S 0325 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING.-ELECTxICAI. • PERMITNO,
BUILDING DIVISION API'LICA'rtON/PERA1IT PLUMBING PROJECT'IDEM IFIL S 0325
BUILDING PROJECJ'IOF,NTIFICATIO\'
SANI'INRY NO. APPLICATION Sl1Bh11'Efgh DATE
BUILDING ADDRESS: qj
OWNER'S NAME:33 PHONE: CONTRACTOR"NA I?: v 1'IC NO N/C CONTROL
MA4101 / 2f - S -7 S �r�E,t�S ❑
.ARCHITEV/ENGINEER: LIC NU: ADDRESS'.
PPr
oN'I'ACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HCDG ELECT PLUMB NISCH
❑ ❑ ❑
LICENSED CONTRACT OR'S DECIARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that Iran Beane]under Prailion,of Chapmr 9 ermaneneing
QaZ wish Sccbam7(pO)of Divixinn 3ofthe Hminess and Prolcs.ionx Code.and my license;, RESIDENTIAL
WO, PERMH'ISSUANCE ❑SPIIWL O KITCHEN REMODEL
CF m full force and eRca.
a USJ LiOaod Clue, Li"# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y66 Ua,, Conaacwr OMCIurl-UNIT OS'IRUCTURAL
ARCHITECT'S DECLARA'T'ION PANELS MODIFICATION
ZOyz Iundm'sumdmy plane shall huxcl a'Public records ITIO 200AMPS
0 ❑IN'IIROVE ❑CHIMNEY PCO
F,aO.FW Licatiod Rofes.'ioail 201-If00AMPR LN I'ROVF:MIiNT SWIMMING P(wll
d s OWNER-BUILDER DECLARATION OVER I(XXIAMI'S OBATIi REMODEI/HI?PAIR ODF OLITION
C C w 6 I hereby affirm that 1 am exempt from the Contractor's License Law fur the OTHER
jf,9 a U following reason.(Section]11]1.5.Rosiness rend Pmfcx'ione Code:Any city or county SIGNS ELECTxICAI.
1+13 LL y which acquiree a panlit it,henvlmcl.Ince improve,dmmMish,or repair any stmemre
I"u'oQ Prit t t: "trame..ho restmard,me applicant fsuch permtt file a signed statement SPECI At.CIRCUII/nISC.
S{a{�ou,, that he licensed pursuant theprovisions of the Contractor's 1 Law(Chapter9 COMMERCIAL:
COVO Iw L lh qcU' 7(KK11 fl)vie III ah Bueimes dP Psion,Code)or TEMP METER OR POLE INST.
C.a ea that he is exempt thefefmm and Ise basis for the alleged exemption.Any Oolvuon of ❑NEW 61,DG/ADDI PION ❑DIiMOLI'IION
Xm4. Semon 7031,56 applicant for.peound,ubjOes the applicant civil pemilaY of POWER DEVICES ❑THISANT OFOOD SERVICE
y any'IPP
not more than five hundred dollars
yemp. OTTA ER IMPROVEMENT
ESC ❑LothewOwner k,the he timm.Or cmyct intended withwages
red forage(Sec.sale compensation. SWI MMING I.00LELECTRIC
a
will Ao the worA,and the swcwrc is nm;Branded oroffcredfar sale(Sec.]IW,Hueineas ❑OTHER
63� enad Yr,,fsiunx Code:The CnnmaYnr's Liceme Law Jots not apply to an owner of 011fl.l?T$-SWITCIIIS-FI%'TUBE
property who builds or improves Ammon.amt who does such work himself or 0mugh NEW RESIDENTIAL ELECT, S C
his own employees,Pool that ower impnrvemenu Ire not;mends]m offend far SQ.FT.FLUOR AREA f/SQ.14.
sale.If M1uwevcp Ne ruilding ur ilnpnrvenanl'IX,nIJ within one year of complminn.lbe ^
owner-builder will have the burden of prating that he did not build or improve for pun P
,pose of sole.). TOTAL !0
Ea I,a,owner ollhc pmpe.Y,ata udir"vely cm,amling with Iwroni contractor,m
constructible project(Sec.704,1.Business and Professions Cosec The Conuactor,s Li-
se Law does not apply an owner of pmPeny who us or improves thereon.and QTY. PLUMBING PERMIT FEE
c
cn hbuilds iroves H
who contracts fnrxuch Pmjmn with euntmutnrT'l licunmd Pursumn m the Conlmanr'e /�
Liccnu law. PERMIT ISSUANCE
[YI um exempt under Sec .B&P C far this maxnn
AL'I'lilt-DRAIN&VIiNT-WA'T'ER IIiAI AI,�A'1'ION
Owner Dam //// VU
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 henry affirm under penalty of perjury one of the fallowing Jcclarvl lam.
