130429APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO . BUILDING - KLEC'FRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.-MECHANIC.AI.
' IIf11LDINC I'ItOdi?CI'IDRNI'IP'ICATION - 1
PERMIT NO.
-8'4999 Q
BUILDING ADDRESS:
LoGy>2� t=c-�-
SANITARY NO.
APPLE CA ION SUBMITTAL DATE
s--z-a-fy
OW ER'SNAME: ^ 1 PHONE:
CONTRA OR'S NAME: LIC NO:
NIC
CONTHOLR
rAe/lXnJrr/Ltr llnor..-
❑
A E TBiNGINEERLI
A -DRB
R /
ONTACE PHONE:
rBUILDING
PERMIT INFO
'
C1.�1-.+
❑ Consultant Facts Paid by Applicant (Initial)
BLDG ELLECIT PLUMB MECH
LJ LSI ❑ ❑
LICENSED CONTRACTODECLARATION
I hereby affirm ohm um 1 littmcd anti visions of Chapter 9 (commencing
with Section 7f)(Knof Division 3oflhe Business and Pmfedons Code, and my license is
in full homeland ellen.
Clan. Contractor
U
QTY ELECTRIC PERMIT FEE
1013 DESCRIPTION
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
El ❑PLUMBING RE -PIPE
❑S'I'RUCTURA1.
MODIFICATION
HRIOR ❑CHIMNEYREPAM
pWZ
4100
C W C)
rZ�J1enxe
m6y❑MULTI-UNIT
p -pm
pr
7Zo)�-
PERMIT ISSUANCE �S
APPLIANCES
1 11'ECI•S DECLARATION
otic. x' nl coxed ue public rca�rds
PANELS
UI'To 21X1 Anfl'S
q
r/r�W
:C
<Og U
i Oye
y .]
x•+00
I, y e a
YXJ 4th,
�ZQnot
�px.,e
6 3 ro
fMPROVRM,N'I' SWIMMING P001.5
❑ BATA REMODEVRHPAIR ❑UFMOLITION
❑ OTHER
_
I en eJ Iesn na
O HR -BUILDER DECLARATION
I hereby uflinn 1 t I am exempt from the Contractor's license Lew for the
[allowing reason. I5ee1i n1U31.5,Businessand l'ndeainns Code: Any city or county
cnnslc6 alter, improve, demolish, or repair any structure
which requires a permit m m
prior to It issuance, also requires the applicant fnr such permit m file. signed smument
u the provisions at the Contractors License Law Watiser
that he is licensed pursuant 9
(exmmeodngwith Section 100(anf Divisinn3(lithe Businessand Professions Code) or
that he is exempt thereamen end the basis for the alleged exemption. Any violation of
Section 70315 by any applicant fur. permit subject the applicant to. civil penalty of
more than rive hundred dollars ($500).
C] has owner ofthe propeuy, army employees with wages as their sole compensation.
will do the work, and the sanctum is not intended or offered for sale (Sec. IDN, BusinessOLO
and Pmfcssions Cale: The Cnmmnnrs License Lew does not apply to an owner of
prapeoy who builds or improves themon, and who Jens such work himself or through
his own enplayas, provided that suchimlmvemen,s arc nm intended or olTemd fur
aide .If, however, the buildingor improvement is sold within one year of completion. the
201.101MAMPN
GVHR IINNIAMI'S ',
SIGNS EhIiC'fItICA1. -
SPECIAL CIkCll 1'1'IMINC.
'TEMP MGIHR OR POLI: INS'F.
COMMERCIAL:
❑ NIiW BLDGIADDTI'ION ❑ DEMOLH ION
.NA NT ❑POOD SIiRVIC[z
I ROVEMINT
❑OTFIER
POWER DEVICES
SWIMMING POOL ELF
OU'r1.ITS-SWOCH S T 0
NEW RBSIDENI'IAi. ELF.CTR
SQ. FI. FLOOR AREA
$/SQ. PT.
owncobuilder will have the burden (if proving that he did not build cr.iminavc for Far-
'TOTAL: SV
Firm
El 1, in owner of the pmperty, am exclusively contracting with licensed cammro,s m
rs
buidsoriproCommeon.Li-
cause La lhoes jmllNly town wnerofprness and
prty who
ttlsamen,f ntapplyman nwnerommenceyweconodJs..a.[ to es thelhercan,and
who a,mract for such Irnjuls with o asmrecmrts) IicenuJ pursuant m the Contractors
QTY.
01
PLUMBING PERMIT FEE
_
License Law.
I vm exanll under Sec. . B & P C for this recon
1'IiRMIT ISS
r
!��
ALT[R-DRAIN-WATIi I:A7
Owner Data
VALUATION
WORKER'S COMPENSATIONllyop DECLARATION
Thereby nRrm under penally of Perjury, turntable lollnwin6 Jedamtinns:
have anti will maintain. CeBhic.te ofCauseln to self -insure for Worker's Compen-
sminn, as provided for by Scclion 31118 of the InMm Code, for the performance of Ito
walk for which this panni, is issued.
