S 1883a
a
CGI CANTTO F!L IN INF0RMi1 fou WTUIN RPD I INFc - 11SE HALL POINT PEN ONLY
CITY OF CUPERTINO
Bull)ING - ELECTRICAL
PLUMPING -MECHANICAL,
PEECp1IT NO. 1883 $ 3
eV
BUILDING DIVISION APPIACATION/PERMIT
BUILDING PROJECT IDP.N'r1FICATION
SANT TARY NO.
APPLICATION SUBMIT IAL DATE
BUILDING ADDRESS:
a Co la,,,yy- v7-
z o
IRAMDR.'S NAME, LIC NO:
'IL�J�
NIC
CONTROL#
T
❑
ARCHITECT/ NGINEER: LIC NO: ADDRESS:
CONTACT: ('Y PHONE:
BUILDING PERMIT INFO
MI'❑CH
rs�r� �
❑ Cunsullan[ Fees Paid by Applicant (lolling
PLUO /' fiRECI' PLUMB
!�✓\ i
Irk✓
• LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF.
JOB DESCRIPTION
1 wily affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70NE of Division 3 of the Business and Professions Code, and my limme is
PERMIT ISSUANCE❑SFDWL
RESIDENTIAL,
in full force force (effect.
(] KITCHEN REMODEL
License Class Li, it
APPLIANCES- RESIDENT] [Al.
❑ADDITION ❑PLUMBING RE -PIPE
Da¢ Cnnitacmr
RAL
❑MULTIANIT MODIFICATION
ARCHITECCS DECLARATION PANELS
1 understand my plans shall W used as Public record.
Oil T02W AMPS
L1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
Licensed Proc,sioral 2111-4000AMPS
OWNER-BUILDIER DECLARATION
OVER IMO AMPS
❑ BATH REMODEUREPAIR❑�DEMOL"�D'[ON
I hcrchy affirm that 1 am exempt from the Contractor's License Law lr ithe
[I OTHER
following reason. (Section 7031.5, Raciness and Profex,max fide: Any city or county
SIGNS ELECTRICAL
LJ
T/ V w
-
j which requires a .are commit, akar improve, drat IM. or repair any to m m
priormitsissuance, also requires the applicant for uch permit to file a signed statement SPCCIAL CIRCUIT/MISC.
that he is licensed pun min to the provisions of the Conoacmes License law (Chapter 9
COMMERCIAL'
(commencing with Section]IX01 of Division J ofthe Business and Professions Code) or
'1' EMP. METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
that he is exenim therefrom and the hasis for the alleged exemption. Any viclmioa of
Section 7031.5 by any applicant lar it permit eahjetslhe Lpplicant to a civil pmthy of
POWER DEVICES
[]TENANT ❑ FOOD SERVICE
not mune thus five hundred dollars ($500).
IMPROVEMENT
I, as owner ofthe progeny. or my employees with wages as their sole compensation,
SWIMMINGPOOLELECTRIC
❑OTHER
willdo the work, and the swtum is nut imm�ded oroffcred Towle (Sec. IDN, Business
ranls License Law ds not apply an owner of
o and Professions Crile: The Comndoes m
(IID'LFTS-SWITCHF'_S-FI%"I FIXTURES
property who builds or improves memom, and who does such work himself or through
his wn c..... ccs, provided that such improvements are oat intended or offered for
NEW RESIDENTIAL. ELECT, R SQ FT.
SQ. PI'. FLUOR AREA
$ItiQ FL
sale. If, however. the building or lniprovcmeol is sold within one yearofcompletion.the
owner -builder will have the burden of proving that he did not build or improve for put -
of
L as owner of the progeny, nn exclusively contracting with licensed contractors to
TOTAL'
wouun the project (Sec. 70Lt. Invitees and Pufcasdns Cade:) The Commmor x Li-
cense Law doenot apply to an owner of properly who builds or improves thereon, and QTY, PLUMBING PERMIT FEE
s
-
who comtactx for such projects with a enurucmgs) licensed pursuanum the Contractor's
License Law. ti
PERMIT ISSUANCE
El I am exempt under Sec. ,B&PCfortio mon
AUTHR-DRAIN & VENT- WATER (FA)
ALUAFION
Ow
Ek' CO PENSAT N DT:CLARATION
BACK FLOW PROT'[CI'. DEVICE
Q Q
I I hcrchy elan under pcnahy of perjury one of the fnlhswing declarutinns:
❑Ihave and will. nwinuCenificateofConsenuoself-insurefor Worker's Compen-
DRAINS- FLOOR, ROOF, AREA, COND.($I
1 PECONSIRUCTION
L
satins, as provldcJ for by St 1700 of the labor Cn le, for the performance of the
work for which this permit is is ord.
