S 4384 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONFPERMIT PLUMBING-MECHANICAL S 4384
BUILDING PROJECT IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z 03 7 �Leve�s C TS/.•v 7 �o^ g
OWNP.R'S NAME:
PHONE, CON/TJJt/ACIOR'S NAME: LIC NO:
(� C h„a2A �n �38-�yyJ /1/,J CD /jt.w�i cil.G��� N/C CONTROLN
\
ARCHITECT/ENGINEER: LIC NO: ADDRESS', / % ❑
LBO �F- Su.-k-K O"SS f.- wPy=If
CONTACT: PHONE: 'l" ➢DILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MEER
LICENSED CONTRACTOR'S DECLARATION Q'pY ELECTRIC PERMIT FEE hereby affirm that 1 am licensed under provisions of Chapter 9(unmmencing t JOB DESCRIPTION
pOWZ with Searien 100(f fDivision 3 ofthe Businessand Professions Cmic,and myliesoms RESIDENTIAL
�W 0 PERMIT'ISSUANCE
FWD nlilllforce and effect669Lgl� ❑SPDWh KITCHEN REMODEL
�UkJ Llccnµc Clac LIc.X
hGW Dam �� Contras �• API'hIANCEs-RESIDENTIAL, El ADDITION ❑PLUMBING RE-PIPE
;:t on ARCIIII'PET'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
C Z�Z 1 understand my plans shall hrd
The,used as public records MODIFICATION
IIP T02fg,AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Q vsF lap] Licensed Professional 201-IM)AMPS IMPROVEMENT I]SWIMMING POOLS
1,y OWNER BUILDER DECLARATION OVER IBDTAMPS ❑BATH REMODEUREPAIR DEMOLITION
IY Q I hereby arm thaam certain 1 aexempt from the Contractor's License Law for the
�L O a ffV following mason.(Section 1031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F O y which requires v permit to csm omen.vlmc impnwe,demolish,or repair any structure
prior to its issuance,alsorequires the applicant for suchpermitao rile a xighedstatemem SPECIAL CIRCUIT/MISC.
C 6 tbm he is licensed momem,ona,pmvionns of the Cominco,Urensc Law(Chapter 9
(cmhmencing with Section7QXdof Division 3ol'(he Business and PnJeasiens Coda)or TE R MI TBR OR PULE INST. COMMERCIAL:
Ihat Im is exempt memfmat and The ho i,mf mo alleged exemption.Any viomtion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^I+N. Se<Ilon 1031.5 by any applicant lura pefmh oAhccoda,sp,dirma o acivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F=Qm more than five hundred dollars(55001. I
ag will do the work,and the sMPROVEMENT
Fl Las owner ofthe property,or my employees with wages as their sole compensation, SWIMMINGPOOLELECTRIGstructure is not intended orofTered for sale IOW,Business OTHER
Wand Pmfessians Code:The Contractor's License law does not apply to an owner of OUTLITS-SWITCHES
-FIXTURES
a'3 property who builds or improves thereon.and who does such work himself or fl rough
his own employees,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL ELECIR SQ 14.
