S 1468 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �`
CITY OF CUPERTINO BUILDING-ELRC I IFCAL PFISIF No. 1 4 U 8
13011,INING DIVISION APPLICATION/PERMIT PLUMBING-NIRCHANICAI. J
BUILDING PROJECT]DENT IF'ICATION
UILDING ADIIRCSS: SANITARY NO. AI'PL1 ,'tl(IN SUIIMI"' hDA'lli
� - a6 ;� 0-
ON'NER:SNAMR: cc PDONE: NI COACTOR'S NAME: LIC NO:
.9-4-IrlJ� A-1/✓-j v� N/c cOYrkol.«
ABCIIIT;11ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PF,RMIT INFO
❑ COnsDltxnt Fccs Paid by Applicant(Initial) BLDG IiLECf rhl1MH •.IiCll
❑ ❑ ❑
I LL1 NM 1l CONTRACIOR S DECLARM ION (yIY ELECTRIC PERMIT FEE
11 t y a n , l (1 f nsed J p s xfChapter 1)(t,m,te )tg JOB DVCRIPTION
Maz wi11S i ](XXB I'll1301he Bu. dl f.vmns COdcundny line : In RESI)ENTIAL:
W Q O I'll
ISSUANCE
=-i-`p) . In full 1".r eat effort. ❑SFDWI, ❑KTICIIFN RCMOF17
QO Lmen.0 Cines hien AI'1'LIANCES-RESIDENTIAL El ADDITION [D PLUMBING BE:PIPE;
HZW Date—Cufuhaaur
v,Qy ❑MULTI-UNIT ❑STR(1C,1'1JRAI,
HDN ARCIII'D?CPS OECLARA'1'ION PANELS MODIFICATION
ZC,NZ I unt,ifonJ;nrpla—half lw used u.puh,u,com,
OZ4-a UPT0200AMPS [_1 INTERIOR ❑CHIMNCY RIzPAIR
Licmu<d Pool'c.slnnal 201-I0OAMPS IMPROVEMENT SWIMMING POOLS
CY�y;
OW'NCR-BUILDER DECIARATION OVER fXAIAMPS ❑BATH RF,MODEI/REPAIR ❑DEMOLITION
C Q 1 hereby alliin,that I am exempt Gum the Connns Cu L Any c Law lin the
3 LLF following,reason.(Section]031.5,liusiness and rmfcstimro Crdc Any city or county SIGNS ELECTRICAL ❑OTHER
w which requite.a Peroit m contract,mass,inipamv.demolish.Or repair any sfuemre
F'y�< Prior m it.issuance,ala,confutesthe.,hreant forsuch pe'rout m file.signed etamment SPHCIAL CIRCUIT/MISC.
E ply ,
that he is licen.e'd pursuant to the provisions of the Communes Lirense law(Chaprer9 COMMERCIAL
@oatmcncing with Section](N(I)of Diviainn Sof the Business and Profe.siom Codc)or ITR MHTF;R OR .:INST.
a a e C that he in exempt thercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D[[if ITION
W^m Satinn]f111.$by any applicant for apennit sublet(.The applicant foacivil Penalty of POWER DEVICF ❑TENANT ❑PDOD.,- cIi
I more than five hundred dollars($500). I OVEMENT
SD I,w ownOmfthe pa,pcny,or myetnplmyees with wages as their sole compensation. SWIMMING OOI.ELECTRIC
H willdomewnk,anA fM1eswvmrc>nmimm�dcJ,rnfferedf0nale(Sec.]M4.IBusincss OTHER
6 3 w and 1'mur,d is Code:The Cmnrronmr's License law Jees em apply m xn Iwncr ml OU 11. :-SWITCHES-PIXY
propery who build%tar improves therefor,and who Jens such work hmtvelf ry through
Itis own r,ndo au,provided mut such Improvements are not intended or of Bred[or NT RESIDENTIAL ELF,CTR V I'1'. SQ.PC FLOOR ARCA $ItiV.I'L
sale If.In-roc,the huilding for inq raveeom O sold within one year of c... pl tion.Inc
,,-car will have the hurdtt of proving that he,hd our build or iinprnve kit pun
pow arvule.). 'TOI'A.
❑I,r ,weer of(hr(n,v,n,,ac,exclusively aim fcdng with 5cceceb tnn(mcnns I,
mol I,t the es notl(Sec.]lard,weer toss end ricy wh i me Codei The C, la,von, Li
cc lawd,c.notal,ploRls lI1aommamnrw farOadJs,rfuno.d.C..rle,o , QTY. PLUMBING PERMIT iii
who aoomds for sueh Pmjcc(.with n cnnnacmgs)hRNN pursmnn Ifo the Qnnmtnr's
Licensor Law. PERMIT ISSUANCE P
I rias wnte (under See. .B A,1'C tariffs¢anon
NTHR-DRAIN k VENT-WAI FR(EA) VALUAI!ON
Owner Dam 'fr�a�.
