99110091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
TY OF CUPERTINO RUIL"ING-ELECTRICAL
UILDING DIVISION APPLICATION/FERMIT FLUMBING-MECHANICAL NNW
F—, IIIJII,DINGPROJF.CTiD�.yr]FICAI�-6--l�
I "P,�;i �
Ll f;ADDRESS SANIFARY, At[ON SUBMI17AL DATE
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)NE CO?O RACTOR S NAME N/C CONTROL#
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Consultant Fees Paid by Applicant(Initial) BLEG ELECT PLUMB MECH
Fomkv< — 2r- Rl- El EJ
I one y LICENSEDCONIRACTORSDECLARATION QTY ELECTRIC PERMIT FEE ''
acez I hereby affirm that I am Incenoed under provisions of Chapter 9(courthencing JOB DESCRIPTION
wo suhSmum700fs.ffA,i,op3.f0w B &dpf riscowleardinylimenowil RESIDENTIAL
F.'2 To full Aa;md effccl. PERMIT ISSUANCE C1 SFDWL C)KITCHEN REMODEL
U Limit Lma:`wv -1 PLUMBING RE-PIPE
am_scW APPLIANCES-RESID17NTIAL LIADD[TION
D - A OL_ - —
ARCH11 EC I S DECI-AR TIO PANELS LJMUI:T]-UNIT El STRUCTURAL
zo�'z I undeimand my plant hall lac used as public records MODIFICATION
Oz- UPTO 2W AMPS
t 0 El INTERIOR L)CHIMNEY REPAIR
W Licensed fic.15b,inmil 201-I"AMPS IMPROVEMENT
m ll'z� ' OWNER-BUILDER DECLARATION _]SWIMMING POOLS
cc=� I OVER cXd AMPS El BATH REMODEIJREPAIR 0 DEMOLITION
E C)W< I onorby.ffirin that I am exempt from the Contractors License Law for the
X SIGNS ELECTRICAL
�U following remain.(Section 7031.5.Business and Prafessions Code:Anv city or couniv EJ OTHER
which acquires a Permit to construct,almr�improve,demolish,or repair my struentere —
prin to its issuance,also reports the applicant for such permit to rite a signed statement SPECIAL Cl RCUIT/M ISC.
he,he is I wer,ed pur,cion to he pr....... ofilwC....tonfor', Law Wh�fwrr 9 —
(commencing with Section 7000).1 Disco..3ofiffic lamunT Profession,Code)., I Elv[P.METER OR POLIT INST. COMMERCIAL,
lt�e.I.,Z that he is exempt therefrom and the basis for she alleged exemption,Any violation of —- — E)NEW BLDG/ADDITION 0 DEMOLITION
X Section 70315 by any applicant for a per subjects the applicant to a cis il perado,of POWER DEVICES
,M"' OTENANT C3 FOOD SERVICE
I z"' not more than Him hundred do[]...(S50(h), IMPROVEMENT
El I..00rqr.fme,o),ery....... SWIMMING POOL ELECT RIC
I., ElOTHER
�O add Professions Code The Common's Livemse Low,does not apply to an owner of OUTLETS-SWITCHES-FDCpURE!S
property w ho builds or improve,Itheressin.and.he does urch weak himself or through
his.,it employms, Emsmad that�..a incTowerprot,am am impaled.,offered for NEW RES]DENTIAL ELECT SQ ET.
sale.If,however Ilso th dialm,nolmol,oneal 1-ld within(11 c" ::' SO FY FLOOR AREA S/.SQ ET.
p!nmrprx!`,'c"
morter-hinkler will h,,c,hc InToRmof pro,iii,flut,he did rwa'[,21'da�a
,,,of salc.)� illig, L
E] L as owner of the pappaterty am exclusively contracting is th licensed vompascmr�to
construct the Project(Sec.7044,Business and Profession,Crale:)'Hol Calumniou's Li-
mr,c Law doe,am ip,1,1.rap,,mr of proupony who build,To inni,ov-dwo,"n,ond QTY.. PLUMBING PERY ?"IlittE
who contracts for such prove,with a conaractorts)licensed pursuant to the Cvntracmr`�
License Law, PERMIT ISSUANCE
1 am exempt under Sm. _.11&P C for this reason —
per D'am ALTER-DRAIN&VENT-WATER EA) VALUATION
WORKER'S COMPENSATION DECLARAI[ON BACK FLOW PROTIM GET
I hereby about under Penalty of penary one of the following dicaclanationi — XIM"h
I have and will maintain a Cerrificarle of Consent to oeff-insure for Wealms Comil DRAINS-FLOORL RWK AREA.COND STORIES - TYPE CONSTRUC�ION
sation,us provided for by Section 37M of the Labor Code.for the Performance of the —
FIXTURIrk-PERTRAP
to,which do,funcon,ued -N
I lone and will inaininin Workers Compensation Inoirance.as remained by Section q
of the Labor Code.for the performance of the work for which this permat is issand, GAS-CA.S YSTEM-I INC.4 OUTLETS OCC.GMQgP APN
My War ge .1VII,migice carrier and Polity, GAS-EA.SYSTEM-OVER 4(EA)
Policy No:ZM113104!
