S 4402 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4402
BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
/9/0 9D 112�101v� �,Qlld,E
ON"�'R'y�� � 1'HONIi: CONTRACTOR'S NAME: LIC NO:
//_, NIC CONTROLN
POW ARCHIIECAENGINP.ER: PJC NO: ADDRESS: ❑
CONTACT PHONE BUILDING PERMIT INFO
❑ CBnndlant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ L�
LICP.NSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby inflict®r that I em Hamed ander provision of Eloper 9(commencing JOB DESCRIPTION
°Oz IsiN Scuon7")ofnivuim l oflle Buaireu,ed Profession,Code, my license is RESIDENTIAL
[-�� in full face ami effm. PERMIT ISSUANCE OSFUWL ❑KITCHEN REMODEL
QL Pride—
Cies, Cormacta APPLIANCES-RESIDE\TIAL -
❑ADDITION ❑PLUh1BING RE-PIPE
ARCHITECTS DECLARATION PANFIC ❑MULTI-UNIT ❑STRUCTURAL
vd myp
,z lunderstanlon shallssblic he usai purecord, FIC
MODIATION
OUP TO XM)AMPS
f-.NF'p 1-wcllsnl Rofmlovl ❑INTERIOR ❑CHIMNEY REPAIR
X11-IIXMIAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER["AMPS ❑BATB REMODEUREPAIR ❑DEMOLITION
C 5 Q 1 hereby infirm that I em exempt from me ContraclMs License Law far de
K3 W Ut following«ann,(Section 703 1.5,Businnf and Pmfcnim%Code:Any city or county SIGNS ELECTRICAL ❑OMER
u] LL which nNuire,it li lac suint aBef,improve,demolish.or relive any sWtture
F1='on
Qt priorm musuv¢c,alsorqulrexdeapplicunt fr,uchpmnit lofikasigoidrcm
statnSPECIAL CIRCUITIMISC
that heulicenscd pursuantmde provi,iun,ofthe CtmtM[IU(r Licrn.sc Taw(Cluper9
AIM (commercingwith S¢li-7000)ul Divlsitm3oflhe TEMP METER OR POLE COMMERCIAL:
a.t1 e C mad re,is eeemp Ihcefirm mol the husis for Rw alleged ef,roWfor.Any violation of ❑NEW BLDG/ADDEION ❑DEMOLITION
Smlion 7031.5 by any aWlirnm for a permit subMta the ap,l'lanl In a civil penally of POWER DEVICES
n]^m nal more man rise huwhed dollars(SSgl). ❑TENANT ❑FOODSERVICE?
=O ❑ l,o,owlwr of the popeny.nr lny anpl�ryers with wages ar lhdr role utmpenainn, SWIMMING POOL EL IMPROVEMENT
EilN will dlhcwurk,.tit ihcumwmrslxN mmnikd unAcrel Lrwlc(Scc.SsO.Bunco ❑OTHBR
al 3 m end Professions Cods, 'I tee Ctm iaauda Joe o Iaw sea Is.apply to an owner of OUTLETS-SWITCHES-FIXT
property who hudJ,or improve Ilwreon,and wow chat amt work himself or through
his awn employees,pmvidnl that such impovenend me wN'mmnded nr offered for NEW RESIDENTIAL ELFCB SQ Itr
mlc.If,hmvever.the huilditgrrchnnr..unixnt is sod withlnau Yv,r of complahm.the SQ.FT.FI,OOR AREA VMy Fm
a-Ini lder will hn,c the harden of I.ovim that Lc did l..bind or Intpn.vc fa por-
n of vlc.).
l as Iwter of be m,an,ant cxda,ivdy contracting with lianas connacn.e m TOTAL:
ennuruct the pmjecl(-Sm.7141,Bminw rev]EM@.cs'inna Code:)The Conuaomr's V-
cwse law dtea not apply,,,anovort Prnl'erry who halls,or improver tlrere,m.and QTY- - PLUMBING PERMIT' FEE
ho rommeu]ar such pot with ocomseon-W Been.i Orrunnl tome Conlmclds 5i�
luxec se Taw. PERMIT ISSUANCE
0lamere Sao ,Is&PCfmihisr sun
AUTE
R-DRAIN&VENT'-WATER(CS) JUL"4" 4999
err
WORKERSCOMPIT'SAIION DECLARATION BACK FLOW PROTECT.DEVICE
l nerelry animt arrear rcnaby afperjary ane or dte following deer an
�IM1ave nsd will minlvnaCmif Ie of Cansem to ulf-inaureta Warkcr's Csmpen- DRAINS-FLOOR,ROOF,AREA.COND. =y__1
TORIES TYPE CON CIIDN
sa,mr,as provided for by Section 310(1 of me Labor Code.fa ma performance M the V
work for winch this permit i,ixsxudI. FT)TURFS-PERTRAP /
O 1 have ed will maximum Worlce.Compcn,uion I.e.n regained by S,Vion
3100 of the latter Code,fair the pMnrsllarcc of the work fa which Nis From,is issued. GAS-EA.SYSTEh4-1 INC.4 OUTLETS OCC.GROUP API.'
