S 1774 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEcrRICAL, rray4Cr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
1774
BUILDING PROJELT IDF,NTIF'ICA'1'ION
JILDINGAODItISS.. SANITARY NO, APYLICA'IlON S013M1'I'I'AL UATF
4/0219 �o s /�oi (0
WNER'S N•1MIc J,O� PyHO�{VL O/� f tM/�S /-/S / ��UAve N/C CON'CROLB
�A CHITEC'UHISGINEER: 7 �LICC NO ADDRESS: '/ ��`� ❑
CONTACT: PHONE: ! BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ID CI' PLUMB MITT
❑ 6 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'pY ELECTRIC PERMIT FEE
I hereby wenn that I am Earaval ander pnwi.ions of Chapter 9(commencing JOB DESCRIPTION
Woz with Section of Division 3 of the Business and pndersionsCish.and my license lc RESIDENTIAL
X 0 0 PERMIT ISSUANCE
FWD ni lull mince:nal ctifi] O DSFUWU ❑KITCHEN REMODEL
QUV License Class Lica APPLIANCES-RESIDENTIAL ❑AUDITION El PLUMBING R17 PIPE
yzw Dmc C, ,,1 r
t-Ow ARCHITECT'S DECLA A f PANELS ❑MULTI-UNIT [I STRUCTURAL
z c y z I undendand my plans shall be owd as dIj,,rc it, MODIFICATION
Oil"r02W AMPS
Q z"p ❑INTERIOR ❑S IMMING POLL
HavIFy; Licensed PnodessmnW 201-Igg0AM1'S IMI'ROVIiMIiNT WIPOOLS
CUT; OWNF,R-IF1111,U13R DECLARATION OVER IOWAMPS D BATH REMODEIJREPMR DDEMOLITION
k 3
C w Q 1 herehy afrm Ilial 1 am exempt from the Contrastive,License Law for the
a.V fallowing rummn.(Section]11315.fusions and Pmfe,00ns Calc:Any city nr enumY SIGNS ELECT RICAL El OF
W LL h which require%a permit nm construct,altar Improve,demolish,or repair any s meturc
st prior in its issuance,also requires the applicant for Inch pennh to file a signed smamln SPECIAL CTR CII IT/MISC,
(hal he is IIse... panvan mLha provisions afthe Cm,crear's License Lan,(Chapter 9
(Wy{5�0 (commencing with Section AMID)of Division 3 of the Business and Professions Cose)or TEMP METER OR TOLE(NST. COMMERCIAL:
Q.L e C That he is exempt Ihcrefion+and Ihu basi-v for the alleged emmption,Any vloladon oT D NEW BLDG/ADDITION D DFMOLITION
W M la- Sredon 7031.5 6 an applicant for T subjects the applicant ro a civil Penalty of POWER DEVICES
n1-mY any 00) C:1 TENANT E]FOOD SERVICE
w=OnI nmre than five M1 prapi Jollam y rout. IMPROVEMENT
D1.as emner of the proµny.ur my employSec with wages ns Their sole nmmpBasin . SWIMMING POOL ELECT RIC
F. will Jomhcsions mod The ntmamrervnol i;Livens straw dosnrsulc,pi, no nBnetuu [I OTHER
W 3= and 1'rn,who b Calc:I he Comraror's License law Jces not apply to if owner nl OUfLEI'S-SWITCIIIS-FIXTURFS
his own who wild,or idedtimproves thereon,and who Joel such work deed or or Through
cls own c—c eyccs,paildi al Ibm such Imprnumcms-am not intended or offered fina,for NEW RESIUUYFIAL IiLEClR SQ FC.
owneohoo'cveetheveIin6urimpmvcrnent i.\at heiithinone yclvfmroscfor the SQ,17.FLOOR AREA $ISQ.FT.
uIf steer will have the buNun u(praving that M1c JiJ not hail)ur in+pnwe for par-
ry+x of ales).
,o 1,an t the p of Tbc pm.70,1 ,H ,iac,ivcly convening wish )]be d smostoera u+ TOTAL:
conwuct doesnu applyoanowne fsaoJry who
h ivav Cnor unpre Cnmrdaon,li PAID p
ansa Law Jnesmlah,unedn Oill. omrwIon,wcesed ls panimpmvn thereCimara. r, QTY. LUMIIING PERMIT FEE r M
who se Law.lime such projens wllhvamwemr(s)Iieen rd pursuammtM1e Comreemr'.
