S 1153 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIALDING-ELF,CI RICAIsPERMIT NO.
]BUILDING III VISION AVPLICATION/IaERMI'P I'LU]i RING-AIBCIIANICAI. Q C
BUILDING PROJECT IDENTIFICATION J J
ILDINGAUDRF.SS: SANI'I'AkY NO. APPLICATION SUBMITTAL DATE
000 Wn"X--�T1�/� �O/l t j
OWNER'' etx PIIONF.: CONT )R 'SMI, /�
fp))p/µµ/G F, Il/�a /� �/'�QVr{/V i� N/C CONTROL#
.AR( ITECHENGINEER: LIC NO: P�O wet ��i� ♦1 � c
CONTACT: PHONE: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG E� ❑l v1AMUCH
Azr& ICA FfiFQ, 777-0pol
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I henchr affirm her four licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�d'Z with Seaion]fXMpwf Divisien3of the lousiness an Pnt es'n Code,and my license is RESIDENTIAL:
W O PIiRMIT ISSUANCE
F W O in full Pone and et _ ❑SFDWL ❑KITCHEN REMODEL
<VU assn I_xx _ p APPLIANCES-RESIDENTIAL [I ADDITION ❑I'I.UMBLNG kF-PIPE.
F. me C.a,
mOy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT' El STRUCTURAL
F MODIFICATION
Z O n Z 1 understand my plans.hall M used as public records
❑
OZ—� UPTO2S)AMP5 INTERIOR 11 CHIMNEY REPAIR
^F r_nFW Located Professional 2II-1000AMPS IMPROVEMENT (]SWI M M ING POOLS
OWNER-BUILDER DECLARATION OVER IOIIIIAMPS ❑BATH REMODF,IIREPAIR ❑DEMOLITION
K w 6 1 herfirNm tnte
by affirm that I am exempt frothe ConcrL
s License aw for the
k3dU followingremnor(Section]1131.5.Businessa.d Profession,Code:Any chy or county SIGNS ELF;CfRICAL ❑OTHER
W LL tatwhich requitemit s a perto emolrea,otic,.improve,demobsh,or repair any wuclmer
�g prior to its issuance.also requires the applicant for such Permit to rile a signed statement SPECIAL CIRCUITIM ISC.
, y that he is licensedpurs.anu.the....kionsoftheContractorsLicenseLaw(ChapterY
X000 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
G W o C that he is exempt there[ at and he basis for the n11,rd exemption.Any vinlmion of NEW BLDGIADDITION ❑DEMOLITION
kcm Station703 LS by any applicantfor a permit subjects the applicant ut a civil Penalty of POWER DEVICES ❑TENANT PO01 `RVIC13
nut more than rive hundred dollars(S510). PROVF.M
ESD (] I......ro[Ne property,or my entpioycex wish wager ac their ml,eompervcatinn, SWIMMING POOL ELECTRIC
(.. will du the work.and lhe,Iructure is urn intended or burned f..rml,(See.A1N.Business %Q
W m and Pmfemions Code:The Coutmctod License Law docs not apply to of owner n( 0l ICUES-FIXTURES
Cw-
progeny who builds or improves thereon,and who docs such work himself or through Ir
his own cmpinyer-v,provided Thal svch improvements me not Intended or oRered for I r-,
sale.ILwv
however the building or intpmvemem is wild within one year of awmpletinn,Ne SQ 14.FLOOR AREA SISQ.FT.
er-builder will have the burden of pmvi ng that he did not build or improve fur par- FEB
awn LD
pnse.f.turner
T'�� ANS"D
❑st uct theeroRhe See.704 am exclusively and cinttudivg with licensed contractor,s m C�I r
instruct the es not (Sec.o an ownBuser
ofw and property
who us dsCourt'I tor provesmranon.and
t-�w'1
seLaw dot for...If If Neto owner...1.0 ( woler"dd.orimpmvee Nemown"1 QTY. PLUMBING PERMIT FEF. Or yV�ttIII1V�f
who mntrnaw for web pmjens wllb t cnnrraeom(sl lic.naed purauanl In the Commmor'w
License Law. PERM]r ISSUANCE
I am exempt under Sm. .B&P C for this reason
Owner Date
ALTER-DRAIN&MINT-WA'I'HR(EA) VALUAT�IONq
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �O ,
1 hereby urian ander ..fly.1 perjury one of the following declamations: _
❑ Ihavc nndwillmvimvinuCenlfrncnf Cnnrnunsd[dnwurclic W.zkcT's Compcn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
mriin,as provided for by Section 3700 of the Labor Code,for the Performance of the
work for as b0i this permil is Issued. FIXTURES-PER TRAP
C] 1 have and will maintain Worker's Compensation Insurance,as required by lection
3700oflbe labor Code,forth.perferormsearthe work for which Nis permit is issued GAS-EA.SYSTEM-I INC.J OUTLETS OCC GROUT' MIN
My Workers Compensation Insurance carrier and Policy number are
Carrier: Policy No.: GAS-EA.SYSTEM-OVER a(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE, GRCASIANDUSTRI,WASTE INTERCEPTOR
(Has retain need nor be completed if the permil it fnrnnc hundred dollars l S l no BI' DING DIVISION FENS
or left GRE AM:TRAP I'LANCIIT;CK F
I«nify that in the Performance of the work for which this permit is issued.)shell SEWER-SANITARY-STORM EA.200 IT.
