2814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nuu.iaNO.r.t.ns.iRdnt. _----- PERMIT NO.
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
3K-;:y'-, '<IIUILDINGPROJECI'IDENTIRCATIONeYp.:,i,e'n*.? 281 ,
BUILDING ADDRESS �/}�- v./ SANITARY NO. �IAPPPPLIICASTION S/SuasinTAL
lOZ s / �I�A-t�j/D LT• UNIT# LOT as
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O ERS NAM11N. /� // PHONE Cc�pq'a ACTOR'S NAM1IE LIC NO'
• 2G7 �7ENi✓y D7�.fZSv/I G.c& ry/� ro;ak y Nrc CDNIRI,La
'A�g JI j_Tl /ENCI TER�: / LIC NO. 911��yyRESS. �/ /,
3 GOgpfjX YTO c���o,L, '�C- �cfe// ❑
CONTACT ONE. ll
/:'%�.7��v �/✓�. �l0 S�� QTY. ELECI-RIC PERMII,.,-!a +II'.Y,.:FE`E .^, - BUILDIN_G PERMIT INFOais
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/ BLDG ELECT PL1:1 a{
PERMIT ISSUANCE hTT-q�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
�pyz, m7006)ofD, ,,,. f the Business and vuiomons;Cod.And mmemm�gwnh
'•+cI(0F��. Smtmn lOWl ofrr.D.�Slv�t�lwnn��J of the Buzlnnaa�nJ�Profemiom Codc,and my bcrunin pMELS ��
<ZU Lclense Class
L¢.X / � UP T031111AMPS {� I '� ✓ �"T�
m?N Data ..COntacmr I X301-Rat)AMPS
ZONox ARCHITECTS DECLARATION OVER IgI(InM15 SQ FT.FLOOR AREA SISQ.F
Z_ 1 understand my plans shall be used as public meant
I SIGNS ELECTRICAL
< j Licensed Processional
yyx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Xis. I hereby mfim that I am escarp,form the Contractors License Law for the
W4Oy following reawn (Section 7 031.5,Business and Pmfessmns Code:Any city or county ( TEMP.METER OR POLE INST
F-rn J which requires a pennu to construct.alter.Impmve,rental nh,or repair any structure
is, prior to its issuance,also responses the applicant for such pmnn ensile a signed natemeat (POWER DEVICES
saeei that he is licensed pursuant to the Provisions of the Contactors License Law(Chapter
st'Kj othat 7WO)of Division Jofll"ged Business and RofesstonsCode) SWIS/MING ELECTRIC � VALUgT1
mZm
or 70315 by lhaefromand the permitonheasegedcplican n.Any nlolanon or FIXTURES / .C(lN�•/�I�js,/'--vr_—Gl
FZ�' notomthaniv only apPl¢anuoanvtlpenaltyof OUTLETS
-SWITCHES- a/7L
fS� era mom than nyllarmycm1. NEWRESIDENTIALELECR S .FT.
C F_o ❑ oche wrk.andepmperty,ormycmpioyeeswM wagesm thevsole compensation, I Q I STORIES TYNE CONSTRLC
i 3=
will and Professions work,and the he Contractors tors Liceese U dos e,apply I.an wine,of
and Pminnobu Cale The Contremor s License Law ass nee apply m an owner of
porpenywha buprmnmpmvestherepeo,enermans._chwork himsel...... gh his I OCC.GROUP RES.UNITS
provided vuamnoumenJ<Jarnfkrte.0h,o nIL _ 1
budder will have onmproprovinuhat he didot build of completion,purpose f I TOTAL:
budder will have[lit burden of proving that he did not build or Improve for purpose of
sale) ,.: ,....w..- wit.%a.•io,eo:r x.,w.•.r'py^ .I+ W"', -
TY,r"'a 'iiPLUMBING PERMIT?'•r -- Ii°-
pmpe y. Q FEET• FLOOD ZONE
❑ Lnow project i n .unenclusry and Professions Conle:j The Conn, nee ;i4,�•,.,.a„yv�• •t,..n .,6Y h+I T'�l entail;`pl APN
construct the protect iSuc 9614,Business untl Rofessions CaleO The Conwanr's PERMIT ISSUANCE I
License rawdoea not applyms with acrofpchural licensed pura m Bathe thereon,and f
License Laws for such pmlecry wnhacontactOgel licensed pursuwuothe Contractora I ALTER-DRAIN&VENT.WATER(EA) -"k^)'sXw�-("rf•FE SUMMARYjJ t.*
❑ 1 am exempt under Sec. ,B&P C for thu rtaaon BACK PLOW PROTECT.DEVICE I OUTSIDE yFev
SANITARY Y N
_ Owner Data RECEl"10—
DRAINS-FLOOR,ROOF,AREA,CONE.
