99100100 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUILUING-F.LECTHICAL PE N
RUn,UI1fi DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. SOOOI
ROII,DINIi PROJECTIDEVI'IFICATION
HIIILDING ADDRESS: SANITARY NO, AFFLICATION SUBMITTAL DAL
F3'[ r ' 0 D 2S=g
PI{ONCL•': a ,I CO CIOR'S i. )
J L NIC CON'IROLH
III' " 1' r IF rk: p r� LIC NO', � A, \ e ❑
CONTACT• o� PHONE: ( DUII-DING PEHMII'INFO
0SMWRVY`OC— ^O�_��I` '^ '�/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 1'lUv MEECCH
'1 l ) /d'- 7VF r-In
LICENS1115 CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby aRmt thin 1 am licensed under pmvizions of Chupla 9(commencing
Z with Smtinn]1XX11 of Division3of Ihu BusinessundPrdossions Codc.ard icatw is RESIDENTIAL'
(❑AQ / I'ERMI"1'ISSUANCE
F cc r in full limcc and cffmt. `I r ' C SFDWL C KITCHEN REMODEL
Q V U License Lia N f s APPLIANCI?S-RISIDf:N'I'IAL ❑ADDITION ❑PLUh1RING BE PIPE
MZm Uulc Contmenrt
res Q a R HI=S DECLARATION ❑MULTI-UNIT C mo6nT UkAI.
~m Z I understand my plans shall be uxd as PuM1lie records s PANELS MOD119CAHON
0� m UPI'O20UAMPS Ll INTERIOR ❑CHIMNEY REPAIR
OZ-�
(-nnN� Licenwd l'mfessinnal 201-UNp nMI'S IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER DECLARATIONOVIiR 111!10 AMPS CBATH Rl:110DEL/REPAIR CUEMOLI PION
C Q 1 hereby affirm that I um exempt from the Co dowl... Liumsc Law for the
XO1V lullowingreaum.(scainn7031.5.Business and Professions CWe:Any city ur county' SIGNS ELECTRICAL C(YfIIIiR
❑1311 y which torpedoes a permit to rnns.0.alma improve.de nofsh.or repair only suucmrc
prion t .gun Iso ry 'th apphc trir. hp Litt flsoaredsmtcmcnt SPECIAL CIRCUIT)MISC.
tWn<j thoth I dp rsua tt thep ns ftheCollimator.,L en. to (Chapter COMMMMMMM
wKQC (eon c g 'thScti FXX) fU":io 3 fE B :' s dI I':.' sCude)nr TEMP.ME7ER OR POLE INST.
a Y eCt,,he is exempt duarfonn and the basin for the alleged exenpuon.A violation of El NEW RhDGIADDITION ❑DEMOLITION
Xnl+. Section 7031.5 bYany applicant forapennit.wbjects thcappllcautlnunvil penaltyof POWER DEVICES ❑TENANT L1 FOOD SERVICE:
y t than rive hmdreddollam(S50().
SWIMMING POOL ELECT RIC IMPROVEMENT
jJER iMENT'
=o CLa.owner nfthe pmpnRm mYem urnmedwiN wogesustbeir Sri.asrt,Moines,
oites, _ CITIIIiR
E. will Nefesamas and the he Contome is gats License
do for of apply to an,B nee(It
63 m and Professions Calc:The Contractor's Licenw Iww dreg not apply to an owner of OU 1'IT.Ii I'S-SWI'I Cf{Ii5-Ii1X'1'URES
propnY who builds or improves thereon,and who does such work himself'or through NIiW RIiS1UEN'f IAI.IiLIiCTR SO IT.
his own employees,provided that such improvements am not intended or offered for q OOR AREA S/SQ.Fri.