RACK FLOW rROrF:(.T.I .li
DIIAIN$-PIAON,H NDA,. D. �-
STO Ifti
'IV PH CONS'fRUCfION
FIX 'I'ORHS - PER 'I'RAV
GAS-BA.SYS'IHM-1 INCAOII'1'LH"'
❑ 1 huvo and will maintain Wmknr's Conlpe(leoon Inmraneo, it, required by Set inn
3400 al Its, Lubar Co.]., fill the per4nal of the work far which this pecan is issued.
OCC. GROUP
MIN
My Worker's Compensa,iun Insurance carrier and Policy number am:
Carrier: iPolicy No.:
- 1
�r�J
��,�CERTiFICATHOF
USTRI. W , Bi INTERCEPTOR
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION TH IS
O z
Q
L)0
LG —
OU
r W
Ps
ice-" rA
VZ
(This section need not bemmpleted ifthe permit is for one hundred dollars($)BILI
less.)
certify that inthe per4srmanceofthe work f.. which this permit is I...ed, Is Ball
employ any person in any mannerso as m became subject to the Workers'Compcn-ENERGY
smionLuwsofCa fornia.Date
Por
PLANCHECK MiL /67. 4S'I
KCiAN-17,A.SYSD7M-OVIdR4S'DiM-OV1iRJ
1'fARY-S'IORMEA.2tXIFT.not
WiE ssIQ
ERWNENT/IdAiM'R
E TREATING
GRADING FEE
Applicanth NOUCE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compenmtion provisions (lf the Labor Code, you mustfonovall comply ximinch provisions or this pecan, shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
Thereby afbnn,hvnherc isamnamnienlenAing agency for performance of
the work for which this permit is Noted! (Sec. 3091• Cl, C.)
Lenders Name
SOILS Ff:E
ICH
PAID
Dam Receipt 26-
b
NEW RESIDENTIAL 1'Ia11f. SQ, FT.
TOTAL.
TOTAL:
-
Lender's Address
info(ln is
BUILDING FEE ��] 7, QO
1 certify that 1 have read this application and smle that the abovemtati
correct, l agree to comply with all city and county ordinances and state laws relsang m
buildingco,mm(iotmal heady:mthoriaa mpresema,ivesofthis cityme"aerupon the
abose-memimoll Inrpeny far inspection Imposes.
(War agree ill save, indemnity and keep hanaless the City of Cupertimi.pumsl
Ilabilitics,judgmems, corm' anti expenses which "lay in any way accrue against said City
in omooryence of the g, I ingol has permit.,
APPLE' T II�`DE }} US ANU WILL COMPLY WE 111 AL4NONP
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE .50
PERMIT ISSUANCE 3
ELECTRIC hili ST 517
A1D!RORA,,TUMHCH, �. xf
PLUMBING PEE
AIN HANDLING f1N1'1'ff010,1X10CPM)
ML'CIIANICA1,11113 5-0
SOU IIi1.it NNAIR
HANDLING UNT(OVEIt 10,01X1 CFM)
CONSTRUCT ION TAX
*District?
ga • fA phont/Ca armor
IIA' , RDOUS MA'IHRIN 9 DISCLOSURE
Will the ulllica" mfmuto building occupant store or handle hazardous mammal
us defined by the Cnpertmo Municipal Cale, Chapter 9:12, and the Health and Safety
Code, Sectio 25532(.)',
[D Yes ilf,vo
Will the applicant orfuture building occupant use equipment or devices which
emit havardnus air contaminants as defined by the Bay Area Air Qualify Management
EXHAUST' I IOODIW/DUCT')
HOUSING MI9'IGAIION FEE
_ _
IIHA'1'INGDNITIrOI(X),DXlll'1'U)
fIEATING UNIT LOVE IlN1,IN1I111TU)
y~�
PAID Datakeceiptx --
VENTILATION FAN LIN NG LH RCSID)
-. BOILER-COMP(JI3P OR 100,M) BTU)
_
TDI'AL: 571-0
BOILER- COMP (OVER 100.00 BTU)
/
❑Yes 71<- ,
AIR CONDI'HONER
I imvc reed the laved PIus .1not,mquiremems uMcr, Chapter rom of the Cali-
forma Heal d Se rte 25585, 2553] and 25S3J.1 a c ply, WI if Ne
building di Io cf,re FYI a mmu. that it is my responsibility) otifY Ie avupant
ofthG ria to kwar"ce of. I tent ray.
` — li DATE
LJ lam/
ISSUED BY: �+�� �" � '�'t
NEW RESIDENTIAL MECH. SQ. FT.
_ TOTAL: 9U•S x7.
Oarmul- Ihnrirde cm note
g
OFFICE