00010127 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELFIJI'RICAL PERMIT NO.
APPL[CA'PION/PF,RPLUMBING-MECHANIC L c
BUILDING DIVISION MIT BUILDING PROJECT IDF.NTIF'ICA'IIUN `TOOOI
BUILDINGADORESS: - SANITARY NO. APPIACAi'ION SUBMITTAL DAD
S an W / -27 '60
OW :S NAME: 1'IONS: CON?RACTOR'S NAME: LIC NO:
U1 Ae ,n: 4gG-483 LUGR97 S'. X2,1d =t OW, CIPIIF05
NIC CONTROL#
Cliff I.Cl7pNGIIl V IC NO: A�RESS�, ❑
CONTACT: PHONE: BUILDING PERh11T INFO
_ I �
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT' P711-
LUA18 MECH
flt-c," L ,253-GLIB _ El El ❑
LICENSED CONTRACTT OR'S DPALARAnoN QTY ELECTRIC PERMIT FEE
1 herchy affirm that 1 am licensed under previsions of Chapter 9(commencing AOR DESCRIPTION
OIZZ with Senion]000)of Division 3 ofthe Berinessend Professions Cade,and my license is RESIDENTIAL,
u100 in I'I:RMI"f ISSUANCE
fun force and eBect. ❑SFDW I. ❑KITCHEN REM1fODF.I.
�UULicense Class Lic,p
APPLIANCES-RESIDENTIAI. ❑ADDITION [E G BINE RE-PIPE
b- W Date Contractor
y 1 ARCHITECTS DECLARATION ❑MUClbUNIT ❑STRUC'CURAL
Z O y Z 1 understand my plans shall W used as public records PANELS MODIFICATION
m
OZ—O UPTO201AMPS El INTERIOR ❑CHIMNEY REPAIR
FBF'j Licensed Professional 201-1000AMP5 IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECIARA'1'[ON OVERKWAMPS ❑BATA REMODEUREPAIR ❑DEMOIO'[ON
C' ¢ I herchy adorn Ihul I am exernpl Bvm the Cmmrumnr's Licemso Low on the -
(?�5r O 0.V following reawn.(Section]031 5,Business and Professions Cale:Any city or county SIGNS ELECI'RICA]. ❑OTHER
which re<ryirw a permit In construct,alter,impmv0.demolish,or mpmr any strvclure
FLLO� pmare its taroance.,lsorequirestheapplicunt forsuch purn wifilea signed utaonicat SPECIAL CIRCUIT/MISE,
SQf that he is licensed pursuanuo the previsions ofthe Contractor's License Law(Chupter9
that
RJ O (eommenebg with Scdmr70(Xhuf Division 3 ofthe Bminessand Pmfeaslom Codc)or 'I'1?MP.METER OR POLE INS'?.
DEV
Sec io 17031.fivehundreddollaror.peerthe s,for theallegedithe oxumpnt n.to Any sip rally ml' ,. BLDG/ADDITION ❑FOOD SERVICE Section 7031.5 any trom and for permit n the the exciantm#civil penally(if POWER DEVICES - •NANT ❑FOODUT[OCE
no, am than
fF� ❑1,as ownermfthe property,or my employes with wages as their sole compensation. SWIMMING POOL ELECTRIC
IMPROVEMENT
3F willdnthe work,andthestructum isnot intended or offered for sale(Sec.734,4.Business kro HER
toil 2 and Prafesnions Core '[he Contractor's License Law does not apply to ea owner of OUTLETS-SWI"FCHES-FIXTURES
�' ti properly who builds or impfovas thereon,and who does such wok himself or through
his own mnployess,provided that such improvements arc not intended or offered for NEW RESIDENTIAI.ELECfIt SQ FT.
sale.If,however the building or improvement is sold within one year ofcompleion.the SQ.fT.fLOOR AREA IJSQ.Fp
owner-builder will have the burden of proving that he did not Wild or improve for pur-
pom of sale.).
E] 1,us owner of the Property,am exclusively contracting with licensed contractors to TOTAL:
aostruut he project(Sas 7(94,Busiecis an I Professions Carlo)The Contractor's Li- t _ -
nsclawdoesnotapplymanownerofprolenywhoWildsol improve,thecon,and QTY. PLUMBING PERMIT FEE
who comrucu for such projects with a contraciumo licensed pursuantlo the Commences
License Law. PHRMIT ISSUANCE
1.,it exempt order Sec. .B k P C for this reason .
