S1319 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICAL PB II NO,
BUILDING DIVISION APPI,ICA790NIPERMIT PLUMBING-MECHANICAL. 1319
BUILDING PROJECT IDEN'I IF'ICATION'
ILDINGADDRESS: SANITARY NO. AL'1'LICAHON SUBMIr+TT1Ah DAPE
21470 41tG qj-Z.q
4AW IRSNAMF,: /� PHONE .'I'RACI OR'S NAME: LIC NO'.
f k F h t /O 'y (J_ (��- '/Q SZ
r3 N/C CON IROLOr
l UtC1H .CT/ENGI ER: I LIC NO: DRESS: ❑
I � S S. C SS iJ�cC
CONTACT PHONE: J(r BUILDING PERMIT INFO
❑ Cnnmliant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
II by affirm that I licensed J p or Chapter (commencing ._. JOB DESCRIPTION.
WIZ wiIhs f 7010b fD ':,f 30 the Buslmound Pnfe:' nC 1 i ylicense is RESIDENTIAL:
WOO it I'IiRMi'I'ISSUANCF. _
F W full f on—ad cjfecl, f ❑Slll\VI. El KITCHEN REMODEL
aUU Limnsc Clae N APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'IAMBING RE-1'11'1;
Nay Uutc �' ZY1 Commdor ❑MULTI-UNIT ❑STRUCTURAL
ARCHI'IECP'S DF.CL jf,/&e S pANIiLS
ZQyZ IunJers dm' mshall he used Iicr nNs PANELS 200 AMPS MODIFICATION
OZ-n ❑INTERIOR ❑CHIMNEY REPAIR
r-'Ili LicensedPm ioa 2II-1000AMPS IMPROVEMENT SWIMMING POOLS
NIiR-HUILDF.R DECLARATION OVER 1000 AMPS ❑BATH REMODEIIREPAIR 0DEMOLITION
C >" I hereby affirm that 1 an exempt from the Contractors License Law to,the
3 F following reason.(Section]1131.5.Business and Professions Code:Any city or county SIGNS[LECIRICAL ED OTHER
m wh q p nn a a t Iter, p demolish. r repair Y someone�.W+�� profr its i......e,id,one,ture,d ppi ,onowt,p 'u File it s,,nO,laNwor , SPLCI ALCIRCUITIMISC. A
Evt'Gy:P (Chapter 9 �r1
GgepO (tom nc o.n,with Section 70000 rf Dmriot dol the Bus nwn+td Plot u rum,Code)or II,M P M1:ICR OR POLE INS'I: COMMERCIAL:
Z d e C than he Is exempt therefrom and Abe Laois for the alleged ceemptio t.Any Aobdon of ❑NEW BLDG/ADDITION ❑DEMOLITION
X.n a' Section]113 L5 by any applicant tin x Ixrmit ouM1jees the aPPlieam m a civil penalty of POWER DEVICES
FZY,' non...ethan five hundred dollars($5000 ❑IMPROV FOODSERVICE
Ih1PROVF_MEN7
❑1.as ow mnAfthepmpmtyonnyanployees with wines.,theirsnle compensation. SWIMMING MILL ELECTRIC
vilid.he worLisndflivorctom is not intemledoroRered bu Nre Ne,.7044.Business op
❑OTHER
W
3 m and Professions,Code:The Contractor's License Law does not apply to an owner of OU'fLEfs-SWITCHES-FIXTURE
property who builds or Improves thereon.and who docs such work himmlf or through
his own employees,provided that.each improvements are not intended or nf'O,Td for NEW RESIDENTIAL.ELECTR
sale lf.hnwevn,the building nr inlprovm..em is,md,ithiusseyarint'mmplutioI,the SQ.FT.FLOOR ARI?A SISQ.IT
- .r-builder willlmvcthe Morfront pmvill.dial he did nil mild Ur i;nprnve fnr per- ,
Fuse,I note). pp
❑ L us owns of the me,,y,atm cxclnxively ounnachn,with Ilccnsul emnocmns ,, ^ P 1 D
...satinthe projwt(Sec.70,14,Businus and Pmfesdom C a,:)The Curnmelor's Li-
come ladoesnetapplyinanownerofpropenywhoboildsorimThereon, QTY. PLUMBING PER"" FEE A
w �eW�A/1
who contracts for such pmjeels with a cmurachu(s)licensed pursuant the Conuacmes INA 2�
Lionise law. PERMIT ISSUANCE tn/1
AN
I at.exempt under Sec. .R&P C for this m...n
Owner DJ1L ACfER-DRAIN&VENT-WATER(EA) urVehypaR"(Inv
WORKER'S COM PENSATION DF.CLARA'I[ON HACK PLOW PRO[EC..DEVICE
1 hereby nffimf under penalty of Iwoury one of the following dmlurutions:
❑ Ihavc unJ will ntninminu CcniBcum ml Consent nr sdf-insnrc lLr Wnrkcix Cunfpcn- DRAMS-FLOOR,ROOF ARI'.R.C'ONU- STLIk D.S TYPE CONS'TRUC'TION
salon,as provided for by Section 9701 of he Lade,Code,for the pednnnancc of the
work for w hich this permit is issue. 171K'IURHS-PER'DOM
I have..it will maintain W'orker's Compensaion Inwrmtce us rcgniond by Scction
37161 of the labor Code,for the perfturnar ,o❑be work for which Ibis permit is issued. GAS-HA.SYSTEM-I I:1C.d()In 1-1: OCC GROUP APN
My w ,yG Or nsaio nyRmntt came Pol' Pd cy n n
Canicc 1A 4L1 t� y,•n.:.,M aDS97w GAS-EA.SYSTEN-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI!ASF/INDU5'IRL WAS INTERCEPTOR
COMPFPSATION INSURANCE BUILIIING DOOSION FE _
(Tink,ecuir.need not he dmf rcmdu Ne,com,is lune hundrtldullam(5100) GREASE TRAP
or less) PLANCfIECK FEO
I certify that in the Ferfonn:mce of We work for which this permit is issue,,shall SEWER-SANITARY-STORM I?A.200IT.
nil employ any person in any runner.t o as to hecome subjeeun the Workers'Cumpcn- ENERGY PCE
zZ 'aiou I.uwe of Califnmiu.Dam WAI HR 1117KI17R WIVIiNTIELEC1 R GRAVING FEE
Q Applicant
NOITCE'FO APPLICANT':IC after nuking his Cenificale of lixanpmmn.You should WATER SYSI VNI REATINO
F'I ? hismme subject to The Workers Compensation previsions of the Error Code,you most SOILS PPE
forthwith...idy all such provisions nr this permit shall Be deemed rc,.ked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDIiN'TIAL PLMH. SQ.ITT PAID
U O IM1erebY anion Na Ncrc ixxumNmnimn lending agency for the perfnrmane of Date Receiptp
W F the work for which this permit is issued(Sec.3097,Civ,C.)
TOTAL:
Q Lender's Name
r W Louder Address `
I my flat l l' e - Id':'pFI Ti dst dalll 1 f 't III111.DING FEE
as k�a,g) tLgee u.crani ly lh all cTy and any ord'anro. Jswu if wx rJ tlnym QTY. MECHANICAL PERMIT FEY:
U z huilAing emnsfrvction,and hereby lwNnri-m,mNuoaivesnf Mosby locntcrupnnthe SEISMIC FEE/
above mentioned property for inspection purposes. PERMIT ISSUANCE
,(W'e)agree m save,indemnify and keep monticss the City of Cupcnino against lil.[CTR :F.
Iiahilitics,judgmenrs.costs and expenxz which may in any way accrue against said City ALTI2R OR ADD TUMECB. RJCAL��E
in asequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,000CFM),RCE REGULATIONS
� AIR HANDLING UNIT(OVER 10.000 CFM) ANplicanVContmcfnr Date EXHAUSTIIOOD(W/DUCT) ION FEEHAZARDOUS MATERIALS DISCLOSURE
Willdsoppiicamor frtme Buildingoccupont onto or hmnlle rmsdous mmceral HEATING UNIT(TO 100,000111'ID
us defined by the Cuperino Municipal Cnde.Chapter 9.12,and the Hcullhand SafetyCoda Scction^_5532(x)? HEATING UNIT'(OVER 1110(XXIBIG)
EjYes ❑Nr -VENTILATION FAN(SINGLE RPSID) Receipt 0
Will the appleved or future building..pan,use egflipmento,device,whish BOILER-COME CHP OR 100.000 BTU)
an
,nit hordous air contaminants us definN by the Bay Arca Air Quality Manam
geent "POLI,:
District? BOILER-COME(OVER 100.000 BTU)
Ej Tills, ❑No
I have read the hamrduus nafcrialx muimmcmn under
Chupm,6.95 of NC Cah- AIR CONDITIONER ISSUANCE DATE
I in Ileafth&Surety Code.Su,lluns 25505,25533 end 25534.1 unJvanal d then if the NOW RESIDEN I Al-MECIi, SQ.IYI'.
building Joe,s not currently have a tenant,that it is my ros,r nomility In nmily the nnmpe nt �//�j/��///�y�O//�^7
ollhe mgmrements which nim,el priorm Emare,ofo Cenilictdc of 0...puney. JV
Owner or aathromad agent Date TOTAL: ISSUED BY.
OFFICE