CE 106)0-14
"rhCATE OF EXEMPTION FROM WORKERS
COMPFNSAI]ON INSURANCE GREASEINDUSTRI.WASTE INTERCTIFFOR BUILDING DIVISION FEES
fGhkouslinormed no, c completed ifffic .it is borrow tooralwaid.11m,IS[all) GREASETRAP
or less.) PLANCHECK FEE
Imitiff,died in the permarrommof the weak f whLch,hi,N...it kromed.14pill SEWER-SANITARY-ST(
not croployacy Ecrom i n any manner so is to becono,subject to the Workers'Courpen - ENERGY FEE
Z .,am Low,ofCalfil a Date WX
Z 2 Applicant ADING FEE
lZ) NOTICE TO APPLICANT.If.offer makin,this Crichficine of E.croplim,y..,hcmld cornplet)w
lNeurpresubject to the Worker's Componsiaman provisions of the Ladvor Crude,you most wAn�gxfflwtn alan ched
ficanivith comply w nut such fonvioncris or this permit shelf The deconed revoked, Ike!e".777777-- i'_ - ccept C
nr nrdl/or Omer a
z CONSTRUCTION LENDING AGENCY NE Rrg��mwi f r corre&U 19 aMr4tyr Date Recent,#
U C) I hereby affirm that there is a construction lending agency for me Performance of
P be work fair whi,h,hi, ..it i,issued(See 300.C.,C.) Ili rpyisions I
Lt. Leader%Name TOTALL
0 U Lcmaf�Addmc
>� W lemnlip
CL conflon I have it this ii,thealitur add one than the above information i� "'. .-tgd Blile NOT A BUILDING FEE
correct.I agree in comply"ith all city and county ordinances and state laws coafin'to QTy 'v Ir y dail
U Z building construction,and lumby andion7c representatives of this city to enter upon dop Per ff*,N6d,ftW(W)-tK SEISM IC FEE
mom-oneopmed property mano,preficir PERMIT ISSUANCE ELECTRIC _�_
(We),ime to save,indelooly and keep harriless the City of Capenion agall,t ETQ'
ALTfre
alilab MBING[TEE11
in conswerfacrace of the granning,of this facrairt, Zl�� LJ IM)l
p/
It
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITC10 I01rAM)
SOt IRCE BE ATIONY t U
-ol'Apflistanicarmarno CONSTRU NT
G
Pit AIR F51901urft) ;TI 0
m It -F Date EXHAUST HOOD(WIDUCT)
ATION FEE
HA�RDOUS MATERIALS DISCLOSURE
�J`Wih the applating ormonce haddiagnmupoint sameor handle hazardous material HEATA410-*( U)
it-leficed by he Culs,nomMunivi,sal Code,Chafk,i9 12,and(lie Health and Safety y
Code See no 25512(.0.1 HEATING UNIT(OVER 100,0t
To
Fq; f mento
Yet 0 No VENGj]ON FAN(SINGLE Rr�lti PAID _D�m Reecam
Will the applicant or boom building occulkon me equipment or dec ter,which
trot oanum.Tu......lancomp,;,,T,finad by he]to,Am,Air Quality Management BOILER-COMP(3HPOR 100.000 BOU) TFAL
Diminclke, FINc BOILER-COME(OVER 100.0))BTU)
I have read the formations material%requirements under Chapter 6m5 or da,Cal, AIR CONDITIONER ISSUANCE DATE
tomn IL,,Im&Safety Code,sections 25505,25,533 and 25534 1 understand han it he NEW RESIDENTIALM11CH. SO,ITT
build 9
of the re at
��i TOTAL: ISSUED BY.
0,2!S,.r-Ydo3ri,ts"it,al
OFFICE