PI%TURES - PER 'I'RAP
Y Vi V ur u o r u
1 have and will maintain Workers Compensation Insurance, as required by Section
J7W of the labor Code, fonhe perlisrmance of the work for whichthis pimriti,tomed.
GAS -EA. SYSTEM -1 INC.4 OUTLETS
tauC APS1
My Worker's Compensation Insurance easier and Policy number are:
GAS - EA. SYSTEM OVER 4 (EA)
Cartier. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRIiASFJINDUSTRL WAS'1'F. INTERCEPTOR
COMI-17NSATION INSURANCE
B IF GDIVIMONFITTS
This section need not bcnoomicom lithe permit k-forcmc hundred dollars I$ IW)
GREASE'1'RAP
PLANCHECKP '
or less)
ENERGY FIB
I certify that in the penfomtxnecof the work for Euchlhi, permil is i ... rd.ldull S12WER- SAN ITARY- STORM EA. 200 ff.
not employ any person in any manner an as to become subject to the Wormcs Compcn-
GRADIN
snion laws of Cnlifonria. Dam WATER HEATER WNENT /ELECTk
Applicant -
SOLI. FE
iNOTICE'TO APPLICANT: If, after making this Certificate of Exemption, you should WATER SYSTENUTREATING
become subject to the Worker's Compensation prnvlsions of the Labor Code, you must
fonhwilit comply with such provisions or this permit shall he demnedovoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB. SQ. Ef.
PAID
])are Receiptp
� (hereby affirm thm them isaconntction lending agency forthe performmce of
TOTAL:
the r which this permit is issued (See.1W7, Civ. C.7
Lender'sN
Lendder's u.e
Lenders Address
TOTAL:
BUTIiE
U
L, I ecnlfy that I have read this application and slam than the above Inl'onnutioo ix
n coma. l agree to comply with all city and county ordinances and stale laws relating to QTY, MECHANICAL PERMIT FEE
building conunrclan, and hereby noncom reparommiives of this city to enter upon the
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
E
(We) agree to save, indemnify and keep harmless the City of Cupcnito against
FEE
liabilities,judgments, costs and expenses which may in any way accme against said City ACT ER OR ADD TO MECH.
in consequence of the granting of this permit.
ALFEE
AP LICAN'1' UNDERSTANDS AND WI OMPIY WITH ALL NON -POINT AIR HANDLING UNITTTO IkOW CFM)
S(' CE REGULATIONS.
TION TA%gnawren,
AIR HANDLING UNIT (OVER I0,0(M) CFM)
plicanUCmmmcusr Doc
FXBIAUST HOOD(WIDUCD
TIIGATION FEE
HAZARIH)US MATERIALS DISCLOSURE
Will[ .applicant or(munt hLllding occupant store or handle hazardnax nnnerial HEATINGularr(lobill,UBIBTU)
ae eM1y the Cupertino Municipal CuJo, Chaplcr 9.12, and rhe Health and Safety
Codde,, Seeeetinn 25532(a)7 III:ATING UNIT (OVER loq(XNI B'TU)
❑Yes 0 N
VENTILATION PAN (SINGLE RESID)
PAID '
Date Receipt #
the applicant or far.. Wilding camapant use equipment or devices which
BOILER -COMP (3HP OR 100,000 BTU)
IWill
emit hazardous air connotations as Ikfined by the Bay Area Air Qualify Management
TOT
District?
BOILER -COMP (OVER 103,1100 BTU)
E] Ynx ❑ No
ISSUANCE DATE
AIR CONDITIONER
I have mud the harallou.u.mcrials requirements under, Chapter frit the Cali-
fomia Health & Safety Code, Sections 25505. 25537 and 8574. 1 understand that if the
Wilding does not currently have a mann, that it is my responsibility to rtdfy the occupant
NEW RESIDENTIAL MECH. SQ. FL
of the require.ems which must be met prior to issuance of a Certificate of Occupaty.
155UIiD It Y: 0
Owner or umhmrired agentDate TOTAL.
OFFICE