S 0476 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'PRICAL PF51I NO. 0476
B1,....1—G DI VISION L. J APPLICATIONIPERMIT PLUMBING-MECHANICA
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. API'LICAl10N SUBMI'ITAI.DAPI
/fS7 G S�D/�yJ
401z
OWNER'S NAME: PHONE: C TRA^CTOIi:S NAME: " LIC NO'.
l-!V' N/C CONTROL#
ER: LIC NO: ADDRESS: �/ ❑
0 ACT. PHONE: BUILDING I'ERMI'f INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICHNSIi CONIRACI'OH'S UF,CLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
M_EDd'Z with Seoion]INXI)of Divisi.n3ol the tluzinexs and Pmfcsions Code,and mylicensc is PERMIT ISSUANCE RESIDENTIAL:
- in full lime u-JelleYy. p / //�/Q/ ❑SI'DWL ❑KITCHEN REMODEL
U Lisxnse C s Lic.p��O
Q U APPLIANCES-RESIDENTIAL ❑ADDITIONMBING HE-PIPIT
r/~i 6 a Dote Commerce
F7w ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT S'TRUUCI'URAL
ZOrNZ I understand my plans shall be used az public records MODIFICATION
OZ4-M UP TO 200 AMPS [I INTERIOR ❑CHIMNEYWEEA[R
F=rin Licensed Pr t 201-100UAMPS IMPROVEMENT E]SWIMMINGPOOIS
.W. yah Q I hereby afRtm h �am�umpt froLDER m the C m ac�r's Licenzc Luw for the OVE EXX)AMPS / ❑BATH REMODEIAEPAIR 0 OEMOLH ION
x36U following reason.(Section 9031.5,Business and Pr ions Cods:Any city of county SIGNS ELECTRICAL ❑OTHER
Y] ¢vFi which requims v permit to consumer,alter,improve,demolish,or repair any stmaurc
toto Q prise,run.......re,almrequires theappream for amen permit m lileasignmxmtemem SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofmc Contractor'.License Law(Chapter 9
W..00 (commencing with Section 7000)of Division 3 ofihc Business and Professions Code)or TEMP.MfTER OR PULE INST. COMMERCIAL:
Q.L ey that he is comp,therc[mm and,M1c basis far the alleged cxcmptinn.AnY vloluuoo of W BLDG/ADDITION Cl DEMOLIT oN
k m 4. Section]031.5 by any applinmt for a permit nubjens the applicant to a civil penally of POWER DEVICES
rn nm mornhen five hundrul dollars fSsglL TENANT ❑FOODSERVICE
H Z'Y IMPROVEMENT
Q
01.as owner of the property.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
PSO will Jo the wurk,iwd ihepnamro isnot inrendedorafced hm.wle(Sec.TW,Business [I OTHER
13w and i., none GMo:iThemp Contractors License Law,do.such
apply toll awnor,of OUTLETS-SWITCHT:S-FlXTURES
his own who ones,or improves memoir,i and who does such work himintended
or oe through
him own employees,the
provided r i such improvements arc not intended or offered for NIiN'RESIUEM1TIAI.GIJiCI'R SQ 19'.
sale.
wnw-however.lhche building of pram,is at he
non yew Wild
improve
fom0c SQ.FI'.FLUOR AREA SISQ.IT
pur-builder will have the burden of proving the he did not build or improve Ern per-
L as oA .
❑ 1,as owner of the Sec.70 am exclusively mmvctins with Cede:)The
i- TOTAL: w A
construct the es mg (Sou 9t an one,of and ny no ons Gde:j The Commoor,Li- -o,(✓e ^I 4
c Lao,does such plroroan nwnerofpmpero whosedJlry improves theme^.and QTY PLUMBING PERMIT FEE /1 '
who commas for such projects with a comracmrts)licensed purzuam to the Cnmmaoh ^ L
License l.aw. YRHMI'T ISSUANCE. L�`/ t1 am exempt under See. .Ii&P C for thin reason
(OwnerDane ALTER-DRAIN&VENT-WATIER EA)/ (- VALUATION
WORKER'S COMPS 1 ATION DECLARATION RACK IlOW PROTECT DEVICE.
