S 1403 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PI:R`p1IT No
RU(LDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. v 1403
BUILDING PROJECTIDEN 1FICAI'ION
TO LUINGADDRI?SS: SANITARY NO. APPLICNION SUBMI'ITAL DAA
(
1649510site, Ln7pFraLs,
PIIONB: 12>_Arz"
CONTRACTOR'S NAME. LIC NO
w Zic.I6 / NIC CONFROLp
ARCHIIICDENGINEF,R: LIC NO. V ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) n1.nG *1 PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hembY affirm Inas 1 ...Imenxnl ander on,of Chaplcr o Inoue on,ing JOB DFSCRIP'I'ION
mai
WOwith Scaim7000lof Division 3 ofthe Husimscand Professions Code.and my licence i. RESIDENTIAL:
to p PIiRMIT ISSUANCE,
H LL:• in full farce and cffnu. ❑SFDWL ❑KITCHEN REMODEL
�U~ Licmw Class Lic.N
Q U APPLIANCES-RESIDENTIAL, ❑ADDI'TION [I PLUMBING RF,-1111113
NQL Date Connector
Fly ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
y p h Z 1 undermnJ my plans shall he used ac public rewords MODIFICATION
UI'T02g1AMPS
p Z.p ❑IN'I ERIOR ❑CHIMNEY REPAIR
aY = Licenwd Protw-mi 201-1000AMPS IMPROVEMENT 0SWIMMINGP001S
OWNER-BUILDER DECLARATION
C OVER 1100 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLI'I DON
C 6 M1ercby.Ilion,,. I am axanm from the fi,,o) Co License Law for the
3 a F Which
requivna(Saban 7I13L5, t.alter. and approve,
de ions h.or:An t I ❑OTHER
6 Y Y county SIGNS F,hI:CI'RICAI.
oto poor
h y permitI Wet p tap J I.h p yta mens
F� pro t t L req theapplicant ohne '9 O -g d.ea.'mem SPECIAL CIRCUIT/hf LSC.
Fn �- throb JI u d p n ftl C I' 1 I' ITh:PIu9
�apC) (commenting with Section 9100)of Division 3 of the Business and Professor CrnlO or TAMP.MCFCR OR NILE.INS'1'. COMMERCIAL
:
a a
se
y� that he is exempt therefrom and me m
basis for e alleged exemption.Any violation of ❑NI?W BLDG/ADDITION [I DEMOLITION
X m V- Section 7031.5 by any applicant fora permi ,uhjens the uppbeva to u mml locally of POWER DEVICES
W^sea
E]TENANT ❑FOODSERVICE
nnl more than five hunded dollars($5110). IMPROVEMENT
1-=6 Ell.as owner of the proper%or my employees with wages ax their ark compensation, SWIMMINGPOOLELECfRIC
�p..p will do the work.and the suucmin is not emended or offered formic(See.7094,Business El OTHER
and Pot—wit,Gale:The Contractor's L kenos Lew does nota I m at owner of Oil'I'LETS-SWI'fCI11iS-IIXTURES
prop�3- k
his ow y who buia,nr ivided 5'tnsuch i and Who does such work dedohimself onienmgh
his own owev ti the Provided that such rent., wms am not intended orpllertn for NEW RISIOIiNT1AL Ii1.EC:H !l'.
sale.I hmideveg the leve the bur improvement is sold wiid n one build
or i prove Tom the SU�II FLOORAREA SISQ.t1r.
sof-Idcr will have that burden of leaving 1Lm M1c did not build art improve lar per-
Fl 1,aswl oc of the property,a xclu wdy removing with licensed common,to TOTAL: P A I Q
mvtmcl the pn.jas'I(See 9194,13-ti us vnd Profmsions Code,)Ge Cnmmetnrs Li-
whe pi law does not applym anosvnend'nr ,y who hu is or Improves thereon,and QTY. PLUMBING PERMIT FF,E
o car.tmna fora racel.withaeammntarf.) paruanttu theCanlmcmrs R 25 ANS'D
Licenm La PERMIT ISSUANCE
❑ I an pt under Se ,B&I-C fan d, ,a
ALITER-DRAIN&VIiNT-WATER(EA) CITY VUR ILIIIInsyALUATION
WORKER'.' MPHNSATION DECLAN ATION BACK FLOW PERU ECT.DEVICE
1 ho y.Blinn under penalty of perjury ane of Ne following Je orations:
itIIhav- nd will maintain a Cmihcate of Consent m self-insure for\ tker's Compen- DRAINS-FLOOR,ROOF AREA,COND' STORIES TYPE CONSTRUCT Oh
anion,as provided lit by Section 371X1 of the Lubar Code,f n the perfomtan,c of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3710 of the labor GWc.for thepurfornmecof the work for which this permit is issued. GAS-EA.SYSTLAI-I INC.4 OUTLETS
occ.cgnuP nPN
My Wurkn's Con.pwnsmion Ina.mna carticr and Policy nun.ncr um:
Career: Policy No.: GAS-EA.SYSTEM-OVER 4 EPA)
CERFIFICATE OF EKEMU ION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRI,WASTI7 IN'TERCEP'TOR
(This section need nal M:cs..Flood if lheper no is far arc hundred dollar'($I W) BUILDING DIVISION IN FEES
or less.) GREASE.TRAP PLANCHECK FIE:
Icenify thelia lbs perany ronocoffic,tobi oteronem It, cutOn,W eke,, Q...or- SEWER-SANITARY-STORM HA.21X1 IT.
