S 0646 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLEC'TRICAL PISMT NO 0646
BUILDING DIVISION APPLICATION/IaERMIT PLUMBING-MECHANICAL PIS
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SANITARY NO. APPLICATION SUBMITTAL DATI
BUILDING ADDRESS:
a� y 2
0 NrNAME PHONE: Co 'TOR" Mli: ./ I.ICNO: NIC CONTROL
I .)
•ARCHITECT/ENGINEER: LIC NO' >D : ❑
CONTACT. P .NIC BUILDI ERMIT INFO
❑ Consultant. 1.Paid by Applicant(Initial) BLDG :I"ECF PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACIOR:S p1iCLARATION QTY ELECTRIC PERMIT FEL JOB DESCRIPTION
I hereby affirm that 1 am licensed und<r rovisinm dChapter 9(commencing
won Sanon satin Dokio z.fineBm' - dvmfe.sC et ndmylimn"i, RESIDENTIAL
}}y}}yr����r�� yyy���yyy������ PERMITISSUANCI:
��� in full force and - ❑SPDWL ❑KITCII&N REMODEL
x IU Licen.�se Class rrr�•••rrrr I.ie# NCE.S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPF,
mGG Co. ❑MULTI-UNIT ❑STRUCfIJRAI.
ARCHITECPS Uli ELS
F y Z 1 undcntand nry,lmre shall he usnd as public re,o ds MODII9(' N
OZ�O
Oil IT) AMPS ❑INTERIOR C a I7Y REPAIR
F-�Ftu limned Pmfessinnal 201-11"AMPS IMPROVEMEN'I' SWIMMING POOLS
ay.YEJ OWNER-BUILDER DECLARATIONOVER 1000 AMPS []BATH REMOOEIIREPAIR ❑DEMOLITION
C C Q 1 hcmby vmnn that I am exempt from the Comocum s License Law for tM1c ❑OTHER
xax06U followingosson.(Section?031.5,Buzinessand Professions Cdr Any city orarunty SIGNS ELECTRICAL
W 3 LL N which requires a proud In conslmet,alter,improve.demolish,or repair any s.mcmre
C� prior to its:. also y the applicantIin suchpe iut,filea vilinctlT temcm SPECIAL C I RCUII'/MISC.
W } that he pursuantl to v :ire: Ito C t t r L I (Chrptm9 COMMERCIAL:
E C 0..n g with Section 7000)of D'voitor a Ofth Business andProfession'Cde)or IFM P MFIER OR POLE I NS'I'. NEW BLDG/AUUI'FION ❑DEMOLI'DON
a a W that he is exempl therefrom and the basis for the alleged cacmpuon.Any v olahon w
W^��'y Section)01LI by any applicant for a permit1-hiers the applicant'.a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE.
not more than five hundred dollars S500). IMP EMENT
SQp ❑ has owner)I the pmpeny,or my employees with wages as their sole compensation. SWIMMING PORI.ELECTRIC R
n,ym will do the work.and Ne afmc.um is not intended or offered for sale(See, Basin,,,
W to and Is nfessions Corr:The Cnntmcmr's License law does not apply to an owner of OUTLETS-SWITCIIIiS-FIXTURES
pnpxny who builds nr im,mvvs domon,and who dovs such work Itimelf o dtmagh
his own employws,provided that such improvements are not intended or nBFred for NEW RBgFDIiN'IIAI.131.ECTk SU Fn'.