sale.If,however,the building or improvnnced is sold within one year of completion,the
nerhuilder will have(he burden of proving that he did not build or improve for pur-
pow nLsalcJ. TOTAL:
1,as owner of the property,ant exclusively contracting with licensed continuous ous to
omamet the project(Sea](W,Business and Professions CWe:)The Comarl Li-
mLaw does not apply toanowner ofpropenywho builds orhnpro,v,, emnn.;ml QTY. PLUMBING PERMIT FEE
who euno-al beach projects with a ennttamory0licenw l pumunot an the Contrxmr's
License Law. THEME r ISSUANCE
❑ I ant exempt under Sm, ,B&P C for this reason
AIa'ER-DRAIN&V L'N'I'-WA`I1R(CA) VALUXI[ON
caner 2—
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p �®
WORKER'S COMPIiNSA'TION DECLARATION BACK FLOW PRITI'IiCI'.DEVICE
1 hereby affirm under Penalty of Perjury one at the Ibllawing twel:uatinns:
Ihavc and will mainmina Ccnifcatc ufConwntm calf-inmmfor Wmkcr's Compcn- DRAINS-FLUOR.ROOK ARIA.COND. S'I ORIES 'TYPE CONSTT RUCfR'
cation,as provided for by Section 3700 of the Labor Cade,for the performarac of the
wofk for writer his pennon ix issued. FIXTURES IIiH TRAP
Fl 1 have and will maintain Workers Compensation Insurance,as required by Secom n
3700ml the lrlxxCsdc.fur the perfornwnce untur.ork forwhich this permit in issued. GAS-EA.SYSTEM-1 INC.4 OU'T'LETS OCC GROUP AIN/
My Workers Compensation lremmime camerand Policy numbsrare: GAS-EA.SYSITiol R4IEA)
Coma: policy No.: O
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE 1 M'ERCEPTOR
COMPENSATION INSURANCEBUILDING DIVISION IBES
IThisscction matt not hcmmpleted ifmcpcomit is for one hundred dollars 1$100) GREASETRAP PI.ANCHECK FEE
or lcscl
Icon lfy thus in the any maianccofthc work for whichthis permitis""Crl'hall SEWER-SANITARY-STORM EA NX)Il'.
' not employ any person in Ymann - � to n ,SpbJ 11seWorkers Compel- ENERGY FEE
O Z sato std hoes of Califomiu..J) o e,n�m �S� N �I WATT7R IWATER WHEN ELECIR GRADING FE-H
z 0 Appllcum
NOTICE TO APPLICANT:IL elmr making this Cenificmc of Eump thio you should WATER SYSTEMORENrINO SOILS FEE
become suhjeu to the Worker's Compensation pmvisiuns of the Labor Gide,you must
W ti fnnhwith comply with such Provisions to this permit Ill.][ dm
all Es, revoked. WAI lip SERVICE
1 QPAID
z CONSTRUCT[ON LENDING AGENCY NEW RESIDENTIAL PLMIL Sp,IT Date Receipt a
I hereby affirm that there is a construction lending agency for the performance of
the work for which this ,.it is issued Ism.1(19],Civ.CJ TOTAL:
Q lender',Non, TOTAL
} lender's Address BUILDING FEE
1 certify that 1 have read this application and slam that the all information is
sF. h cored.)agree ui comply wise all city and county ordinances and.small,laws relating to QTY. MECHANICAII,PERMIT FEE SEISMIC IPE
(„) z building construction,and hereby authorise representatives of this city to enter upon the
aho'e-mentiond pmpmy fix no,ev ion puHto.ws. i'ERMI I'ISSUANCE ELECTRIC FEL.
(We)agree to save,indemnify and keep harmless the City of Caperton against
Iidulittes.judgnenu.cwt,and expenses which may in any way aceme against said City ALT ER OR ADD TD MECH. PLUMBING PCE
in consequence of the grnping mf this permit
A I'I.ICANT UNDI'RIioiANDS AND WILL VJIPLY i' ..NON-PO I' AIR HANDLING ON['I'(TO 10.000 CI'M) MECHANICAL FEE
S L CE RE(iUL l' )N. O
AIR HANDLING ON]](OVER III,IXXI CPM) CONS'TRUCI'ION'IAX
Signummof Appllucrntm!dcrramm Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thcupplicant or future bulWingocoupuntelnre or handle h:rardous material HEATING UNIT(TO IBB.gN)d I U)
as defined by the Ceponino Municipal tide.ChaPoer 9 1 and the Health and safety HEATING UNIT(OVER 100.000 BTU)
CWe,Section 25532(a)'r
C Yes CNo VENTILATION FAN(SINGLE RESID) PAID
Date Receipt4
Will the upplicwt or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.0g)BTU)
emit hazardous air contaminants as defned by the Ray Ara Air Quality Manogensc t TOTAL: 1
District! BOILER-COMP(OVER 100,010 It I'U)
❑Yes [3 No
Alli CONDI I IONER ISSUANCE DATE
1 have mud the h ore,S s Heap, 5 requirements under .1 and 6.95 of the it li-
add.licalth&Saldy CW,,Smlinns 255(15,85J3a 25.S.M.l undcntand that it the NEW ItiiSID1iNTIA1,MECiI. SQ.FT. /•O� e1 7�
on dnc nm au'm 'M1un mm�am,th my nihil notify the<a'c 'nt C�Ji
d m a nth uw be mel ofuC i s y.
TtyrAhl ISSl1ET,BY
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OFFICE