My Wakens Companwion Insu.earner and Policy number nee:
Carrier. Policy No: GAS-EA SYSTEM-OVER Y(FA)
CHMECATE-OF HiXEMPfION FROM WORKERS'
COMPENSATION INSURANCE GRIASFITNDUSTRL WASTE INfERCEPIOR
BULLRING DIVISION FEES
(Thi,rarim rcNrla to canpelw if the permit i,for one hundN ddlun(5100) GREASE TRAP
a lust PIANCHECK FEE
I cenify0ut in that performanaofthewmk fawhich Nupemdti,iawad,IJWI SEWER-SANITARY-STORM FA.Xi(I FT.
rot employ any Persian in any Irenrer so a,m Faeroe mbjeei to the W'orkm'Canpen- ENERGY FEE
Z suction Taws of California.Dau WATER HEATER WNEN-DELECTR
OO Applicant GRADING GRADING FEE
Z y NOTICE TO APPLICANT:If,afar nuking thin Ccniflrne of Exemption.Y.should WATER SYSfEAVIREATING
become sun I to tho workers Compensation f the lana Code you mad SOILS FEE
js Alton povniaa,a
W faMwtm amply with inch provision,tar thisprnnn shill be deemel revatrd. WATER SERVICE
Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET. PAID
V O I hereby a0irroLdthen is a curumcl itmlendi ng agency for the perfnlmuce of Uwe Raip0
me work for which in,pcoon is ixsucd(Sec.31191.Co.CJ
OU Tenders Name TOTAL:
V lender's Address IOLAL:
F, y I certify that l have mad lhLappication unit state that the ahore information it BUILDING FE
to ..red.Iagreetocmmtplywithallcitywitta,umyadinamex:L Lalaelawsmlwingnt QTy, MECHANICAL PERM IT FEE
UZ handing co ,rouidim,and lhcrchy aumorire mlereaemit,ox of this city to enter uIpt,o me SEISMIC ITE
above-nsentitmcd FmAny Ew inspection purIxoss. PERMIT ISSUANCE 3
(Wo)agree to save,imlemnify mal keep homtle"Inc City of Cmen'mo against ELECTRIC FBE
imcorticucncot togrannt,atemis Fc'whichmay Innnyway aacrvcagvinatsaidCity ALTER OR ADD TOMECH.
nnscquclx'c of IbC gmnling of This pcmtll. PLUMBING ITS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 Itk(MXI CPM)
REGULATIONS, MECHANICAL FF,F, e
/) ATR HANDLING UNIT(OVER I—CCIT1) CONSTRUCTION TAX
'igtumne ofAppIwmUCo1.I... 7tat EXHAUST HOOD(WMUC) HOUSING Nil UGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtteappltcm,nr to,.Wildingmcupamuom nr handleM1uv,hus matmal HEATING UNIT(TO IWA00 BTU)
an defined!by Enc Comeo no Municipal Cale,Chapter 4.11,and the health ami Safely
Code.Section 2553Xa)'I HEATING UNIT(OVER 1 W,0)0 BTU)
❑Yn ❑Na
VFLTILATION PAN(SINGLE RESIU) PAID '
Will the applicux a future Ervilding mouparn use e9uipmrnl or devices which DLe Receipt N
emit'__ .._s an,cvusurn nta in defued by the Bay Area Air Quality Mini' cm BOILER-COMP UHP OR lW. Ml Bill)
T
District'
OYn ON. BOILER-COMP(OVER 100dW BTU)
IhaveradthchuardownamAls itmeruum Cbu 695ofthe CMi AIR CONDMONER ISSUANCE DATE
!area Health&Safety Code.Section,25505.15533 tad 255. 1.1 undwmd thin if the NEW RFSIDE.NfDAL MECH. SQ,RE 7—
build nit cwrndy lnveamn .Ihwitisonyruryn,JnhymoaJy
mmis wM1; miaaEr,
mc of.ca f '^
aaalson ed agml Oa TO L: ISSUED BY:
OFFICE