❑Ihave rend will maintain aCerificam of Conunun xlf-insure for Worker,Cnmpcn- DRAINS-FLOOR.ROOF,AREA.COND. STORIES PAPN
suunn,nx Pmvidal lir by Section 37M of the Labor Code,for the Perforznonce of the
work far which Isis pemlif is issued PIX'1'URES-PER q'NAI'
O I have and will maintain Worker's Compem pion Insurance,as mquircd by Section
3]1X1 of the],an Cmlu,lir the performance okin,work for which this pemand is issued. GAS-EA.SYSTEM-I INC.J OUTLETS sJCQGROUP
My Worker's Compensation Insurance carrier and Policy Bummer are: GAS-IA.SYSTEM-OVER d IFA)
Carrier: Policy Nn.
CURI'IFICAIE Oil EXEMPTION FROM WORKERS GRIiASIIINDUSTRh WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(Tri,sectinn need.,,,the completed fabs permit is feaunehundrecidollas(S 100) GREASETRAP PLANCHECK FEF.
or lues)
Toy any)Kaonthelnymannro ffie work far as
suijM1 thin rhe nd Wrm""C"abld- SEWIiR-SANITARY-ST(IxM F.A.41X1 F1'. ENERGY PI]i
not employ any Peron in any manner as m henmh subject m the Worker'Compen-
z .'cion Lows of C:Jl�fnr W-Daly' WATIiR HEATER WNENT/ELECTx GRADING Irlili
zQ Applicant=L t5e�
NOTICE TO APPLICAN'P:If,ufi,r making this Certificate of EsIo Non,you'haul] WATIiR SYSTEMNREATING SOILSFEE
a ' become eabbet In the Wmker,Cmnnenxarnn provision,of the Lcemeobo Code,you ain't
..� forthwith comply with such pmviaionsor this permit shall
MdJ revoke]. W'q'1'ER SERVICE
(] PAID
CONSTRUCTION LENDING AGI7NCY NEW RESIDENTIAL PLMB. SU.FIL I Receipt X
C7)Q I hembyaffrtm deanherc iso constriction leningagencY for the performance of
[I. f•' the work lir whichthis Permit ix issued(Site3097,Civ.C.) TOTAL:
O lender's Name 'ICTAL.
(ULl Lender's Address BWLUI
1 certify that I have rend this application and state Ben the alive information is
iii. T�/z c rzcmJv agree f.cora 1h 111 cit slid ordinances and cum law,rclaingm l'Y. MECIIANICAL PERMIT FEE
e Py with yon yo Q SEISMIC ITiP
(,J •Z Building conmmction,and hereby uutboriu reprewmaiven of this city menmr upon the
above-dardamned property For inspection Purpose'. PERMIT ISSUANCE ELECT FEE
(We)agree m mac,indemnify and keep hurMus the City of Cupertino aguinxt
liabilities,judgments,conn and expends which may in x.y way arerueagainsl,aid City ALTER OR ADDTO MECH. PLUS LING FEE
in consequence Of the granting of this Permit.
APPLICANT UNDERSTANDS AND WIL AMPLY WITH ALL NON DINAIR HANDLING FIND(TO 10,000CPM) MECHAN ' LFEE
SOURCE:REGUL PNS. 'J
� a ✓. - - n AIR HANDLING UNIT IOVE IB.(XRCFM) CONSTRUCTI NTA%
QA L[I5/x-ry
SlgnaurvafApph�c.0ComEmmr One E%fiAUSTHOOD(W/DUCE) HOUSING MITI TION)Illi
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle tamrdous material 1117AI'ING UNIT(TO 100,00 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.13,aM the Health and Safety HEATING UNIT.OVER 100"NO BTU)
Code.Salton 255320)t
❑Yes 0N VEST ILXI ION FAN(SINGLE RESID) PAID
Date RcniPt p
Will the tmplicnnt or faire building accupunt use cyuiPmomtordhviceswhich I;OILER-cUMP pHP OR IOf1,INNI BTU)
emit hazardous air conaminams as delineJ by the Bay Arca Air Quality Manugenrent 'I O'IAL:
District! BOILER-COMP(OVER 110.010 BTU)
❑Yee 0N
AIR CONDI'1'IOSER ISSUANCE IJATFV
I hath mad the h ode, us materials 255 raquire33 as under Chapter rven )'her Cali-
fnmia Healthglow&Safety Code,Sections 255.5,2553?and 25504.I I nnotify the
thus If the NIiW RIiSIUENT1Al.MECII. SV.FT.
building Jos not currently hoe a¢mete that o is Illy re of
C"i m notify cc pancpard
y.
of the rcyuiremcnts which run be met prior ;,sures of a Ccrtificam of Occupancy.
� Owner or amM1orizwl ager
Dore 'I OTAL: ISSUED BY:
OFFICE