S1086 k
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO Buu.DING-ELECrRICAL PEgu r No. 1086
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL J
BUILDING PR(1JRCrIDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL ONE
' )N' CONT CTON'S NAME: LIC NO:
OW' ME` a /Q a� �_ ,a C NIC CONTROLM
7-2422
ARCHITECIPENGINEER: LIC NO: L ADDRE S: �_/ ❑
CONTACT: PRONE: BUILDING PERMIT INFO
n �y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED COM'RACTORS DECLARATION QTY ELECTRIC PERMIT' FEE JOB DESCRIPTION
I torch,aft rte that 1 r e.wd d p s of Chirped 9( +mac mg
HOZ lM1 Srct nn 7000)lot i lit Hun dPr fizvin :Cd d nlic c pEl2Ml'I'ISSUANCP. RESIDENTIAL:
in+fur furremadmtfcel �1207J� n ❑SFUWI. ❑KIICHLN REMODIiI.
a_u 1 n Claes JJ�Lic.q / JJ P�'wiL APPLIANCI3-RESIDCVI'IAL DDITION ❑PLUMBING RE-PIPIT
(-Z ate �\T Cuntrucoo-1- S
3 �- __ �ARCHITCCPS DECLARATION I MULTI-DMT El STRUCTURAL
1„ PANELS MODIFICATION
Z p N Z 1 understand my plans zhall he used as public records
OZ=O UP T02(x1nh/P5 ❑INTERIOR ❑CHIM1INF.Y REPAIR
I.iecnsed Rofessianal 201-1000AMPS IMPROVEMENT LDSWIMMING POLLS
OWNER-BUILDER DECLARATION
C C¢ 1 hereby affirm lM1ot I am exempt fmm be Qmtracmr'x License Law en the OVER 1000 AMPS ❑BATH RIiMOD1i1JREPAIR DI OLIl10N
X C W V following reason.IScerinn 7031.5.Business and Profasium Cade:Am city m enure, SIGNti ELECfRI COTTER
W W h which requires a permit to construct,other,improve,demolish,or regale any stmaure
0� pdo t t a .Nhelium,fl pph tor- llPermlu file g dsutemenl SPECIALCIRCU /MIS .
E�} that he licensed purs a thep .Io :of the C e nor 1 La (Chapter4 COMMERCIAL
-
W [core 6 th Sect 91X0) ID isi 7 fth encs dP fie.. sCtdgon TI:MV.METER OR P01,131SIT.
d y o tL that he is except Ihcref errs and the hnsia for the alleged excmpmm.Any violation of ❑NEW BLD(IrAI)Plr14ND Q DEMOLITION
W so4N. Section 9671.5 by any applicant for a permit mbjeemohmapplicant to a civil genultyal' POWER DEVICES -1 TENANT Y' W ❑FOODSERVICE
f
m more then Eve hundred dollars($510). IMPROVEMENT E has owner of the progeny.or myemployees witty wages as their sole compcnvtion, SWIMMING POOL ELE IC
[- will do rhe work,and theswcrure is not intended oro8ered forsale(So .9004,920s�
......s ❑OTHEWOV 1
C 3 m and Professions Code:The Contractor'%License Law does not apply to an owner of OUTLETS-SWITCHES-PI TU �M ��11LLVV
pmpeny who builds or Improves thereon,and who does such work himself or through
his own entpluyces.Provided that such impmvemmnta ore net imcndcit or u111 1 hx NEW HHSIUENTIAI.EI.PC'I'R S
774
sale.¢hmx n me building orimprovement is sold within one year rfdm+plear.. S/SQ.<T.
owner Wdder will have the burden of proving that he did not build or improve for Put-
,,o,m sale.)