not employ Y prison in any manners.as r hesyW li attolh.Workers Camper. IiNiiHCY FfiI
Z ,mi ei 1 to yqe su�„_ • WATER HEATER W/VENI'IELECTR
ZApplicao ea� • V• GRAUINO 'li
NOI'ICE'TO APPLICANT If, for making rh a dicate of Exemption,you should a WATER SYS atMTR EATING
f-' hcutme subjectm the Workers C.mpensminn .v sods tithe Labor Codc,you mudSOILS blit
WranhwiN comply wi absorb powor lis nr this permit shall be denned revoked, ` WAIER SERVICE
Z)
� Z CONSTRUCTION LENDINGnGENCY NEW RESIDIiNIIAI.i'LMIi. SQ,17, )'AID
V O k for
rwhichaffirm flatturretsis
ex,309lending agency far the perfarmantt of Dice e'1'tM
0 U L the ader's or which this permit iw iswucd lSec.3rN],Cir.C.)
O U Leader's Namc OI'A L:
>, Ltd Lenders Addres 'TOTAL:
1 certify that 1 have read this application and state that Ne above information is IIUILDING FFIi
F• r4 correct.1 agree m comply with all city and county ordinances and stat,law,relating of QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby amriahorcprcsenerives of Nhi.c city it)enmrupnnhe SEI SMC
PE
aNwcmena.ocd property for inspection purposes.
PERMITISSUANCE
(We)agrec No pave,indemnify and keep hamJrss Nu City of Cupeeino ab incl FIECTRIC E
00 tic
liabilities,judgments.costs and expenses which may in anyway accrue against said City ALTER ORADDTOMF,CH.
in co
nwgecrec of the gmming of his perana. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONMINTAIR HANDLING UNH(TO 10,0W CIM)
SOURC' �.GULA'r ) S' MECHANICAL FEI
�•��//� /�'/��S AIH HANDLING UNIT(OVER IILgXI CFM) CONSTRUCTION T.
♦ /`/'4/K/r J
Sign euf Applicard(Gmmclor Date EXHAUST HOOD(W/DUC`U HOUSING MITIGATIO. FEE
I IA'LARDOUS MATERIALS DISCLOSURE
iA lhcapplicun, future Wileingoavpanlwne nr handle afraid....mutedal HEATING UNI'T('IT) W.000 BTU)
in,defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532pn9 HEATING UNIT(OVER 104U00 li'rU)
p Yes No PAID
VEMHLATION FAN(SINGLE.RESIDI
Will Nen laced..r future huilJin eu I use a r.r devices which Dom Receipt p
pp gee pant gwpmen
mor hazardous air continuations as Jcrincd by the Bay AreaAir Quality Munagem.m BOILER-COMPOHPOR 100.0(10BTU)
Of..icC 'I(YI'Al.:
p Ye, C]No NOIL[R-COME(OVER 11X1.004)BTU)
I have mad the hreadous mmetials - AIR CONDITIONER
tegmmmen�under Chapter 6.95.11he Cali-
0
ISSUANCE DAT)?
Ioraw Health&Safely Code,Sections 25505.25533 and 255N.1 understand that if the NEW RESIDENTIAL NIECE, SQ.ET.
building docs not currentlyhave a tenant,atm it is my m,pntalhiiity m nmirythcoccupanl
of(he mquirements which mud Fc met prig m .monsee ur a Co ifcate of Occupancy
Owner or authorized agent Date TOTAL: ISSUED BY.
OFFICE /