B 0452 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUn.DING-ELEC TICAL IPERMIT NOa- 0452
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BUILDING DIVISION APPLICAT70N/PERMIT PLUMBING.MECIIANCAL S0001BUILDING PROJECT[DENT FIC,\TION
BU1LDINGADDRESS: SANTARYNO. APPLICATION SUBMITTAL DATE
3 w e .
OWNERHH'S NAM1tE PHONL CONICTOR'S NAME LIC NO:
NIC CONTHULX
ARCHRECDIL'GINEER: LIC NO: AUURESS. ❑
hikybi-S 7;7111
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CONTACT. PHONE: BUILDING PERMIT INFO
670 ✓LI V {-J�rC-) C831)gp4 5133 ❑ Consultant Fees Paid by Applicant(Initial) BLD EO PLUMB 4101
J LICENSED COMRACTdOB:S DECLARATION QTY - ELECTRIC PERMIT S yrJ�(
1 homy vlfimi trot I sun licensed neer Pmvisioco of Cbnlrcr v(onmmeneing JON DESCRIPTION
oaz with Section 71(10)ofDivisios3ofthe Bminevand Prnfeuiora code,and mYresnseis - RESIDENTIAL
�O p PERMIT ISSUANCE
W= in felloommWdT r. ❑SFDWL El KITCHEN REMODEL
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Lie.Class Cwaanm API'LIANCFS-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
�h ARClII'i'IiCI'S DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAL.
'Z O r�Z l undm+ard my plvu shall be uuU as public roods UP TU NMI AMI'S MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
fa-t?~W Lieeval Professional - 101-I/100AMPS IMPROVEMENT 0SWIMMING POOLS
G�� OWNER BUILDER MiCIARATION OVER ItMMl AMPS El BATH REMOUIi1JREPAIR ❑DF1.1G1.1TIGN
a I Noehy affirm that I an eecmpl from the Cortwor's License Law for the
x a W F folbwin6 reaam.ISnrion 7031.5,Bu.dnru mW Profesxiom Cole:Any city or nmmy SIGNS ELF IRICAL DTHIik
u] y whseh tc,mms�'u Permit mul,cuUm.alter,improve, len rloh,m re,it aatrturt
ny ucf"Cn b('JZ (a ✓' /�'��
f'1='fig prim to its issuarm.also reyui s oe applicant for such pemdl to file a ugrrd srvcrrmrENEW
IRCUITW ISC.
�} I not he is l irnmsul purwvntm the provisions of me Cominelor's license Low(ChvlPer9
amp (rnmmeuiog xith Snrimn]fl(()of Divisian3ofrlr tlushrns ami lhdcisiore Cadc)mER OR POIF.INST COMMERCIAL
a 1 e floor he is caem A thcreGom and Ile hniv for the tile,1 exemption.Any violelion of
-1 NEW NhUCJADDITION ❑DIUIOLII ION
Section 70313 by any appl'rant fm a Permit subjects the t'inantm v civil penalty ofVICES
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mot more than rive huMrtJ dollms($5001. ❑TENANT. El FWD SERVICE
F=Q I,urrunn oftM lmspertY•ur my cmpNrYees with wages as their sole rnmpemwim. GP(OI,ELF RIC
[]OTIMPRHER VEMEN'I'
F Q will do the xrxk,acrd the umcrure is nn inrerWed ordfered fm ole lSm.70N.Posiriecs
Tai] and Pmtensimm Com,:The Contmctm's Limnse Lw dxs most apply m an owner of SWITCHES-F
e' IA mrry who builds or impoi Breams,and who docs sum work hori m Brough
i his ton employe¢providm mar such impmvcmcnd ore nos inter♦led err offensI forDENTIAL ELECTµ
sde.if.lmves willhbuildingmim ofmroeminaMd h]mer
eYcmof r,on,,for rte Ff.FL FA Fi.