SQ.IT.FLOOR AREA 5/SQ.ELsale.If,however.the building or impmvcment is add within one year ideomplaior,the
caner-builder will have the burden of proving that he did not build or improve for Pur-
pose of sale.). 'F(YAL D
1,as owner of the pmlrm,,am exclusively...howfir,with licensed contractors to
mswct due p...jea(Sec.7041.Business and PmFce ion C.dc:)The Contmcmrs Li-
come Law docs not apply m an owner of pmryny who builds or improves lecmon.and QTY. PLUMBING PERMIT FEE ]SEP 6 REC`
whoenntrretsfor such projects with a cmtradorrO licensed pursuant lo tine Cmnocmr's 1/ �
Limmse Lrw. 1.17RMIT ISSUANCE CoI Ant eaempl under See .It M Is C To lhisreason b
ALTER-DRAIN A VENT-WATER(EA)
Owner Date
WORKER'S COMPENSATION DECLARATION BACK ROW YR[ttBCT.DEVICE
I hereby affimt under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conent to self-insum for Workers Crimped- DRAINS-FLOOR,RODE,AREA.COND. STORMS .11' PE CONSTRUCr101
cation,as provide:)for by Section 3910 of the Iatan Code,for the wi-formance of 0e
rork lar Thi,icon..is inured. FIXTURES-PER IRAI'
tEJ hd will mninmin Worker's Compensation Insurance,as mquired by Section
3700ofthelaMx Ctde,tonic perexmancc of fine work for whichfhis d GAS-EA.SYS'IPM-IINCAOU'I'LE1S OCG GROUP At'N
My Wer and Pare ���'''`^/'/��
Cart: Tx Policy Nn.M� GAS-F.A.SYSTEM-0OVER
CERTIn A,,OFEXF,MPDON FROMWORKERS' GREASEANDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION 19113
(Thiasafo.need in.be conoullad it the pamtit is fortune hundred delta,($10p) GRF,ASETRAP
I or less) PLANCHECK THE
or
I ccn,,,aft info,pcnbrman,rof the work lir which this Panni f is i11ucd,lahall SEWER-SAN]'TARY-S ORM EA.2s)F I'. ENERGY F9iH
not employ ally palinal In any manner so as income subject.o the Workers Compcn-
C) Z sa.ion laws of Culitornia.Date WATER HEATI7R WNENT/ELECI'k GRADING LEE
Z Applicant '
= NOTICE TO APPLICANT:If,after making this Certificate of Temp i.......hould WATER SYSTEMiTREATING SOILS FEE
f-' become subjert m the Workers Compensation pownions of the Labtx Code,you mss.
(Yi forthwith comply with such previsions m this permit shall he deemed resmked. WATER SERVICE
W Q
:ZI
CONSTRUCTION LENDING AGENCY NEW RESIDF,NTIAI.PCMB. BQ.I'F. PAID
11
UIherchy ulBnn.hunherc is nmstmmion lending vgcncy for fine Performance of
.he work far wh'oli nd,,omit is issued(See.31X)7.Co,C) ref 'IDI'AL:
0 1-' Lender's Name
U Isndcr's AJJrtss 'I(YI'AL:
} I certify that.I hove mad this upPlirminn and state rim tine aM.vc in0mnmion is BUILDING '
n' - 6 QTY. MECHANICAL PERMIT FEE
U Z coneng commotion.
wife all city and counryntaiwncef end city
it)enter
he SEISMIC PIiIi
U z handing r.namrd.n,aw hereby ame.d..rcprcaemmivratunhLrhy to rmertuprn the
above-menioned pnpmny for im,a lion pur,rocs. PERMIT ISSUANCE PLECI'RIC UFF
(We)agree to amc.Indenmlty and keep t,auruss the City of Cupcnino again',
*ucnc
.coae drape a,whichinuy loan,wary arcme aguimt laid City ACIERORADD'IOMPCH. PLUMBING IyiL'
e gm r bmfthispemti..
.RS ANDS ANO WILL COMPLY WIf ALL NON-POINT AFk HANDLING UNI'I'(F010.(IW CFM) MECHANICALPI31i0 ))) AIR HANDLING UNIT(OVER 10,000CPMI CONSTRUCION'1AX
nt/ ntiacmr v� D/ac EXHAUST HOOD(W/DUCq HOUSING MITIGADON FIE
HAZARDOUS MAI ERIA S DISCLOSURE
Will the up,l la nlnr fumrebud rmcnp� ms ne nr h� tulle U¢anluus material HEATING UNIT(10 I(XL( XI BTU)
as de.Sed iIft,o .M1e 32m)?nn Muni'; Cln a Chapter 9.13,and.he.Health and Sulity HEATING UNI"I'(OVER 100.1")BTU)
Code.Section 2553Aa)1
❑Yes VENTILATION FAN(SINGLE RESIUI PAID
Date Receip.p
WiFI ma ap,Iiran.or mu g Occupant use equipment or devices which BOILER-COMP(3HP OR If0.000 BTU)
:tui.hm,allous air enmaminenIs a cfined by the Bay Area Air Quality Management '1'Ul'AL:
District? BOILER-COMP(OVER 10L.0 BIUI
El VCs No
AIR CONDITIONER ISSUANCE DATE
c re:W tine M1ma mumriuls qui enter under Chapter 0 95 of the Cali"
fo cal.h Safety C e 'evions 25505, 5533 an�d 2,553) 1 undero nd tem if the NEW RESIDENTIAL MECB. SQ.FT.
'n -ml learn.remit my ms�ryry��.^^�/yyly.lity ly thcoccupan.
e t which an prim. nuance �Sirtf.QetW]ri
)wncr or aufh e.cJtgc
/ Dum 'TOTAL: ISSUED BY:
OFFICE