S 1534 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTIN0 I BUILDING.I:LECITRICAL PHSIT NO, 1534
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`
BUILDING PROJP.C'1'IDEN'rIF'IC'A'I'[ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
03t�r\
NER'SjNA z t PI NC: ^�� CONTR CTOR'S AME.:0f aloct6�IC NO 6 /-, CONTROhM
ots
ANCHTI'ECT/IiNGINl31?R: LIC Nf: A TRESS: ZL 66 ,fp�Q�/\r_
CONTACD PHONE: I
.jo BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) RI.DO ELECT PLUMB MECH
❑ ❑ `61 ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEF
I hereby affirm that I am licensed ander provisions of chapter 9 mon mendng JOR DESCRIPTION
O=Z as StationuYllDivision 3afIn,Business and Pndcssi...Cdcandmyliermseu RFSIDFNTIAI:
m O O PERMIT ISSUANCE
F, in full fnrteand am.,. DSEDWL D KITCHEN REMODEL
-UU License Class Lie. APPLIANCES-RESIDENTIAL DADDfTIQN LHMBING RE-PIPE
F Z W Date Comrm:nr LL�TJ.�\
rnQa 0MULTFUNIT S RUCfURAL
ARCHITRCPS DECLARATION
F.D y PANELS MODIFICATION
'4 l undernanA my plans shall be used a.puM1lic na,Ns
0 Z'4 UP T0200AMP5 DINTERIOR El CHIMNEY REPAIR
F��;ul Licensed Pmfevsionw 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
�aqn, OWNT:R-BUILDER DECLARATION OVER IWf1AMPS ❑BATA REMOUF.IJRF.PAIR GDEMOLITION
p.tY�< 1 hereby uffiren that I am exempt from the Contowtorz Lmrnm Law for the
x06U fie"',in,
reason
.(So"ho901LRNosiness unit profession,Gyle Any city or county SIGNS ELECTRICAL [)OTHER
W 30.F which requirex a permit m construct.alter,improve,demolish,or repair any mecmre
prior to its issuance,also requires the applicant for such penman filea,ignedstammem SPECIAL CIRCUITIMISC.
that he ix licence)pursuanuonhe pnrvi.vinnset he Contractor's Jerme Lw(Chapter 9
00 (commencing with Section 7000)of DivNinn lot the Daeinazvnnd Poressionv Code)or 'r EMP METER OR POLE.I NST. COMMERCIAL
that he is exempt morefrmn and the havix hor the Kluged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
X 4. Section?031.5 by any applicant for a permit object,fire applicant nu civil penalty of POWER DEVICES OTENANT ElFOOD SERVICE
�..m not arcthan five hundred dollar,($5110).
6 mDl,ox owner of the properly,ni my enployces wire wagesas their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Sa pr'.O willdemewnrk,and the structure is not metaled or offered t io sale(Sec.9044,Biomass GQTIII?R
jy 3 an and Professions Code:The Confmcna's License Lnw dncv not apply a an or,of OUTLET-SWITCHES-FIX'I'UNIiS
properly ho build,or improve,demon,and wlm dues such work hhaseRnr through
hie own caoino,es, ancid,d that.veal,imprnvumcros no,not intended or ogcred lar NEW RESIDENTIAL P.LECTR SQ FI'.
sale.If.howovcr,the hoildln,arlmprorrocm'm told w heinom Ywr...con.plmbn..rho 'Q11U'. L RAREA $ISQ.FT.
plir-huild,will have The In an of proving tent he did nm huild orimprove for pur-
yc aIsola.).
D 1,a,owner of the properly,am excrosivoly contracting with licensed mnlacilm to 'IOIAI.: R 2 0 �11W rD
construct the project($ce.904Pronasion.