not employ any person in any manner no lea m bannm.suM1jmr to the Worked Can.pcn- ENHRGV PBB
OZ sumn Laws of Califen.ia.Date WATER HEATER W/VIiNT/BLEC'FR
Z Applicant GRADING FEB
p) NOI7CETO APPI.ICANT:11,after making this Ccnihcam of eacmltion,you should WAFER SYS'I EMT RUNI'ING
Hx1-^ become auhjvO to the Worker',Compensation provisions I the LaborCMe,younitst SOILS Eli
i�
forthwith comply with such pmvixiomonhis permit eball be deemed revoked. WATER SERVICE
a0
.�T. Z CONSere m ac ONLENDING
ng agent NItw RF,SIDIiN'I IA1,I'LMB. SQ.I'1', PAID
U p If Which
tbaObn iso issued
lending agency for lwrfnrmancc of Doc R I b
U. I" the woT1 for whim this nemtil is jawed(Sec.3097.Co.C.)
C) U Ixnder's Name L:
Lcni Addle, TOTAL:
Fy 1 cerify that I have read this application and spite that the above information is BUILDING F.
tZ) correct,l agree to comply with all city and county ordinances and stale laws relaingm QTY MECHANICAL PI7RMIT FEE
U Z buddingcomlmnio 0.and herchyamhnriw rclrewnmtiveaot'it city,color upon the SEISMIC THE
ulwve-mentioned prol.my for inspection purposes. PERMIT ISSUANCE
(We)agme n,save,indemnify and keep harmless the City of Cutworms against IH.E(.TRIC FEE
Iiabilitics,judgmwms,costs and expenses Which may in any w.ayacemeagainstwid Cay ACI'RRORADDTOMFCH,
onseyuancu ofthc ng of this permit. PLUMBING FEB
AI'PLICAN'I'UNI CANDS AND WIL C MPLY WITH AL1 T 'T AIR HANDLING UNIT(TO 10.100 CFM)
SOURCE RIi . TI
. ONS. MIiCHANICAI.FEIi
N HANDLINGUNI'1'(OVER O.000CFM) CONSTRUCTION TAX
.Ignutu dAPn' mrContracmr I Drop XHAUSF GOOD(W/DUCT) IIOl151NC.MII'IGAI'IONilil
HAZARDOUS MATERIALS DISCLOSURE
Wil ealplicunl or future building occunaniz
l store or handle hardnus mate' T(T
HEXI'ING CNIO 100,000[it If)
as defimcd y the Culmina Munwipal Come,Chapter 9.12,and the Health and Safety
Calc,Section 25532pp? GRATING UNIT(OVER 1001000 DFD)
F-1 Yes [:1 NO,
VENTILATION FAN(SINGLE RE-SID) PAID -
• Will the applicant or future building occupant use equipment or devices which Date Receipt b
mit hazurde s air counio ni as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,00011TU)
F)"hicfl TOTAL:
E]YO, Fl No BOILER-COMP(OVER I00.00 H111
I huvc madthc hvmnlnus mmi:Js ayuponecan at Chapter 695 of Else Call- AIR CONDII IONER
ISSUANCE DATE
ibmia llcuhh&Safety Cole,e.leans.that,25533 and 255:9.1 mmol a.d that if the NEW RMIDESITIAL MECH. SQ.FT.
huthe re dtcs nm i which huvc a tenant that o is to ce of a ihiliry to naify the pancy.
of lhcreyuirc.n rota which must he tan pnnnoiswanceofoCcnihcic of(Occupancy.
Owner or main...ol agent Dam TOTAL: ISSUED BY:
OFFICE