S 1761APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - KLk:ITI'RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MRCIANIC.,M.
BUILDING PR01KCC IDKIr i'IFICAr10N
PBtlI NO, 1761
`\1
BUILDING,SDIIRIISS:
SANITARY NII.
APPLICAI HIS SUPMI'VIAL DAP I$
I O o
6� N- yFf
OWNER'S ME: 110sl
CON'] RAMOR'S NAMI;: NO: �'
NIC
❑
CUN'BOLp
ARCHI'1'F,CDEN NpBR: LICNO:
IUHLS$, ��� q���
CONTACT: PHIINIe
BUILDING PFRMITINFO
141.110 DL-LjC�'II'Ll1M1f MSCII
❑ ❑
F i 1 3 344
Cl consultant FOUR Paid by APPheunl (Inithal)
LICENSED CONTRAC011S DLCIARATL(lN
I hereby uffnn that I vn Iv,ar d under provisions of Chaper 9 Bomeminin6
With Svri.u7(KBof Divi.ion3.fthc Husincx nnJ Pofessions CsNe.and mYliccnu i.v
'a lull me"" cO'
License Claw F)�
Umc Collle..
QTY ELLCMIC PERMIT I'I41i
JOB DESCRIPTION
RESIDENTIAL
❑$FDWh (]KITCf1EN REMOUEh
❑ADDITION ❑FLUMBINGRE.1'I111i
❑MUhI'IdJNI'I' ❑5'I'kHG'TDIYAI.
MODIFICATION
❑IN'1'IiRIOR ❑ CI{IMNLY RIJ'AIR
IMPIEOVF,MIiNT E) SWIMMING poulS
�C`
PEHh11T ISSUANCii U
APPLIANCFS-RES IGF UAL
ARCIIITHCI'S ULChARATR)N
I mdv,Imd my plane shall be used a.v public records
'
PANELS
UP TO NAI AMPS
Licensed Profic,ionol
201-100AMPS
OWNER-BUILDFR DIiCLARATION
I hereby mins that I am exmnpt from the Contractor's License Law to,
following reason. 6entlon 7031 S, Buxincxx and 11 fiv,ions Cndc: Any terser county
which requires a pcnnit n, cons:mct, aha. Inmmve, the file nr repo, any smuoune
pritolum.... an't, alvn re...... tht.mle,z lormch pension lilc::xigncdsancmcn(
that he is licensed pun tion to the use vi.ionv of the Cormwon'x License law IChapRr 9
(commencing with Section 70LC11of Divininn Sof the Bmmes—nd Pmh,x,mns Code),"
that he is exempt therefrom and the basis for the alleged exemption. Any violation al
Section 7031.5 by any applicant for a pcnnit%objects the applicant,, a civil Penalty of
❑HATHRI!MODELJRI?PAIR ❑DI?h1OLITION
❑OTHER
,G
Lt. ch trSin
OVER 10(111 Ahf CS
SIGNS LLFCI'RICAL
SPECIAL CIRCUIT/MISC.
T&MP. M BE TR OR PILL I NST.
COMMERCIAL
❑ NEW KLUG/ADDITION ❑ DIiMOLITION
❑TENANT' F001) SERVICE
('OWER DIiVICP_S
nu t more than live hundred dollars ($500).
IMPROVEMENT
❑Las nwncroflhcpmpnty. or mYenlpinyea with wugd nv tbcirsolc cumPervwtinn,
will Jo the worIbr sale pwc.7044, Burncvs
and P..fi,"Jons Cnd,'. The Commeasls License Law docs nm apply to nn owner of
SWIMMING I'UOLHISCI'RIC
❑OTHER
(JUTIJpI'S-S W I'ICIILS-PI%'TI1121iS
NF,W RC.SHMN'I Ad, ELECI'k SV 1°I'.
prnpcny who builds as improves t xorea.lunl who dosssuch work bivudf or Through
his own employnz, envideJ that such impmvemcnr% are not intended of offered Tor
.sale. If. however. the building or imprnvmrcnt is sold within one year ofcomplction. the
owner -Wilder will have the burden of proving that he did not build tit improve for put-
50.1.1'. FLUOR ARBA
5/SV. IT.