License law. ,B&rc u,rmis PER ISS C E 8 ANST
D lameaanln mmersu. reason
ALTER-DRAIN&V W' IR(EA) VALUATION
Owner Irate
WORKERCOMPENSATION DECLARATION
BACK'LOW
1'ROTF,(T DIiVI C�IY Ur IJVI'Cm sr"I'`I hereby afro+under peachy of perjuryo.r of Ihc followmg ded-dions:
D I have and will maintain a Certificate of Consent)self-Isure lin Worker's Compel. DRAINS-FLOOR,RUDE AREA,CONI(. S'r(1R11iS TY PECONSTRUCTION
Saban,a,provided for by Scraim 3100 of IM labor,Cale,for the perfomare d The
work lin which thi.v,emit is I...rill. FIX9'URr:S-PER TRAP
I have and mill maintain Workers,Compensation Insurance,as required by Section
3700ofthe Labe Cudc.for lin,patormmoceuf llmwnrk for which This na'und is ivoreL GAS_IiA.SYS'IEM.I INCAOU'1'LETS
(ICG GROUP APN
My Workers Compensation Ivuruna camcr and Polity number arc:
Corner: Policy No.; CAS-IiA.SYS'rEM-OVER 4ILA) '
CERTT IIICATE 01'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDIISTRI,WASTE INDiRCEFFOR
(I his section mud nl be compinN i OrbeT iv forone hundred Jnllac(S 100) BUILDING DIVISION FEES
peau GREASETRAP
or leo) 1'LANCI IECK PEE
Ic,d,fy@at in the palonnancuol IM1e work for which thi,p anni,is',ind.I shall SEWER-SANITARY-
not employ any peal in any manner m as T t m the Workli Co.,.. STONM EA.2N)FT.
ale jo � +Y F-m�upta T;NERGY FIIII
z lallon Laws of C %
z 8 App,icmnl 1/ WATER VIIiAIIiR WIV IiNT ?LECIR
an L C-ti GRADING ITE
y NODCI:T I' ICA :If.a(Ier making lM1is Ccnilicvm of Exemption,you should WA'I'ER SYS]LMfl BEATING
a > x ome sab c I m the Werke,Ck... rr,lamm proviaon,of the Unfair Coda you most SOILS FRE
W forthwith comply with...h provision,ormis pcnnit,hvll brdeened revoked. WATER SERVICE
a Q
z CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL('LMB. SQ.PL ('AID
V Ilot.1wO mnharramois.nit(Se,om len ding agency(oohs per0mm+nnccnF Datc Receipt#
CS. F-' the work Lor which Ilii,permit is LoucJ(Scc.30)].Civ.CJ
Q V Lenders Nvnm TOTAL:
Lender's Address TOTAL:
Hy 1 testify that 1 have read this till and stere that the aMrve inlimnatinn iv BUILDING FI+.:
N comet,l agree to comply with all city and cm.nfy ordinances andnta,laws rcmtinb l++ QTY. MECHANICAL PERMIT FEE
Vz haildingcon,mInimmid hereby aahmvc repremntmive,id this city menteruryr,be SET'MIC
above mmltimad propony for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep battles,an,City of Capenln,against ELECTRIC FF.E
liahiliucs.jadgnmm,, ...1,and expenses which may in any wvyaccmcagainsl said City AU 17R OR ADD'FO MECH.
to consequence of the granting of this permit. ECONSTRUC
FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alk HANDLING UNI"I(TO If1JM1U CFM)
SOI1kC1?R1F.UL / 1 ) AI FEE
,?-C/ AIR HANDLING UNIT(OVER 10.000 CFM) ONTAXwjofnpplicuMC mrxmr Dae F.XI{RUST1{OOD(W/DUCq TIGA'FION PRIi
IIA%ARDOUS MAI'I:RIAI.S IIISCI.OSURE
Will the applicant or future building occupant store or handle hmeNoua material HF,A'rING UNIT LTO lft(001TTU)
as dcGnral by the Cupeninn Municipal Code Cl 9.12,and the I Icalth and Su Ray
Lose,Scctinn 25532a1! HEATING LINT F(OVER 1011.010 B"I OF
❑Yes 0 N
VFN'11LA'1'ION MN(SINGLL REST Of PAID
Will the applicant or future building encu quipmm� Date Bee I
pp g pantrAre sloy Micecn'tem B0ILI'R-COMP(3HPOR H)IIJM)unrf,I)
mil liar vdnus sur mn0:uninume m define)by ilia Nay Area Alr QuuEry Manugen eel
DlancC OTA(,:
❑Yeas r-1 III, NOILI?R-COMI'(OVIik IOU(MI00'FU)
I have real the haeardous materials IquiremenI.niter Chan,6.95 at the Cali- AIR CONDITIONER ISSUANCE DATE
Forms 11,1111I&Subtly Code,Sections 255115,25533 and 2551).I understand that if the NEW RESIUENFIAL\TECH. SQ.PL
buildingdves an currently have a Tenant.Ihm it is my reerymsibility m notify the occupant
of the«,their emu which mnsT b:mal prior to issnunev of Cenificam of Occupancy.
Owner urnnah... rd.gent War TOTAL: ISSUED BY,
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OFFICE