sale.If,however,the building or improvement is sold within one year nfcompletion.the S .FI. ORA ;A / PL
owner-huilder will have the burden of proving that he did not build or improve for pur-
"eafaale,. - 6 199
I,us owner of the,m,scdy,con exclusively mtmmr,ing with limnsed ecnuacmrs os TOTAL JUL
instruct The project(Sec.1044,Busiorw and Pnsfesaions Cn w:)'I he Cownuclots Li- - --
,se Law does not apply to an owner of property who builds or imprm<s themoo,and QTY. PLUMBING PERMIT,' FEE
tabu mnrmmsforsueM1 projects wish venmracmr(s)ficenred pursrmnuo the Contractor's p
License law. PERMIT ISSUANCE By
I am riming,under Sec. ,B&1'C for this reason
Owner Data ALTER-DRAIN&VENT-WATER THAT VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
Fl I have and will maintain a Ceniriane of Consent to self-insure far Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'I'RUCTION
satinn,as provided for by Secdah 3700 ol'the Labor Coda,for the performmiee of the
rk Es,which this permit is issued. FIX'I IT RES-1117 It TRAP
I have and will maintain Wasker'x Cnmpetsation Insurance,as required by Section
3700 of the Labor Code,for performance of the work for which this permit is issued. GAS-IiA.Sys TLI-I INC.4 OUTLETS OCC.GROUP APN
MY Work'kyg Compens;tion In urllp�cc i Icy No.Ynu4ti'C%4/6SL9oo GAS-IiA.SYSTEM-OVER 4(EA)
Curio. 1 Yu.0
CERTIFICCO COMPENSATION
I N FROM WORKERS'
COMPIiNSAT10N INSURANCE GRFASUINUUSTRL WASTE IM'ERCFa'iT)R
(This me,mn need nu,be completed iOhe permit is(crone hundred dollws(SIDB BUILDING DIVISION FEES
or Ices.) GREASIiTRAP PLANCHECK FEE
Icenifytheam,he perfomanceofthe wark(arwhichthispermit isia.a:ed;I,hplI SEWER-SANITARY-STORM F.A.200 Ff.
not employ any person in any mother m as to become subject d the Workers Co.pen- �Q ENERGY FEE
O Zin fumiu.Dare WAIT7R HITATER WIVENT/ELEQ'I1 Q
Q Applicants of Cali GRADING FEE
NOT ICE'TO APPLICANT:Ifalio makingthis Certificate of E.en t h Id
p Ion,you s oo WATER SVSTRM/IRP.ATING
become ,cantmthe WotAero Coons or this
provisions of the created
Labor Code,you most SOILS FEE
[S7 forthwith comply wish such previsions or this permit shall he JcemN rcvoAN. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FL PAID
I.I l hereby which thi that i is a construction(See.ion lending agency for pednrmance of Da «apt X
fL F' the work for which this pem,ir is issued(Sec.3091,Civ.C.)
U Lenders Name "TOTAL:
Lenders Address fyfAL:
i certify that 1 have reuJ hisapplication and score that the abuse Information is �'P
BUIIpING
.Ni V1 forcer.I agree to comply with all city and aunty ordinances wed slam laws relating to QTY. MECHANICAL PERMIT � PER'
L1 Z buildiagconewcrien,and hcrtM1y nuthnriz.e mpmaentntives of this city rd enter upon the SEISMICP
uMrvcmemioned property for Impecliou u,,s.. I'IIRMI I'ISSDANCE
(We)agree rd save,indemnify and keep harmless the City of Cupcnimn against IiLECTRIC F
Iiabilities,judgmenrs.costs and expenses which may in any way secure against said City ALL 17R OR ADD TO MECH.
in asequence of the gaming of this Taman. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM)
SOURCE REGULATIONS. MECHANICAL FEF,
m������ ,7 dl,;)
pJ2 AIR HANDLING UNIT(OVER ELECT)CFNU CONSTRUCTION TAX
Signature of A�plicam/Centmetor Dme 17XIIAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theii,hemoor fnuue bdldingnccapaht vtomor handle horardous material BESTING UNIT(TO 100,000 B OU
as dedihcal by the Cuperian Municipal Gds,Chapter 9.12,mW tho 11,41,and Safety
Code,Sermon 25532(a)? HEATINC UNIT(OVER 100,0011B I U)
❑Ye /���s ({ n PAID
VENTILATION FAN(SINGLEREST])) Date Reccipt
c Will the air conn m future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Arca Air Quality Nunagaslem BOILER-COMP(JHP OR 100.00(i
District? //�� AL
C]yes X. BOILER-COME(OVER I00.IX1)BLV)
I have real the hazardous mammals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Eahiu Health&Safety Cade,Serious 255115,25533 and 25534,1 understand Ihw if the NEW RESIDENTIAL MECH, SQ,ET
handing does ma,uneally haven lanlnt,thin itiamyre,onvihilily lu notify lhencer,am
nl the nyulrements which nnlM hd mel poor to iaauanw nfu Ctrl 'tcyf Occuptmcy.
Owner ora ori Wager D m TOTAL: ISSUED BY:
OFFICE