04 I hereby affirm under penalty perjury one of the following Jednrutions: V
I hmsemal willmainmin a Cen'�of Consenlm uF-i more for Workers C..... a- DRAINS-FLOOR,BOOK AREA.COND.
'm'ti.n,as provided far by Seri 3]q)of the talo'GMs,Ibr the perfnrmunce nl the STORIES TYI'li CONS'TRUCT'ION
work far which this permit i .sued. IIXTURES-PER TRAP
❑I have and will main n Workeei Compemx^tion hourance.as required by Section
3900ofthe lame C,�Ir,fnr the perfnsurtueof the work fnr which Ilii,permit is i...ed. GAS-FA.SYS GEM.I INC.4 OUTLETS OCC.GROUP APN
My Warkce's Com nation Insurance carrier and Policy,number arc: '
Camicr: Policy N^: GAS_EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEd NDUSTRL WAS TE INTERCEPTOR
BUILDING DIVISION FRES
Oixsd1hwh
nnplmeJ ifthc permi,is for one hundrcddollam(SEW) GREASUI'RAP
r Ices.) PLANCHECK EFF.
I eemifcofthe work fin whieM1 thispenNtklss.eJ,Ishall SEWER-SANITARY-STORM G.2LYIPT.nut employ anlentotheWorkcriComps^- ENERGY FEEOz smion laws ourn oe lµ�c< cell' WA'TGR IIEAI'IiR W/VEN'T/ELE6TR
z Q Applicam - / / GRADING FEE
NOTICE TO APPLICAN:IL cher nm'rng Nis Ccnilicmu of Eiemptiam,you should WATER SYSTENITREAI'ING a SDIIS FEE, become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply wim,wh proviaiom or this permit shall be deemed revoked WATER SERVICE
d Q
UZ CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Ef. PAID
U O Ibercb,mr.mnhauhefe is.c^nmuchoo lendlngugsncy for geperformaneeof Date Rec #
W. P the work Ra which this permit i—,wal(Sec.30)].Civ.CJ
U Lender's Name 'I' 7L
I.endcr's AJdrens I
F 0. 1 middy that 1 have mad this application and smm that the above information is E
G FEE
pp e+mee.Iagreemcomplywithdlclry ounryominances and.arcs law.,relating br QTY MECHANICAL PERMIT FEE
U 7. building construction.and hereby au ercprcumntiva of this eirymenmr upon the }li
above-mentioned propenyfurins on purposes. PERMIT ISSUANCE
(We)agree m sass,ind -y and keep hmmless the City of Culw�rino against FEF,ibud8menN pensee which may in any wary:ams�gainst sail City ALTCROHADUTOMT:CIi.ncoasequenceofa of Ibis permi,. G FET: `
APPLICANT U I . ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM)
SOURCE REC AT S, MECHANICAL LIE
p AIR HANDLING UNIT(OVER 10,000 CFM)
/a7 CONSTRUMIONTAX
Srg C mmcter DD am EXHAUST'HOODOYMUCffOUSING MITIGA'I'10 FEE
HA,ARDOUS MATIiRIA1,5 DISCLOSURE
Will thcapp'vm nrfuwrcbuilJing omupum urs nr handle h...rtlonx materiel HEATING UNIT(TO 100.000 BTU)
as defined by t .penin.Municipal Code.Chapter 9.12,and the Health and Safety
Code,Secti 5532(x)? BEAT ING UNIT(OVER 100,000 BTI)
s ❑Nn
VENTILATION PAN(SINGLE RESIDE PAID
mll c am mbug equipment deviceswhich -CO�YLHPOR Ig1,XXBTGI
Data Receipt#
(iM1aowdotuair coramouoxas _-it by the BayAre.AirQuality Management
BOILER
TOTAL:
--imno9
E]Yes BOILER-COMP(OVER 100,107 BTU)
I have read th maurialsrc Mwcwx.mder Ch,w,M1.95offlc Cali- AIR CONDITIONER
9 ISSUANCE DATE
forma health&Safe .Sections 25505,8533 and 25534.1 undcreend the If,hc NEW RESIDENTIAL NIECE].
bnilAing does nm room.the it in my resporoibili,y to notify the tenipom
of the mquim met priorm Issuance of a Ce ta-escofSOe�p2^
Gore,
ua / Dam_? TOTAL: ISSUED BY:
OFFICE