Owner Doe Cr
A17R-DRAIN&VENT-WATER(EA), VALUATION
WORKER'S COM PENSATIONDECe folio Ing RACK PLOW PROTBCC DEVICE'
I hereby under Penalty of of Cononeof thefollowingfor orket'Co _
,Ih:we and will far
eCmi37M of theL ar Code,
for Workersncof.he DRAINS-BOOR.ROOF.AREA,COM). STORIES TYPE CONSTRUCTION
ration,as provided fm rm Section 3]00 of the Labor Csxlc,for the pertonnnnce of the
work f his permit is issued FIXTURES-PER TRAP
gR.<, ^nil will nntimain Woders Cmar eumlan Imusoso,as wrmm l by Semion
370lnl the Labor Code•motive perforrnuna ofthe work for which this permit is issued GAS-FA.SYS'T'EM-I INC.4 OU I'LETS OCC.GROUP A
Cartierr sCs>mZ��tion.lparygncec rand Policy p_-ySrpfFxY1 S$ GAS-EA.SYSTEM-OVER 4 G!AI
,GATE-OF
R� Policy No.:WORN �' /
CERTIFICATE OP SATIONINSURANCE 1N FROM WORKERS'
COMPENSATION GREASMNDUSTRL WASTE INTERCEPCOR
BUILDING DIVISION GEES
0Lis section need not he completed i l'the permit in for one hundred dollars ISI WI CIREASE'fRAI'
nr less.) as
THE
I minify that in the pertom^uce ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM PA.20117.
manner so as to become subject the W orkeK Conipen- ENERGY 1'lili
not employ any person in any m
OZ cation Laws of California.Datea WATERHEATERWNF.NT?LECTR - GRADING PI?E
Q Applicant
Ln NOTICH TO APPLICANT.IL after making this CerliOene of Hsemptinn,gnu should WATER SYSTEM/TREAFING
become subject m the Workers Compensation provision,of the Lou,Code,you must SOILS 171711:
UJforthwith comply with such provisions or this Permit shell he deemed resulted, t WATER SERVICE
0
CONS'1'RUCDON LENDING AGENCY NEW RFSIDCN'GAI.?LMB. SQ.17. PAID
I hereby affirm thunhcru isaconstmnion lendingage^c4,Tonle penurmm�cc of
[)are Receipt If
@a work on wbillidiis permit is issucd(See 31197,Cu,C.)
OU Lender's None TOTAL',
} D.I Lenders Address TOTAL:
y 1 certify that I have mad this application and state Ihat the above information is BUILDING P19i �l
F' rq corrcd.l agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEF •�
(� building construction:mth
d hereby auorize representatives ofihischy to enter upon the 1! SP.LSMICFI:E
above n mane cd property ka inspectom purposes. PERMIT ISSUANCH
(We)agree to save,Indemnify it keep harmless the City of Cupenim ugainv t
liabilities.judgments.roslmnd expenses which may in any way^ecom against said City ALTHRORADUTDMECH. J in
m,caummeofthe gra ng ofdtis it. MECHANGFEE
APPLICANT U'DE LANDS WILL COMPLY WITH ALL NON-I'UINT AIR HANDLING IINITITO I(1,(XMICPM)
SOURC° ONS. MECHANICAL fFE 1
Z•�,-O� AIR HANDLING UNl'I'(OVER INNIDCFM) CONSULT Pi'fO1P'1'AX
Sign Plicant/Con star Dam EXDAUSTIIODD(WNUCI} ~2--
HOUSING MD'IGA'f10N ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding oocupam store or handle hazardous material IIExrlNG UNIT LTO 100,003 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Codu.Sec1io^255321^)? IIHAI'ING UNIT'IOVBR 9,01(111113)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future Wilding occupant use equipment of devices which Oam Recmpl# '1- I
At hazardous air contaminants as deOnW by the Bay Area Air Quality Management BOILER-COMPURIPOR100,(101 BTU)
TOTAL:
,nct? BOILER-COMP(OVER 100,000 BTU)
❑W, No -
I have medthe hirardoas nvabrimsrequirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC17 DATE
famiu IRohr A Safety Code,Sections 25505.]5533 and 2.5534.1 understand Nat if the NEW RESIDENTIAL MECIL SQ.PC /�
building does no currently hove •tont,that it is my responsibility to nadfythe isalum ( — 27— Z �1] P
ofh_ ui�ents�s'�iiehmu met prior to isuarmulr Cmilicate of f7Rcupaacy. [(
Own autbo sal agent Dam TOTAL: ISSUED BY.
OFFICE