❑1.as owner of the property,am exclusively mnuacting with licensed contractors to
mama the project(Sec.90,11,Business and F'rofeszions Ede:)The Contractors Li-
cause Law does not apply to an owner of property is ho builds or improves moment,and TY PLUMBING PERMIT, FEE
who conmmu boosted Projects with a commemn,)Poor..W gl rsumat to the Conm+etor's
Licence Law. FERMI'r ISSUANCE
El 1 am exah,a under Sec. .B&P C for his rearm
ALTFR-DRAIN&VENT-WATER(EA) VALUATION
Owner nam
WORKER'S COMPENSATION DECLARATION' PACK PLOW PROTF.CI'.DEVICE Q ��
1 hand waffirm under Certify oe perjury one of the insure for donates Co
various
as and will maintain Certificate of the LabrCusinsur the Workersce of th- DRAINS-FLOOR.R(IOIi AREA.GOND. STORMS TYPECONSTRUCTION
evti Is l , provided for ea Section,Isu79100 of the InMsr Coslc,fur the perfnnnuncc nil the
work for which his gennh is iwwar "SANITARY
-PEH TRAP
❑ 1 have and will maintnio Worker's Cnmpensetion Insurance,as required by Section
79(X1 of the WMnC the performance of Nc work fnr which this permi is iawcJ. YSTEM-1 INC4UN"LET. 51000 nPN
M WnrkersC Insumr+ce cartiw and Policy �y .�y./f [� SYSTEM-0VER 4(EA)
ec� PufiicY No.�✓" OfJyJ'
TIFlCO DF1SNFIO INNFROM WORKERS' DUSTRL WASTE,INTERC PB)H
COMI'F:NSA'TION INSURANCE BUILDING DIVISION FEES
Olokwotiun need mnbemm+plciediDbcpcmetls 1bnecbunereddnJaes(51010) AP
'T
loss,)
Loy a.,that in toe of maniciffthe aryeahoo,-loo, delk lla wbicahis varshe W is issued. ahal I- ANITARY-$'TERM FA.20)FI'.
no,employ any person in anY onunncr sn vs n+h aloe subject it she Workeri Cnm{em ER .. �
Z scion Laws of California Dam ATER WNENI' LECR
zC) Applicant I GRADING FEE
cO NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTENVE BEATING
become subject it) Worker,Com sution f the LoMm Cade,you Ired
SOILS PF:E
J goo. promnumau
fnnhwith um+ply with such pmviaione nnhis permit mull he deemed mvokcA. WATER SERVICE
0
7z CONSTRUCDUN LENDING AGENCY NEW HESIDENTIALPIN B. SPP[ PAID Uate Receipt
L) 0 Iherchy arfirtn d+auherc isacnmwdinn lending agency file doe performance of
D. — the work for which this permit is issued No 3097,Civ.C.)
V Led Name
TOIL\h:
r Lead,Addox,,
is f
1 rely that l h' 'e this application and state that the ab f 't + MMECHANICAL
F. y ren r 1 tame to comply with all<IY cold county,re nun.e tad state laws ml ll+b to -�TY �MECHANICALPERMIT -FEE
V Z building construction.and hereby authorize representmlves of this cimso enter urysume
abtnc-mentioned property for inspection purposes PERMIT ISSUANCE. E.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmems.costs and espcnas wIt °Jaym y waymcniertgaind said City ALTER OR ADD TO SUCH. -E
osquenecufrhegmnting to
pe df/
APPLICANT UN 'TANDS A ' 4LL MPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(1010.00CFM) THESOURCER ONSNNIIANULIFGUNII'((IVL?H In,fXN1CIsM) (yN'fAX
amrcnfA+plic, onovctor Date EXHAUSTHOODM'/DUCT) HOUSINGMTOGA1lONFEE
HAZARDOUS MATERIALS DISCLOSURE
dElIhe applicanror future building occuWnt store or handle hazardous material HEATING UNIT(TO 1(X1.000)BTU)
as defned M1y the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25572(a)'? HI!APING UNIT(OVER 1X0.01(1 BTU)
p Yc,a ❑No V,rfILA'1lON FAN(SINGLE RESID) PAID
Date Beattie p
dft W+11 the applicant or fume building occupant use cgcipmem or device,white BOILER-COMP(JHis OR 116.(0ID BTU)
emit hazardous air contaminants a%defined by the Bay Area Air Quality Managemem TOTAL:
DistncR BOILER-COMP(OVER 100.000010) _
❑Yes 0 N
I haemad the hlrsallousmamnalsrc Ire C1W 6.95tdnbe Cull- AIR CONDITIONER ISSUANCE DATE
quir
forma Ileal ,&Safety Code.Semite,25505,25517 rod 25574.1 understand into if the NHW RESIDENTIAL.MECII. SQ.Fn
building does not currently have a tenant.that it is my re,andi ility to notify the occupant
of the myuitc ado s which must be met prior m issuance of a Certificate of Occupancy. �X ,
Owner or authorised agent Dae .1. ISSUED BY:
OFFICE