L� /1
-! s V y
'TOTAL 79t u
1, asviowner of the primary, am xcltwively conferring with licensed contractors to Prow
O
naract the P,,,jnn (Sae. 7144. Baso cvx and professions Cole:) The Co.tomeo d% LI-
scLowdocxnolnpplycaaowor, el rolsny who Wild -a imp^+vex lhcrcon,II
who eosomet%for such pr jeet%with o venimchoW licensed penman to the ConnamoFu
QTY. PLUMBING IIFRNUT )'Tai
Linn¢Iaw.
PI:RMIT ISSUANC
1 am exempt under Sec. . Ii K 1' C for this mason
- �_ t
ALTER -DRAIN E -�q.' l )
�1
BACK PLOW I'R(YTIiCT DLI'
VALUAI'IUN f,
/ V
/.. U�.
VVV VII
Owner Dote
WORKVR'S COMPFNSA'I'ION DECLARAL'ION
Ih by tt d Penalty tpalrY of the fill 0;,
ll C it 't f( tt 11 -'xC �
sant p J I by I t 371X1 f Ih I h C,J f 0 1tl
wnrAf h hth: R t u J.
')R -ILOON
lRIBS
^ p
T M
IYPI! CONS'IRUCI'ION
F U US 1'L:RTRAP
❑ I h J II to t N k C pc i I. h_ t
3700 ef1he Lasso Code, fnrthe per(n'nc Ithe work forwh aL th epc
AS A SYSI'IiM-I LNC 40UTLETS
sKC. GROUP
APN
GAS -1iA. SYS'TKM OVERJ(EA)
My Worker',Com,a,mian lnsumnce currier and Policy number art:
Cartier: Poliev Ne:
4 n„LSrD
f�Ih7
CRBASILINDIISI'Rh WASTHIN'I'HRCIiVD)N
CIiRUIKATLOP t NO MP1 GIxi FROM WORK17RS'
COMI'IiNSN'ION INSURANCI
BUILDING DIVISION FUNS -
GREASH'I RAI'
�gLAnG'HI.rcIMM! 1'r s r
Uhisscaion nreJ notreeontplcmd if lhgpnnit is Wrone hmWred dollar,($list)
ksX)
I ceailY that in thefreDnminncm,l the wat, for which thisft, Wrise.Culxhull
n cenplol any peri yman e,boeome 1. Ereuothe N'nrkera'C.mPen.
m nnrnan �`I'"Pau
)EWER-SANITARY-SIDRNI IEA. 21X1 FI'.
FEIi
WATER f{EAfLiR N'NF,NTrtELLCfR
WATER SYS' I'I:MITREATING
GRADINNURGY
GRADING Eli)?
spino Laws al G ,U to
1 Applicant 114
j N(yTICI+.'1'U N'I'. ., If, after making thiv Ceniticute of linemption, you should
inn pv s nth, labor Cndc. Ynu aura
s becontc.subject it) theW ok s s Compcnsmm
SOILS hili
WA'THR 6ERVICH
I'unhwuh comply with such provisions to this permit %hull W Jcnnnl revoked.
NF.W RI:SIUENTIAL. ('LMB. SV. FT.
CONtiI'RUCfION LENDING AGENCY
I hereby .Minn that herc iso cominetion lendmg agency for the performance of
the work for which this permit is issued (See. 3097. Civ, C.)
PAID
Date Receipt
TOIAI
:
TOTCAL:
Lender's Name
Lenders Address
BUILDING [71F
vn mfo+toom lx
I cealfy thw I have read this amliention unJ stair the the an,,,.m
i ConeCt. l agree tit Cmnply with all city and c..unty oninunct, and nl;nc laws rclaing lu
haBd{ng a nstruction, and hereby nutborim mpoe enmtives oI this city,, cava upon the
above mentioned propeay for inspection purposes.
(We) agree e, wm, Inncmnify and kccp hmales.v the City of Caperton. against
IiabiIdies,judgmems,caa,mol expenses which nanutty any way acamc ugaim'said City
Q'PY. MECHANICAL PERMIT I713E
SEISMIC IIip
PERMIT ISSUANCH
IiLLM RIC ITE
ALTER OR ADI) TO MECH.
PLUMBING FIT.
ia,mrv, mc,,ofthe 6mn,icg ofthis pemJt.
