S 2829 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-BLECI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. C� O
NUII.RINGI'RO,IEC"I'IDEN'f119CAT10N J O
29
RUILDINGADDRP_SS SANI'I'ARYNO. APPLICAHONSUI{MI'1'1'AL DN'li
�csv��s -� -�
OWN iI 'NAME: PHONE: C NTRAC'IIIR'S Mli: IAC NO
/ GEe 0 � Nle. oNl'ROL«
A ITECT/F ANIELx LIC NO A ES.' ❑
3 -37
o e quo Ct�35�lZ /l 4yd(
CONVICT: n PI{ONL: n RUILDING PERMIT INFO
1%6 ) -�J/J/ ❑ Consultant Fees[laid by Applicant(Initial) 11L ELECT PLUMB MIiCH
Y r/ (/ ((/� 7(,( ❑� ❑ ❑ ❑
I,ICIiN$IiU C'ONTRACIOR;S DECIARM ION . QTY ELIECTRIC PERMIT' EEE JOB DESCRIPTION
I hereby o into that I am licensed under provisions of Chapter 9(commencng
WOZ xith Section tl(XXR of Division 3oflhe Bminessand Prokwiorm Code,vnd my license i. RESIDENTIAL:
WOO in PERMIT ISSUANCE
CSF (sell tura and vdivt. � Z(�` Z ❑SFDWI. [I KITCHEN HGMWFa.
aVV Licanv Clu^. Liu.M— APPLIANCES-RESIDEN'I'I Al. ❑ADDITION ❑I'LUNIBING RI PIPE
H Z uI DmC con vacna
y Qp, ❑N1UI.T[.UN'IT ❑STRUCI'URAI.
D N r RCHITECPS Of I ARATR PANELS
Z O t^Z l understand my plans shall be used a,public records AfOD119CA'rION
UP TO 21X)AMPS ❑INI ERIOR ❑CHIMNEY REPAIR
Ll .W4,Pnl..^lonvl 101-1UN)AMP1 IMI'ItOVI:MIEN'I' QSWIMMIN(I POOLS
OWNER-BUILDER DECLARAIION OVER HXXIAMPS ❑BATH REMODEI/REPAIR ❑GP_MOL1'1'[ON
K ¢ 1 hereby a1Enn Inas I am exempt from the Contractor'.License Law for the
y Olaf V ❑OTUER
FLLON follow g S l ]031511 :' JI f .Cd AYdty only SIC NS ELECT R[CAI.
hoh 4 fk tet te t all p d lids p y.tnamrc /�
tel ll nt fl 6 am
dmed SPI.CIAL C[RCIA I IMISC. A
F.' y
Ill.,hlicamwd, l or'ill provilion,Idthe Contractile,L1 (Cnapter9 COMMERCIAL;
Ed<C, (cat emmngwth Section 9(X1(6 of Division3 fth Business dPrf:' ,Ctde)in rLMP MCI'IiH OR POLE .I'.
a a e 5 tom he to exempt tbmnliom and the basin fill the v11c,ed cxcmpnnn.Any,Wa000 of [I NEW BLDG/ADDIT[ON C]DEMOLITION
Section 911315 by any applicant for a pcmnf.nnhjecutc a,robcanl ,,a civil pcnall,ol POWER DEVICES ❑TENANT C]1;001)SERVICE
not mm oIhvn Five hundred Jolla-(E51HB. IMPROVENIEI1'I'
I-Za ❑Las owner of the pmpeny,or my empinyvas wish wages as lM1cirwlc compensatiab SWIMMING VC01,ELECT RIC
PFO will do the warA.and tneswnure is sol intended orottcreJ for vle(Sec.]IW.Ru,iness ❑GTII).R
{may w
not Profession,Code The Collonemr'I License Low urea not apply set an owner nl' OUTLETS-tiWITCHF.S-FIXTURES
n r prnpe.ty who nnllds nn improve,theram,and who docs tech work hlnudf or Ili In
his own employees,provided that n
such un, wanenu arc not intended nn offered for NEW RESIDES TIAL ELIi0 R SQ IT.
sale.If.nowevea the building or improvement i-old willonson yearofcomplenon.Ihc SQ PI'.11UGH AREA EISQ FI'.
er-builder will have the burden of proving that he did not mild or improve for pur-
pWw•ofsde.)" TOTAL:
1,an owner of Ihc property,ten exclusively conlmming wile licenced contract-In
am
mas the pmjea(Sec,9(W.ButineA and Prufesiom Cove:)'[Le Conlmelor n[.i.
Law does nolapply to an owner of property who bui Ids or improves thereon.and QTY. PLUMBING PERMIT FEE
mC
who
o cnmls for such pmjreu van
with a conm(O licensed pursuaun raam
nthe Com 'n
Liceme Law. PERMIT ISSUANCE
❑ I'mt Lx nVtumder See B Ne PC ler this rc.son
VPR(��DFVICE
AIN.k VENT'-WATER(RIO VALUATION
Owner Dara
.
