S 1899 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE [TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1899
IIIIILU1Nf:PROMiLI'IDENTIFICATION
BUILDINGADDRIiSSt SANITARY NO. APPLICATIONSUBMITI'AI.DATE
X1-75 Pr ry 2. er-};no ( �?So l Z- 2
O :R:S NAMIi: 1 PH(lN � CAjJq 1p ,, LIC NO:
NIC f1�CONIKOLp
•ARCHIEHCIFNIGINFER: V I.IC NO: k'Sti:� - e ❑ y 92�
CONTACT: NIONE: lr^i V BUILDINGPERM1(ITINFO
^'AW
E:1 Consultant Fees[laid by Applicant(Initial)
BLDG _ ELECT _ PLUMB MIS
❑CII
LICHNSHD CONTRACTOR'S DECLARATION QTY GLI?CTRIC PERMIT NEI?
I hereby amm,neat],,,a licensed trader pnovisin I,of Chapter 9 mammenring JOB DESCRIPTION
WCID with Section 9100)of Division 3 of IIIc Business and Prcfexsinm Cede,and my livenw i, RESIDENTIAL
WOO PERMIT ISSUANCH.
CIF in full force undefft. � �3 ❑SFDWL ❑KITCHEN RFMODEL
GzW )are Cl9 Lich APPLIANCES-kfSIDENTIAL ❑ADDITION EI PLUMBING RE-PIPE
N 6 q Mete Convector
CHITFCTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL.
FmZ Iunderstandm I shall be used us public record. PANLIS MODIFICATION
OZ- ypansx a pu UPTO200AMPS
OZ- C1 INTERIOR ❑CHIMNEY REPAIR
(• ~W Licensed Professional 20I-1O0AMPS IMPROVEMENT 0SWIMMING POOPS
CY�a OWNER-BUILDER DF.CLARAT]ONOVER 1000AMI'S C1 BATH ❑
BATH REMODERUJIMOLITION
C Ct 1 hereby from that I am exempt from the Contractor's Liceme Law for the
at 316 H following rennin.Section 7031.5,Business and Proossinns Cale:Any city or county SIGNS Id_iC1'RICA]. El OTHER
m Ithish ac,ion,sa permit III m ct he, p dcoulkh,o,actesirim,-ouchron
; no,u,it,:. n alk.oc,pire.,tis ppl nt ko,tich,snuil file 0 lioured'unnowdo SITClA1.CIRCUI"MISC.
y 'hal lc is licensedTom In lot 1101i'mon,ardo,C aOu Lived"L't (Chnp'er9
Q� (u 6 'O Sect ](N10) f D vis n
3 f list H :'m> and I Jwv'om Code)or TI3MP MI:']'HL(1R POLE INST COIAMER
d y o[L that he is cxanpt therefrom and the basis for the alleged exentphon.Any violation of ❑NEW BLDG/ADDITION ❑UFMOELI'ION
if 4. Section 91171,5 byanY applicant for a permit subjects the applicant to a civil penalty til' POWIiR DIiVIC1iS p,2 ❑'TENANT ❑FOOD SERVICE
F_K w not more th to five hundred dollars($51X).
=G [D 1.us owner of the property,or my employees with wages ax their sole cumpencatian. SWIMMING MH)L ELECTRIC []OTHER
1- will do the work,and the structure is not intended m offered floristic(Sec. Business ❑OTHER
W3 'ted Profession,Cade:The Cannot License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his non employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELFCZR SQ FlIst
sale.If,however the building or impmvemem is sold within one yearaI completion,the SQ.FT.FLOOR ARFA LSQ.IT.
owner-huilder will have the burden of proving that he did not build nr improve far pur-
pose If sale.).