APPI CANT UNDHRS'FANGS AND WILL CONIPLY WITH AL1. NON.POINT
AIR HANDLING UNIT (TO 11.00(1 CPM)
MHCIIANICAI, FT -11
S IRC E(AIN.AI'IO
NNIIANIILINC 11NfC10VCR lf1,(IINI CPM)
CONS 'IlillCl'[ON 'IAX
�A1�ILll!//yy
SI cn APPliconVC.nmcmr Date
H%HAUST 11001) WIDUCI')
HOUSING MI TIGATION FEE
I IAVARDOUS MAITRIN S DISCLOSURE,
nt stare or handle hatdous material
0511 the applicant or future buildingoccupav
us defined by the Captain Municipal Cndc, Chapter 9.12, and the I{eaRh and Safety
Cndc. Section 25532(u)1
10 I.OBTU)
HEATING UNIT -( 00W
HEATING USE I(OVER 100.0X0 it UI
PAID431�_ S/y7
VPN'III.A'I'I(INI'AN/51NG1.1a11!SIU)
❑Yes E] No
Uecc RccnPI a
Will the up,Ii,ca or future hutlding occupant use equipment or devices which
mit haeurdoue air conminition, us Je nual by the Bay Arca AI, Quality Management
BOILER -COMP (31411 OR 1B),000 II'TU)
'1010:
BOILER - CUMP (OV HR I00.(XX) B I U)
-71
Dilm011
❑Yix CI No
-
/ Y Ea
AIR CONUI'I'IONFR
ISSUANCE DATE
p
Ih :Seth h J t I r 5 Chapter of the Cel
li, Health N Y ry Coax. S .255115 5533' d 25530 .. Iy'r that'("'°
NLN RLSIDI:N'I'IAI. MI!CII, SV. FT.
buheocquv, nos s tlythcoaup.+n
s
(�
neetniet
racer a C.clfi
of the rryuirtlncnts which nest Mo ton prior m iswmme of a Ccniliaum of (keuP:mcy.
,luck must
TOTAL;
;�
ISSUVII try L o IZ 1
Owner or amhodmd agent Dam
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
" ..... .g
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL 1 61
❑1
-y- yg�
OFF
CIII�TCC�'f/f:N NCEk: LIC NO:
)DR•
�tTl
❑
CONTACT: PHONE'.
_ BUILMNG PERMIT INFO
1 "5 3 y4
❑ Consultant Fees Paid by Applicant (Initial) ---
RLI%'] ELECTPLUME MLC'H
•
1:1 21%L�I�k I% ❑ ❑
Ia,with
--
V F
aVV
;Z,
�Dm
ZOradZ
O7,-1
LICENSED CON TRACTOR DECLARATION
I hereby pIBI,b lion l on llcenmd undo powo,i.ns of Chaplain 9 ernore eing
S,,lin i 910sh fPivimion 3 oftbc Stoine,1ard Pnncmdo.., Code. and lay limner is
I- full hnce octet ckfcc A , I
Lice,rw Clays Lica
Dne Contractor IiIQ%
ARCHITECT'S DECLARATION
I undellbodmy plans,loll beoxtlaspublic,.od,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
R =51DEN
Lam_TIAL:
❑ $FDWL O KITf.'IiGN REMODEL.
EIADDIT'ION O PLUMBING RE-PIPC
0MULT1-UNIT ❑STRUCTURAL
MODIFICATION
Ll INTERIOR ❑CIAMNEREPAIR
IMPHO\'EA1EN'f SWIMMING I`OOLS
❑ RAI'H REMODEIJRIiVAIR ❑DIiMOLD'IDN
�S^
❑ OTHIik +FIC
PERMIT ISSUANCE 3 S
_
APPLIANCES -RESIDENTIAL
_
PANELS
r
UP10200AMPS
wF
��
Y
WQ
j O y UF
Lo,cnwd Vmfeammml
OWNER-HOILDERDECLARAI'ION
I he]eM1y affirm Inst I am e¢mpT from tire Cuntmnor', Licntx Law for the
(npuwin6leo.on. IScutiun 11131.5, Huainess Incl R'nfexions Cock; Any city m county
201-1000AMPS
OVER I" AMPS
SIGNS ELECTRIGL
a. LL c. O N
F }�pnorw
mlli.h require, a peril to conswa, oiler, impnwc, lcrioh h, or repair any aruchout
its i¢uanre, aLw requites he applicant in inch peirlo to flea,innecl%utetmnl
Lha he is hearted pursnanito the provision, of the C'onlratoci Liea,e Law OChzpmr9
6
�
SPECIAL CIRCUIT/MISC.