WOR KI?R'S CONI PENSM[ON DECLARATION BACK 'PR(HLCT.DFVICE OO
M1Crchy NBnn under punchy of Ixrjury one
of'he tllnw'mg dcdunntns
I lomv-J will onarbin a ClIllnm of Con,annasell-l.Xaref..Worker's Compen- )R.ROO EA.COND' S'10 'S 'TYPE CONS'I'RUC'I'ION
nation:vs provided lar by Section 3WD mIc LaMu Cde,for Ihc perhamm�ex of theforwnich this perm isis,ueJ. .RTRIhaveandwillmaintainWnrkur..Gtmpensalinn)nsurunce,as rcyuireJ try Sectionl]Mlaftbe Luhu.C...le.for 11hr,rlbrmance al the cook fur which this lxrtit i,Issued YS'1'R. '.JUUTLE. I)CCGNOUI' AI'N
MyWurk r'� iunsmi Insanmcc carrieramd Pnlilyt t aolicyNo YSTIiM"(IVEH l 7m I.I AtNIPIFN ,',r,ITNUROMWNCE RLSBUILDING DIVISION F[ES
USTRL WAS F, .EPfOR
flhi,ncaamoced solbecompinul it tire pm'ntitis l'or one handled dolbtrt(A 100) GREASE'I RAI' -
nr Icss.) I'LANCI IIiCK IEE
vanity that in the performance of the work for x hich ihis,Wmah is issued.l shall SIEARS-SANITARY-STORM EA.21X)IT.
sol employ any Ierum in any manner so as In Mcnme-object to the Workers'Compete ENER
Law
Z alien Lows of C likoroa.Dam WAI'IT,HEAI'I HR WIVEN'T/Ii[.l R
O Applicant O UI G19t,:
'�r y
NO[ICE TO APPLICANT:IL often making this Ccnibvale of Exemption,you should WATER SYS'FEM/IREATINC, LS 1911:
? bean..subject m the Worker's Compensation provisions of the Labra C, c,you in 11
W '. forthwith comply w BM1 such provtmons or pmmut shall hi,deemed revoked. WATER SERVICE
Q PAID
CONSTRUCTION LIiNU1NG AGIENCY NIiW RESIDIiN'I'IAL PLMIL ti0.t1'. R,,cipl#
U z I hereby ulfmuhat there is a conamclion lending agency for the performance of
L4 r- the work for which his pCnnil is issued(Sec.31Y)].Civ.C.) 'TOTAL:
O U Lv W's Name
Ixvdn's Addm,.n '1(YfAI,:
r a I levity that I have tend Ihis a,dan tioo and ,all that the aMwe Inhon alion in 11UILU 'I'Ii1i
F V) atneei Iagree set comply with all city and county ordinance.-and arae laws mining to QTY. MECHANICAL PERMIT' FE5 SEISMIC]
LI ,Z, nuilding conslrmmion.and hereby authorial representatives of city it, p
enter ot the
"hove-men ...war pony fm In""imt purposes. PERMIT ISSUANCE ELECT NIC FEE
(We.)agree m avve,indanmil'y and keep hound",tiro Coy mf Cnpcnlma again^t
liaNIow,,jud,menls costxund call"Ishills tory in anY way-low against said City ALTER OR ADD'ID MECIL PI.UhIBING FEE
to n.seyuence of the gonion,Win,permit.
APPI.IC N"I'UNDERSTANDS AND WILL COMPLY WL"I'H ALI.NONPOINTAIH HANDLING UNIT(TO 10.(1(X)CFM)
MECHANICAL MHz.
SO REGI 'IONS.
_ AIR HANDLING UNI'I'(OVER 10,IHX)CFM) CONS'IRUC'I ION'I'AX
,nam Appliv WC,,.I.ur ' Dat EXHAUST HOOD(WNUCO HOUSING MIT'IGA'TION FE-H
HAZAHIN)US MATERIALS DISCLOSURE:
III the uppllcam or bmtrc building.meltpant^min=or handle M1nnvdnm material I IEA TING UNIT'(TO I(XI,IHXI TU)
11
ax dell.w,by me Cupennor Municipal Calc,Chapter 9.12,and Ihc llcallh and Safety
Covet,Sevainn 25532(.)! IIIiA'ONC UNIT(OVER IIXL(NX)IT
E3 Yes Qic V ENTILATION IAN(SINGLE RES)Of PAID
Date Reecipi a
� atWII Ihcappliclvn ser lave hnllJing ocvnp;mt use c9nlpnmml or devices which I{OILER-COMP(3I11'OIt I00,(X)0B'RJ)
tit haamdis,air conlarninAn6 an dctivad by Ihc bay Arca Air Quality Management 'IUI'AU
D""w:' ... BOILER-COMP(OVUR I(XGX10 RT U1
❑Yes
Ihave text the hvurdoaa matcrids Test,ire orot^under Chaplin 695 nT thC Calf- A I R CONDIIION17 R ISSUANCE DATE /S
lo .Icallh M SuRt G 'anion,255(15,25533 send 3514,1 undenlmtd that If[lie NEW RGSIDIiN, AL MECIL SQ.PI'. Q��. � V
builJin,d Ica yh' camwnLlhalitivnyrespmsibilitymnmi(ylhedreupam J /
often" me .i be incl prin t issuance of v Ce"o d y.
r rt Jugcnt Uwe IOI'AI.: r•ISSUED BY:
OFFICE f