4,B-in...raid Code:)The Connector's I pp
cense Law does ma urpply toanownerol'propcny who MhiMsor imom,wic,meremi QTY. PLUMBING PERMIT �
whonmtowls(or.uch projectswith a contruenons)licensed pursuant tothe Connector's �IIJI'[Y111P1U
License Law. PERMIT ISSUANCE lI•�l I/ Ur
D I am exempt under Sec. .B&1'C for In,...a
Owner Uafe ALTER-DRAIN&VENT-WaxnR(IIA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby tffum under Certify ne(if Co enc of the following Workers a:
., Dlhave andwillorby Section Certificate he La lie addeCar the Workersuen of the DRAINS-FLOOR,R(IOF,AREA,GOND. STORIES TYPE CONSTRUCTION
cairn,r provided for by Section 791X1 of the LaMhr Gale,fur fire perdbnnance of the
work for which this pcnnit is issued. ITXTUR[S-PEN TRAP
D I have and will maintain Workers Compensation Insumnee,as required by Section
37W of the Lahr Code,for the performance of the work lir x6ichthiz per mit is issued. GAS-EA.SYSTEM-I INC.40VTI.h OCC.GROUP APN
My Workers Comperismom Insurance carrier and Policy number arc:
Carrier. Policy No, GAS-EA.SYSTEMOVER 4(EA)
CHRTIFICAT11 OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Gbisxection toed not be completed if the Permit is for one hundred dollar,($100) GREASETRAY
or less.) PLANCHECK Flili
I terrify that in the performance of the work for which this permit is Issue),label) SEWER-SANITARY-STORM EA.2110 EI'.
nm employ s��`�10 y ryyrpyy�yn M1yKh�wEject�Ip Workers'Compen- ENERGY FEE
,� sation Law,ryyTyf�LL] r '1"IIFN 1 U�_ WATER HEATER WNF.NI'/fiLECfR GRADING FEE
7 m
q ^
NOTICE TO APPLICANT:It;arta making this Certificate tc of Exemption,you should WATER SYSTEM/I'R[ATING
a ,
Become h,on,dm me ach Worker's i,ionx r his pmmt sir s b the Luber Ctde,you roust SOILS PEIi
LTI ronhwim comply with such prnvi,ion, his permit shall he Accrued revoked WATER S[RVICF.
Q
U Z CattherRUCT[ON uction NG AGENCY NEW RESIDENTIAL PLMB. SQ.lel'. PAID Date R eip1N
U O I for which rnuhunhure ix u canvwed 0 lending agency for the perfnrntance or
The work for which this perndt is issue)(Sea 7(19"!,Co.CJ
OU Lender's Name fOTAI.:
Ixuder,Address
I
�yy, RWi ccrlify flat I have rcaJ this npplicmiun and state few the shove information it BUILIrtgo
Lr Cn correct.I agree meomply withall city and county ordinances and state laws eluting to QTY. MECHANICAL PERMIT FET?
U 7. building construction,and hereby autfnri/c minescnnniYes ofthiscity mentorupon llhr SI?ISMIC 'T:I?
hr Arve-mentioned prnpufy for in,anti....puq....es,
hPERMIT ISSUANCE IIC'IRIC
171
(We)agree ah save,ludumnily d keel, nrndess the City if
I'nrhllitic.v,judgmernv,cavtaan(I expense,whwhnu,in any wayacxeen,ainst said Cify ALTER OR AUD'I'O MHCH.
imm�scquencc ofdm gomlin,ol dolpennit PLUMBING/H,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(1,0()1 CEM)
SOURCTyJ![ UI 1� CON%I IN :TIONT
\/W-]Lt/tel G_ f.— AIR HANDLING UNIT(OVER 10,000CPM) CONti'1' LTION TAX
Signature of Applicam/Commwor Dec BXHAUS'1'HOOD(WIDUCT) HOUSI ITIOATION FEE
HA'/.ARDo US MAHHRIA S DISCLOSURE
Will the applicant or)'cure building occupant nnrc.r M1andletiaLanJousmmcrial HEATING UNIT(TO I(X.000 BTU)
as defined by the Cameroon Municipal Code,Chapter 9.12,and he Health and Surety -
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
D Yes (7 No VENTILATION FAN IS I NGLP.RRSID) PAID
apt x
Will the air coma in(alae building by the B use aArequipment of dMana which
i emit haeNous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,00(1 B'f U) TOTAL:
DinrimP BOILER-COMP(OVER 10X1,000 BTU)
Yas GNo
I have read the hanadou,materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE ATE
(mora Health&Safety Cale,Sections 25505,25571 and 25534.1 anabi,tand that if the NEW RESIDENTIAL MUCH. SQ.FT.
buildingdhes not currently have a metal.that it is my responsibility to notify the occupant
of the requirements which must he met priortoicauanceoro Cenificateof( pang.
Ownerorauthodzedtgent Date TOTAL' ISSUER BY:
OFFICE