W'ORKI'R:SCOMPHNSATIONDECLARATION BACK PLOW PROILCT.DEVICE POO 3 A I'
• ehy elfrad under Penalty of perjury one of the following declarations APR tune L«
0 I have and will maintain a CcniOcam of Consent to wlf-insure for Worker`.Compn- DRAINS-FLOOR.ROOK.AREA.GOND. "TTH
TYPH CONSI RUCTION
cation,as provided for by Section 3]00 of me Labor Code,for the performance of(he Crt iw
work for which this permit is i...cal. FIXTURES-PER TRAP
I have and will maintain Worked Compervtion Insurance.as required by Section
3700ofthe Lobn Coda for the performance Of the work far wInch his Permit is issued. GAS-EA.SYSI'UF I INC.a OUTLITS AVN
�«GMY Wodcfj Cp pepsPinnl rpt. cc Policy
Sgoy�wntbcgo�.OG_ p� GAS-PA.SYSTEM-OVERJ(EA)
/L Jro LC1iRII'IFICA'IG Up FXEMPION FROBC/WOORRKKERS)a 3 ty GREAS"INDUSTRL WASTE INH RCEPfOR
COMPENSATION INSURANCE -�ZYn V'� G DIVISION FIiIiS
(TIn,sefion need nor be cnnrpineJ if the pemlit is(nr one hundred dollars($LIN)) GREASE TRAP
tar less,)
I nlythal inh1 f n of the kr` which this Pe t'. Jlhall SIWFR SANITARY S FORM F.A.21X117L
m 'I r. y a Y ( b hi t fM1 Worker,'(: p
c) 10 Laws, yI DI WAfIRIIIAIF.RW/vCN f/F.1 hCI'It
z '1l I
(HI(I I' 1P ICAN111 ft rk ytl Cn'Ic(c fI pI „ ymt :1 should WAIIR SYSTEMfl RF,ATING
.. net felt new k C 1 t provisions of the Labor Code you,nel
W mrnw m - r w d .nen pr.d.:On: m pe 'I.Ian ne aremed res„knl won k SEkvlce
ACONSTRUCTION LENDING AGENCY NEW RISSIDENTIAL PLMR. SQ.1'p
Z IherehynIr...i draffien,i—orno,maytimn lending agency for the peffimnan¢nr
U” be work for which Ihk Permit is issued(Sole 3(E,].Civ.C.) TOTAL:
Q Icnder's Name 'DOTAL:
} Fk1 1<nder's ArWress BUILDING FEE
0. I ccre fy that I have read this application and trade that the above is fnmutrm is
Fon correct.l agree to comply with all city and county mdirlancos and state laws relating no QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U ,Z building ammrucfion.and hereby amhorile representatives of this city to enter upas the
abase-nianioned pmperty,for inspection proposes. FERMI"T ISSUANCE, ELECTRIC FEE
(We)agree I.eve,indemnify and keep ham the City of C.Ndinm against
Iiabil'nics.judgmen(x.costs and egrenses which may in any wav acerae against wad City AMIiRORADDTOMECII. PLUMPING IEE
in antseyuenmc nl the groaning or this pence(.
APPLICAN'TONDIiRS'I'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO 10.00C1'M) MECHANICALFEE
SOURCI?RliGlll 'PIONS.
AIR HANDLING UNIT(OVF.R 11,(XOCFM) CONSTRUCTION TAX
'Ip t "'Ilan our fmr Data 17XIIAIIST HOOD(W/DUCT) HOUSING MITIGAION RiC
HAZARDOUS MAERIA,S DISCLOSUk.
the n14,IIc;n1 nr Genre huilding mecupanl.to¢,r LunJlu Ime;vd,ux n;:nrrinl IIIiA'I'ING UNIT DIO I(X),IN)II II'I'U)
as ddlred by the Cupenlnn Mwticipal Code.Chain,,9.12,and Lha I Imhh and Sale"
Code.Sanino 25532(u)'I HPATING UNI T(OVFR I(X),( 13'111)
[-1 ye, ❑NnPAID
VIiN'I'IL,ATION PAN 151 LH RESIDI Dat Role lat
Will the applicant for runrc building moeupum use equipment for devices which BOILER-COMP(3 OR 10010N)BTU)
mi(hamNnus:or co uniwnn us defined by he Bay Arca Air Qualify Management 10TAL: to
Diviner? BOILER-CO. (OVER 110.000 BE HE
❑Yes 0 N
I have read the ha.ardofx mamrials requirement under Chapter 6x95 of the Cali AIR CON IONLR IS, t NCI:DATE
Forma Hadih:@ Safety Code.Sections n505.'5533 and 2!Uui.I unlmfond that if the Nli ESIDENTIAL MECH. SQ,IT.
building docs am formally have a coram,that it is my mspmsihilify to unify the occupant
of the tapin'ntcn0-which must per met prior to issuance of a Certificate Of Oceupamq.
Owner m authmritN agent Irate TO VA L: ISSUED BY.
OFFICE