WORKMAN COMPENSATION DECTARATION SCHOOL TAX YN
,',� kLibertby atfimrthm(haven amficauofconsent to selGmswe.orattnifoomof FIXTURES-PER TRAP RFrFlm'a
V&Vri COmpensanon Insurance or a certified copy thereof(Sec.3800.Lab C.)w heh (PARK FEE Y N
covers PolicyplemTJncjees tin �pepnll-��Sr- GAS-EA.SYSTEM-I INC.4 OUTLETS I REC'EIPTp
Company !�^ /4�N BUILDING DIVISION FEESn g
GAS-EA.SYSTEM-OVER 4(E,) PLANCHECK HE
❑ Certified copy is hereby furnished
❑ Ccmfied copy n filed wuh theory inspection J...sum. GREASE4NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' I (GREASE TRAP (SOILS FEE
COMPENSATION INSURANCE
(Thissecmnneed nmbecompleted ifthepermn isfmonc hundred dollars(SIM) (SEWER-SANITARY-STORM EA.200FT. (ENERGY FEE
or less)
I ccmfyeau in the pcRmormice of the work for vinchffin, .ius Issued,l shall WATER HEATER W/VENT/ELECR
not employ any person in any manner so.Ili become sublect to the Workers - PAID
Z Comsensation Lawsof Califomm C-,- WATER SYSTEMIMEATING Data Receipt#
zANOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PIMB SQ FT.
pfA become subject the Worker's Compensation provisions ofthe Labor Code,you must TOT
W � forthwith comply with such provision or this parnul shall be claimed rtvokcd. (BUILDING FEE L'
?' 'sr, SEISMIC FEE V
1 CONSTRUCTION LENDING AGENCY - -....,. ,-. t
U z Ihcmby affirm that there isaconstruction lending agc«yfor the per(tiruwKro of; - -
UOthe work for whuh this Ammo is issued(Sec.3009,Co,C.) I""' TOTAL: ELECTRIC FEE
Lender's Nam' el 1 ��
O U Landers AJdr••• r 1t G^-+sa}'MEMIAL PERIs�ITJar,SiU '}FFE��Yay-I PLUMBING FEE
Ip■T'Sy�I� -!/•`4.+a:. c. c :k'.P. sF, std"',
1 certify that I have read this application and state that the alopa ..oc ianto FX--� -f
correct. l agree m comply with all city and county ordinances and emtilawsrelmin to 1 PERMIT ISSUANCQ I —MECHANICAL FEF. I „
F' y buildingcmi,imumn.end hereby ewhnnze rcpresemdtivn of lhucnymenteto n - 't (CONSTRUCTION TAY I 1
U Z above-recmmnW property formspectua purposes. N. ALTERej)i])D� ECH . I :.1 -S
(We)Agree 1.1.va,indemnify and keep harmless the City of Cupemno agairo // i -
Iiebilnmv,tuJgmenn.cmttand expenses wh¢'h may in any way accrue�gninw lend City _ EIIR fIANLI{JNp UNrIT ITO I� fj'hll
m conssqucnce of the greetingof this pertnn' j``� AIR HANDLING UNIT(OVER I0,"CFM)
Signature of APphcanUComr«m `r Date �A11aSD5:..{ D,tW(DUnIjYS�]C1�:-••"� I PAID
#•M
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00i BTU) I Dita Receipt#
Wmll rhea beam or home haddin y
pp gce,Chapter handle h.w41u+mateml IICATING UNIT(OVER IINLBIMI BTU) TOT, -
CodefineJ by the 32(a)?Cinema.Munimpal CWe,ChnPter q 12,And the Ileahh and Safety #
Code,Seai❑Yn3'(al' ❑No VENTILATION FAN(SINGLE RESIDI I f
BOILER- i ISSUANCE DA'
Wmllthcu lican¢a fuwre buddin COMP(JIIPOR 1(10.000 NTUI
pp g«cuhe BAY Am Air Qraeveowbchcmn 8�P {
M1a>trict?av somaminunn m define)by the Bay Area Au Quality hlanagemem BOILER-COMP(OVER H#YM)JOU1 I f A 1 I {
Duna! I
❑Yn ❑No NEW RESIDENTIAL MECII SQ.IT.
1 have read the haaafd.ms imeno,s regmremetns under Chapter 695 of the Af f
Cahmmu Hicaldi&Safmy Cage.Sec unns"55B5 m
33 and 25534 1undeand that I JUN a
if the buJil r+mn nurremly hevea .nth cis rcsp0owbdny me notify the
Ice eon whi< be t p m isauance of a Ccn rkme of I CID Ur r {
t 'up r /'- 9 �)�--' I G///I, e
- -
Owner or euthnnecJ Agent- � �O%l Date TOTAL:
ISSUI%�yYr��2��{'�a�• _
OFFICE