'rEMPMEI'ERORVOLEINST.
COMMERCIAL:
❑ NEW BLDG/ADDITION Cj DEMOLITION
W <C)
a X
feammencingwith Scclion lrXl111 of Diviaion3ol the Hu,inev, and Pnrfca<iom COJclar
tom he i, exempt Therefrom and Inc Fads lin Inc alleged emctmniom Any violation of
I-ZY
a
fF�
L s'
Secuan TIU 1.5 by any u,iikunt faro pernm uhjecn dm applicatn air a civil pen:dty o1
tln.rethur Eve nulldriddollan(S500)
❑ I.a,msnuofllxpmpcny,ormyemploymswitli agC mlLmirw)ccompcnmTbn.
will do The wok.and he structure it not inmmkd or offered Ruwle(Scr. 70,14. Hu,,.,,
and Profeainna Cade: Me Cnnuanor, I,iccnx Lm Juex not apply to an ownet ofOUTLFTS
pI'alcny who mild, in unrmves thn'eon, and who deer inch work hill or b ... ugh
hiv own nnploycn, pfnvidrd Ilett .inch onpmvenients art nal intended or o0etcl on
%ale. If however. the nuildmg or lmpmvemenu, mild within orb)omm ofcotnpletian. the
wvnerbullder will lave the burden of pnwing that he did lint bulletin, impmvc fnr FurI
POWER DEVICES
❑'TENANT ❑ FCOD SERVICE
IMPROVLMENT
❑OTNEN
SWIMMING POOL ELECTRIC
-SWITCHES - FIXTURES
—
NEW RESIDENrIAL ELEC' R SQ R.
SQ. Fr. f1 AOR AREA
ESQ. FT.
Uma
�/ •y(1
pox of snle.l.
L] 1, um owner of the prolxny, ant exclusively count cting wile li,en,ed cnnuuemn un
mmun the prnjecn,Sec, 70,14, Eminea and Prolc,siunm CWv;, Ior 111 --on . Li-
U
TOTAL: 79 a cm
re -re Law Joe appy man lune, of prnpeny no build, or hnPn ret Thereon, arm
QTY. PLUMBING PERMIT FEE
wnn cootrart, far wen mojmm who a eonvmn nal Reacted pu,..o. to me CPntmetnla
I'ERMrr ISSUANC
ALTER - DRAIN F - I
RACK FLOW PROI'ECIC
-'
Liter Law.
E] I am exempt under See . H do 1' C fonhia reuwn
Owner —Dale
WORKERS COMPENSATION DECLARATION
I lmreby affirm under Orth,of pcllu13 one of the ollcming J
VALUATION
U �
V 0 V U
r
.. I hove and will lnaintaina Ceniricmcul Cunxelt To selGinsum film r C
as - n pmvuled lar by Section 3701 of the L:dxn C.Id0. lar the pier tlp ,
)I-VLAOR, R(`Gf,AREA.COND.
STORIES'
TYPE CONgI'RUC`I'ION
aonk lm which thin perms i, i... ed. �'�qpI
❑ I hu,c net will unint.i. War knl Cuntlxmatinn In.umnce, es n E� itJ
TU -S-Villi TRAP
y� q
q•• A a �,
1700 al the Lallo Cude. for me peruncre, nl the work forwhich lhr. pe t
S -A. SI'STEM- I INC. J OLD LETS
{X;C l:RAOUPMuc
AYN
,My Wnrkcr', Cornpeoa1 rInwr.nm can mr and Pol'Icynmm�cl art'.
