_SWITC FIXTURES
d 3^ property x'hn builds or impmvcx thereon,and who docs such work himself of through
his own employees,provided that such improvements am not intended or one"lot NIiW RESIDEN .ELECTR SQ
sonde.If,howen'er,the building or Improvement is said within line year ufcompichon.the SQ.FT FLOOR AREA 81SQ.FT.
ownecloilder will have the burden of proving than he did not build ter improve for pur- P A D
Puce of sale.}
_1I,as owner of the property,um exclusively contracting with licensed amtreunrs to TOTAL'
instruct the project Ser.'IMJ.Business and Profes.sinnc Cade:)ThC Counci r Li. ��� �U(1s®
cause Law does not apply m m
an owner of property who builds or impvcx thereon,and Q'FY. PLUMBINCI 'ER. FEE. MIN
who compacts for mob projects with a contrecmgs)I send pucman n the Contract nr'.0
Licenxe Ia1w, PERMIT ISSUANCE
❑I am exempt under See. Bre P C[,itmL.reason CITY Uh I,UI'CI1111VU
ALTER-DRAIN k VENT-WATER(EA) - VALUATION
• Owner Dare
^
WORKF:R;S COMPENSATION UECLARA'1amION BACK FLOW 1'RQTECI'.DEVICE 2♦✓
1 hereby aBmn under Penalty ofperryry ane of the follov ag dectim limns r�
El I have and will maintain a Ceritieatcrl"Corwin to elf-metre Ili,Workers Conlpem IIRAINS-ILOOR,ROOFARIiA,COND' STORIES 'IYI'ECONSTRUCDON
tion,a,Pn iJnl for by Section 3901 of the huMv Corr,for the perfumruneact he
t which this Per t 'issued. FIXTURES PER TRAP
I Ih I ll ire IIIC p -I' l lbyS ins
.] l.fine Labe.Core,for Heperl lirnameof the work for which heiennt is 14 .J, GAS ITA SYSTEM-I TNGa OU'TL615 OCC GROUP APN
My Worker's Com c xv In In:urancr c:nrzier mW i'nlleyJ�Ilii{hert a�•''�/
Currier D I ION FROM
WOAKFRS'-�— GA ASE11NSYS TEM-0 FR 4WASTE
I N
CFRTIPI OM OF EXI1ION(INN FR A NCH KERS'
CUMYIiNSAII(IN INSUItANCIi X09- CIItEA51%INUl1.5'I'Rh WASTIi IN'I'IiRCFITOR Thi GDI':ION EIi[S
fTho,ecionneed nut be....nplater]it or,lvnn'dls lbrone hand sidollarx IS 011 GRIiASE'IRAI'
oJJ YLANCHECE
r less)
I certifythat ln the f eof he workl hich mi,scalull IN ooAcd.II'ai SLWBR-SANI'T'ARY-S'ITHRM EA.200 ET.
non
pI Y )P'non Y sen as F hi-II 11 W k..i C......wn ENERGYF. ��
Oti eclion Lawsof C.1iI forniu.Dutc WAIFk H1IAI'ERWIVEN /EI_U-IR
GRAD CPBzApplicant
NOTICE TO APPLICANT.11,alcrlinkingthis Ccrltieate o1I?xolnp ,you should WATIM E
SYS FMG RUN'I'INC, SOILS L
ti
I� beemauhjc,h the Wickens Cmnpenxation Prolillool(11ID I,:1ntlr Cod,
m YuII 11111x1
W7 forthwith comply w hill such of iooax of This per shall he deemed revoked. WA'T'ER SERVICE
Q
C(INSTRUCI'I(1N ENDING AGENCY RI
iW RIiSIUIiN'I'IAL PhMIL SUIT PAID he Receipl4
L)Q 1 henry about that a a arrFhaclion lendingagency ror the lerkmnloce of
fY — re work for which this peril Motor] AY)],Civ.CJ
U Lenders Name TOTAL:
U Leaders Addreae TOTAL:
>1 I certify that I have read this application and state that Tho ablwe infonnntion ix BUILD] �FEE
Fy rorest.l agreetocmnply wan Wl Coy andauunly ordinances and lune taws,rclaling m M ECH AN ICA I,PER M I'T FEE SEISM 'FEE
UZ building construction,and hereby euthorim reprco,mau ves of this city Ill enter upon the
above-mentioned property for inspection Purpose. :RMI'T I SSUANC17. ELEC' RIC FEES(We)agree m rave,indemnify and keep harmless Ibc Cityof Cu,maho against
experul which miry in any way arrive against saidCityUFFRORADD9'OMECIL PLU BING FEE
in ncequence of me granting of Ibis peril.
APPLICANT'UNDERS ANDS AND WILL COMPLY WITH ALI,NON-POINT' IR IIANDI.ING ON I'TUFO 10.001 CFM) MEC( 1NICALFEE
SOURCEREGULATIONS. ///
M�'I F,M,t � l` AIR HANDLING UNIT(OVER 10.000 CIM) CONSTRUCT VTAX
Si amre of AAppplloard/Comracmrki "— I1 DLate HNIAUS I'I IWD(W/DUCT) HOUSING MI GO ON FEE
HAZARDOUS hl ATERIAl S DISCLOSURE
Will the applicant or future building occupant score or handle haxardoux matedul MEATI NO UNIT(TO 100,00 BTU)
as defined by the C,eman Municipal Code,Chapter 9.12,and the healon and Safety
Code Seclimn 25532(x)? HIiATING UNIT(OVER I00.0N1 BTU)
El Via, []No V EM1LAI ION PAN(SINGLE RESID) PAID Dae ci,#
e Will the applicant ter future building tccupam use cyuipmcm or devices which BOILER-COMP(JIIPOR 1O01X10 BTU)
mil hmmNnus air nmtammunu as def ncJ by lilts Hay Arca Air Quality Muwgcnmm
Diarist' BOILER-COMP(OVER I0,000BTU)
❑vex ON.
I have mail the havmNous matenalx"uimmens under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEIIIATE
hernia Health&Safely Code,Sections 25505.25533 and 25511.1 umlentand that if the NEW RESIDENTIAL HECK SQ.IT
building Joe,not currently have a tenant.that it is my responsibility to ramify the occupant
of the renuirclrents x'hich must be met poor to reliance of a Cerilicate of Oceuparcy.
Ox'neroreotholion!agent Dur TOTAL: ISSUED BY:
OFFICE