❑ L ax owner of the propert,nm exrlmively remaining with licensed cromemo m T
mnruct the pmjeel(Sec.7094,Business..it Professions Cou.;,The Contracmrs Li- y J
conic Law does nm apply to an owner ofprofer,who builds or improves thereon,add QTY. PLUMBING PERM �Wlk
who cvmtmess lie each len ea,with v commands)licensed pursuant it)the Comairm8s
Licmaa Loa PI?RMI'1'ISSUA bCIt
❑ l I I color under Sec 11 A,P C to,his reason Y`k
AIA 11It_I]k AIN R VENT-WATIStNJ VALUATION
Owner Date
WORKER'S COMPENSATION DFCI.ARA'I'ION BACK FLOW PROTLCT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: Q
❑I have and will maintain aCenificatc of Consent msdf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. 'TOR ES 'I'YI'Ii CONS']'RUCTION
satins,as provided for by Section 37W of the Labor Evac,for the perfame nce of the
work file which this permit is issued. FIXTURES-PEN'I'RAP
ETThave and will maintain Workers Compensation Insurance,as required by Section
17O0of IIII,Lalor Care,Pathep��eerrmomuceof the work fee which this permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
my wok I C
dPI
no a
Crane
art r:r 'C I��EOFn,P.kX^t IONyf,O�
'f1WOHKF.HS GAS-IiA.SYSTI:M OVLR4(EA)
COMPENSATION INSURANCE. GRRASHoNDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not IN completed iOhe famit is for tine hundred dollars($100) ORFASHTRAP
or ltxa2 PLANCHF.CK FEE 3(
I cenlfy l hat in the performance ofthe work fin which this permit i,issued,l shall SHWHR-SANITARY-STORM EA.21X114.
not ctnploy any person in airy manner so as to become ahjeol m the Workers'Compen- f?NEk iE
z xatlon Laws at Cold nrnla.Date WATER I IHA'117R W/VIiNIHIll,ECIA
2 Applirnm GRAq; C
blUICH'I'0AITLICAN'P:ILoformaking this Certificate of Exemption,you should WATT?N SYS'fEMIi'kE.AI'INO
a ? become sub ret m thu Wnrker'x Com ensatien ('he[.ubnr Code,you must SO1 EF
j p snail,heln
LkI
Forthwith annply with oris provisions or permit shall he AccmcA rm.d:cd. WAI'F,H SERVICE � /k
(, V
p" CONSTRUCTION LENDING AGENCY NEW RESIDiiN'1'IALI'LMB. SQ.FI'. )
U z Dae Receipt p
VOIf whihthit Evemat i isaed(SeemmlesdlO,agency fa theperfommnceof
F 'he work far which this term%is issue)(Sw.3119],Civ.CJ
Lenders Name
l'OTAI.:
WLenders Address TOTAL:
y rtify that 1 have read this application and ante That the uMvc info action in BAR DING FEE 00
to correct.l agree m comply with all city and county initiatives and state laws relating to QTY. MECHANICAL PERMIT FEL?
V building commotion.and hereby tuddamise represeramivesol'this city m enerupon be SIi15 CFEG
abovetnentinn id property for inspection purpose,. PERMIT ISSUANCE O
(W,)agree m save,indemnify and keep harmdcxs the City III Cullom,mainat ELEC]R ,FEE
6V 1
Imbllities,jndgmcn......ts and expenses which any in any way name against said City AIJ]'HRORAIID'TOMFCIL
incnnscqucumof the granting ofthispennit. PLUMBIN P[B
APPIACAN'I'UNDI!RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLING UNIT('10 n,000CFM)
MECHANICAL FF.F
S(URGE It F:CULAI'll]NS
2 �I^„ I nit AIR HANDLING UNIT IOVHR Iff"CFM) CONSTRUCTION TAX
.STlgtiuwre of Al�dicanVCnmractor Dune 000 MIAUS'1'11001)IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSUNI?
Will thcapplieantor future building oecupant norear handle hazardous mmenai HEATING ON IT T 100,M)BTU)
as,defined by the Cupcniso Municipal Cede,Chapter 912,and the Health and Safety
Code.Station 25532(m? 1 HEATING UNIT(OVER 100,003 BTU)
O Yes VENI'1LXFION RAN(SINGLE RFS]D) PAID
Dale ReeciptX
Will the applicantori or fns a building by the H use ea Air Qu or devices Management
emit hazardous trio mmmminamx as defined by the Buy Area Air Quality Mnnagemen' BOILI3H-COMP(3HP OR 108,000 BTU) 1Y)TAI.
Diane)
�ycy /h"vl„G BOILER-COMI'(OVI?It 110,0XI0 BTU) '
I have ,ad list hawrdousinterim],myaimemis under Chapter 495 of the Cul i- A]R CON DI'1'I ONHR ISSUANCE LATE
It.... Ilrhdlh&SuliOy Ctxie.Bernina 25505,25591 unA 2559), ande.samdthan ifthe NHW RI?FIOENI AL MHCH. SQ.Fitsee e2
bu lling Acts not currently hove a Homo,that h is my rmpnnxihillly In ramify thunccupant �-7—,Y
of the reyulremam which mum be met prao to i...;mre nfa Cenilleate of Occupancy.
Owner or into nzed agent Rafe TOTAL: ISSUED BY:
OFFICE