Cunicl; Policy Nu:
4 I��01aD
GAS - EA. SYSTEM -OVER n 1F.A1
CERTIFICATE. OF EXEMPT (ON' FROM WOR KERS'
COMPENSATION INSURANCE
GREASIIINDUSI'RI. WAST r:IN1TiRCEI'TOH
;S-••FFI...D�7QL�1tihiMiq!.(ltsr{':(''
etrcd dolla0S110)
('ITissmtinn nccA not h<umple,ulrftne petmili, I:uane lunn
or I<md
GRPASETKAI•
�H�.F,ACi1Ghk4F.J': t.r•c
centlydr, in the pvrTrmnnceofbm..rk lm which lhispem,il ivo,urd,!.hell
1�. a xubjen m the Wrnkcrs Compen
nm etnpluy any Pnwn 1n any man99 �� ore
SEWER - SANITARY -STORM EA. 21X119'.
ENERGY FEE
WATER HEATER WNF,N PELLET
Z ,alio laws of C Waite ld4��f 4�S
j
�2 Applicant ((
s^Nn NOTICE TO AP f, after making this Certificate of Exemption, you should
a bcontne .object on the Worker's Cnmpetl pmvisiom of The Luton Code, you ..it
iothwah comply with much provisions or (his pcnnd,hall bx record revoked.
air 0
CONSTRUCTION LENDING AGENCY
V O I hereby whirr that is a construction lending agency for the perfnnnanee of
r. the work fnr which thin Penton int ixmed (Sec 3191. Civ. C.)
W. ULcndel's Name
LendersAdrc.,
I renify Nat I have read thrs application aryl ,bite that the .hive irformmiun is
N amen.I agree Iocmnply with all city and county oNilunces and mute laws retailing w
U Z building, nsimetlon,undherebyaulhoriralcplcsnuauvemorThiseitylnemeruWnlbc
aboec-mcnl loocrl plopnly for i...Pectin. mnemes'
(We) agree err ,.,e. unsound, and keel I..rnMsx the City of Cupeoino against
GRADING PF]i
WATER SYS EMITREAT'ING
WATER SERVICE
-- _
SOILS FEE
PAID
NEW RESIDENTIAL PLMB, SQ, Pr.
Dae RmcilnN
'-
'1'01'.AL
'PUTAL:
BUILDING FFR
QTY, MECHANICAL PERMIT PEE
SEISMIC FEF.
PERMIT ISSUANCE
ELECTRIC FEE
�• u
ALTER OR ADD TO MECH.
PLUMBING FEE
IianiliTin.judgmm�n.aoaLv and espcnxa whicbmay navy waymerve,ama mid City
in cou, a urns ofthc fronting of This Pennio.
AIR HANDLING UNIT(TO 111,000 CFM)
MECHANICAL HE
APPI CAN' "T UNDERSTANDS AND WILL COMPLY WITH ALL NON.POIN'IF
S HC E R.:YIlU75.
'`���(�
Y/
PIR HANDLING UNIT 111,11011 CFMI
_
CONSTRUCTION'I'AX
St c u AppheanJCnmmctor Date
HAZARDOUS MATERIALS DISCLOSURE
ID( RUST HOOD(WIDUC)
HOUSING MITIUA'I ION FEE
HEAPING UNI I'(TO 100.11X1 HTU)
Will The applicant or luture building cxngmnt wore or handle haramou.material
an defined by the Co,, lion Moniripal Code. Chirpier 9, 12. and the Health and Safety
—'—
PAID
Date Receipt a
Code. Section 25532(sl?
ElYe, 0 N
Will the a liras or furore hulld n • .cell device, which
Pp F eByLxea A.,Qmo:
hurumaum air mnbiminam. its AebneJ by the Hey Area Av Qnelity Mnnxgemcm
octet 1
❑ Yea �No
HEATING UNI' I' IOVER I00OX) Il' NI-
VENTILATION PAN (SINGLE RCSID)
BOILER IIXI,gXI BTU
TOTAL:
1GTA1,:
_--
BOILER - COMP (OVER 1f0,IX10 BTU)
AIR CONDIT'USER
I Im.e read the Imaudnua..... niam luuirunmin. tmin Chx In 6.95 orthe Cali-
huniagoesnSur-rcCede,eatarm2551!5,but, and 155?q.Iundersand Isar ifthe
building lure nob curmney huve a mmol, that it, my re>Iof Cenotiw notify the ncrupant
ISSUANCE DA'I'F.
3_9
NEW RCSIDHNTIALMECH. SQ.FT.
_
a
of the requircmentx which sun h ext pnnno u,unnm of a Ccniticam of Drrulvney.
of
OFF
0
•