Pone.-'gnfe.r will Iwvc the Mrrdcn o(pruving that he JiJ oast M1uiW m impmve for per- Dr
Pose of ode.). D
I.as.sumer N the poWrnY•an excluuvelY contracting with IicensW cmtrMtm to TOT
mnrmh the p,-,(Sm.70114.Bnom—end 1'mfersiomv,Cn4::)The Cnnuanor'n Li_ MAY 1 2
eense low does rw.+pply to w owner 4 loperly wM builds or Grynovn thereon.mrd QTY. PLUMBING PERMIT � E f 199
whommmns Rr,,uch smjmu with arnmlmcmHq hrenunl pursuant to nMContracmr's
License Liw. PERMITISSUANCE
I am cacmp rad..Sm. ,B&P C for Ibis reason B
o mm Dam ALTER-DRAIN&VENT-WATER(EA) TION
-0, WORKEH'SCUMPI:NSATION D[CLANATION BACK FLOW PR(JIECI'.DEVICE
I heaelsya(fimr mndmp alty4 perjury.of the fdlowing dcclasmcm:
1]Ilu>carrd will maintain aCevifeimot Consunun elf-insure for Workda Cmnp:n- DRAINS-IL(OR.ROOF.AREA,GOND, STORIES TYPE CONSTRUCTION
suiom ns provided for by Smoot 37M of the labor Code fm Bre Irrfmmaree of Ne
Z❑r whim This,moit is issued. FTXTIJRLS-PER TRAP
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1 have vol will maintain Wmkern Campenaion Imunree,as remind by Smtim
311(1 nine Utero Corejerrhe pcdum .fthc work fmwh.eh this per mit is inn d. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AVN
My Wnrk}'s Ct ratpm fns Hicr sed l'ulicYJ
Mantic'. r TO4Z9� GAS-EA.SYSTIiM-0OVER FA)
/ Policy.nay L
CERTIIICA'IY,OFEXEMPTION FROM WORKERS'
COMPRNSATON INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('This section rrWnt hemmpleted ifthe permit is tone nhundW drllms(SI00) GRLASETRAP
or less.) PLANCHECK IY3.
I mfify dent tribe prr(rmurntt nftbe wok(mwhich lhlapermiru iw ,l shall SEWER-SANITARY-STORM W.IW IT.
not employ any person in any nrenrcr so,as to hecome whjcet to the Workers'Com fe. ENERGY FEE
�zsaroa laws cf California,Dare WATER HEATER WNPMIFlECIIt GRADING FEE
y NOTICE TO AI'PLICAN7E If,after making this Cer iflei of Exemption.You shouD WATER SYS TIMTREATING
a ; fimoma suhjccuo the Worker's Compenwrion pow&inns of tk Labor Gale,yoo most SOILS FEE
hmhN'iin mmply with such provisions or this pervdl.lull Ne Jeenred revoked. WATER SERVICE
Q
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Receipt
U O I hereby affirm that there is a cnnas nim lenlrmtri y fortheper(mmmreeof
Us I" the wok Inf whim this[Motif is iswml(Sm.N07.Civ.C.) TOTAL:
I.aders Norm
V Loco's Adda.0 TOTAL:
W rend BUILDING FEL!
11 lance eIhave with
all
it,and
munt,odi1e flat Bre above.,rellalinnu
Z arreeLlagmcmcvmply withynymxl county mdiremat ntl nee la enter
n,,o the QTY MECIIANICAI,PERMIT FEE
U z hoildimgem�mnim.and herehY auNove rtpe¢mativa of his drymemeroprn the SEISMIC I'FS
` above-rnemioornl
refry for inspmion pooPoses. PERMIT ISSUANCE
Wry agree Io se,holm mfy end keep formless do City ml Co,mr.vgnimet ELECTRIC HE
IiaMlitiea,judgrrcms.•'"'.annd eslsruea which may in any.oy..,amen said City ALTERORADDTOMECH. PLUMBING FEE.
cm.yuena of the Granting of chin permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000CFM) MECHANICAL FEE
/ SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.((()CFM) CONSTRUCTION TAX
t Sisnot re of AIt"; Conuwmr —ITte EXHAUST HOOD fWIDUCTI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the upplknm m Orem huilding omr,nnt eme or Iwndla hesardnus mamnol IDEATING UNIT(TO I X),M)BTU)
in,dein by the Cupenrro Muninpal Code.Chapter 4.12 told BIB Heahh and Safny
Ctdq Section 25531(a)'tHEATING UNIT(OVER 100,00()BTU)
Ye
VENTILATION FAN(SINGLE RESID) PAID Dmc HvenpM
( Will the vpplwamt or Iuturc No lihng ncupant use mripmem m devices which BOILER-COMP(3HP UR 100.(100 ETU)
.mit hvudmn air corms noona as defnmi by the Bay Arta Air Quality Ma otilmeem TOT 1.:
111` DistricB
❑ BOILER-COMP(OVER 100.000 HTO)
Yn 7D/
Ifin.Waif Bc hvvdws maaials mquimnemaoWa Chaper 6.95 of the Cod,
AIR CONDITIONERISSUANCE DATE
forma health R SefnY Code.Sections 25505,25533 and 15511.1 uralnnvol flout irrhe NEW RF_SIDEN MEAL MECTL SO.Fri.
huilchog dxa nun comndy have a lmumL lbw it is my rgmrnibillty to nnify(hemaywnr C
of Be oryuirerrrenp wTim ern M nlfifaim ro issturce M a Ctttifiotc d Oavpaorcy. ♦ '�-/y�J
Ownerm authnrcd egrnr Date TtTTAL ISSUED BY:
I OFFICE