S 0124 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO,
BUILDING DIVISION APPLICATIONXERMIT PLUMPING-MECHANICAL 0124
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANIT'A14Y NO, APPLICATION SUBMITTAL DAT]
Il �[ Scl h f
. OWy f''S NAME ` r PI10NP � O CONTRRACTOR' 11ddS AME: LIC 0.�
`` .-GG]] ^ ` f l NIC CONTROL p
RCHITECT(ENGINEER: LECNO: ADDRIiSS: ❑
��u ��� �...II Srd•7" �rsiie
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT E'l.0 B MUCH
LICENSED CON'rRAMOR:S DECLARATION QTY ELECTRIC PI7RMIT FEE E:1 El
I hereby affirm that I am licensed under provisions of Chapter 9 Uommcndng JOB DESCRIPTION
C eeZ withSeminn 7(Igtl ofDivision3ofthe Bueiness and Pmfcxxinns Crde.and my license ix RESIDENTIAL:
Fo� ' full font and efl'ecl (( l '� PERMIT ISSUANCE! ❑SP)WI. ❑KIT'Cl IEN REMODEL
=_F- License -�b Lic.0 J
aUZU L Class APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
.Pec, Data _iU Contractor
H Drn ARCHITECT"S DECLARATION PANIJti ❑MI11.T1-l1NIT ❑STRUCTIJkAI.
y1Z 1undersand my plans shall be usnl as puhlic record. MODIFICATION
pZ p IIP T021p AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional exempt
20110AMPS IMPROVEMENT QSWIMMING POOLS
6
a OWNER-BUILDER 1 hereby nflirm that 1 inn exmnpr Irmo the Contractor's License law for the OVER HAW AMPS ❑IIATfI REMODEfJREI'Alk DEMOLITION
3O6 UF following.,air.(Section 7031.5,Business and Professions Cale:Any city m county SIGNS ELECTRICAL �fOTHLIi
411;Fyy which requires a permn m construct,alcor.improve.dcm.bah,or repair any xtmnure
N¢ prior to its inumnee,also reyuircsthe applicant rim such perntit to rile a signed statement SPECIALCIRCUIT/ SC.
f }•..11 that he is licensed pursuant to the provisions of Contmnnrs License Use(Chapter 9
(commencing with Section 700)of Division 3 of the Business and Professions Code)or TEMP.METER POLCINST COMMERCIAL;
a o e• that he is exempt therefrom and the basis I'nr the alleged exempBnn.Any violulion of ❑NEW DI,DG/ADDITION ❑DEMOLITION
-^,Y Section 7031.5 by any applicant fora permit s1nhjeasthe applicant to a civil penalty of POWERICFNANT_S ❑TEFOOD SERVICE
�Y not more than five hundred dollars($SWI. IMPROVEMIXI
sit []I.as owner ofrhe property.or-my employees with wages as their sale compensation, SWI ING POOL ELECTRIC
C Sp will do the work,and the structure is nm intended manatee for salefi—I.—I..usinees ❑OTHER
W k and Pmressions Code:The Contractor's License Law Ames not apply to an owner of TUTS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended nr olTeml for NEW NISIDI!NTIAL T:LECfR SQ FT.
sale.If.however.the building or lntproventent is sold within one ycaraf emnpinlon,the Q.FT.FLOOR AREA $/$Q.I']'.
owner-builder will have the human of proving that he did not build or improve for put-
- Pmole.)
I,m owner of the prnpeny,am cxdusnaly common,with licensed contructoo n, T(YfAL:
c.nslmn the project(Sec.70,14,Business end Professions Code,The Come......Li-
eenseLaw does mnapplytoanowner in prupery who builds or improves Rancor,and QTY, PLUMBING PERMIT FEE
who counters for such projects with a contmctnrls)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE.
❑1 am exempt tinder Sm. .It&P C for this reason
Owner Data
ALTER-DRAIN&VENT-WATER(UA) VALUATION
PAID
WORKER'S COMPENSATION DEte follow ON BACK PLOW I'R(YI'UQI'.DI!VICF,
I hereby al mai under penalty of pe jury one of the following declarations:
Ibave and ned!far by Se Certificate of the Latour
sal Linmrche far iWorkers Conifer. DRAINS-FLOOR,ROOF,AREA,COND. ST(1K1115 T'YI'Ii CONS'1'RUCI'IOD
s tion m pow a th for by Section 37W of rhe LuMa Cale,for the perfnnnance of the nM �1A
�J��((((IIII k
have
and this Accede is issued. FIXTURES-1'ER'iRAP
I M1ova and will maintain Workers Compensation Inxuana,as requital by Section
Weft La r odgfnn pc qurmanttmthcwmict' whichmis permit is issued. GAS-I!A.SYSTEM-I INC.40UTL1!TS f�fa'y(Y1y� f1f,Y�q
My Wer r'x m ensmion [Policy // �/'� (�11I I I'Uf (vV t`H'I IIPIlY1 N
Currier: •a'^ mm Polley Nn:&WE•'{ bi 1 GAS-HA.SYSTEM-OVER4(EA) _
CERTIFICATE ntrlY LXfMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASFIINDUSTRI,WASTE INTERCEPTOR
BIIILDINC DIVISION PCES
(This section Iced not IN,mmplemAif thcpermit is hsrone hundred dollars IS 100) GREASE TRA['
orless) PLANCHECK ItlJi
I certify that in the performance ofthe work for whichthlspeman is issued,Is hall SEW17R_SAN]rARY-STOR M UA.VIII Fr,
not employ any Personin any manner so as to become suhjecno the Workers Cam n- ENPRGY FTSE
� zsada.Laws of California.Date WATI7R HEATER W/VFNLEiLECfR $
ZApplicant ` GRADING FEE
to) NOTICE ID APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYSTEMTHREATING SOILS ETF,
a [' hocomes d,ject m rhe Workers Compemodoe provisions of the Labor Code,you must
fonhwlthinot with such pow...ane it,this permit that be deemed revoked. WATER SERVICE.
0. La
CONSTRUCTION LENDING AGENCY NEW RESIDI!NTIAL PI,MB. SQ.FT. PAID
V 0 [hereby affirm that here iso nmstmdion lending agency lin the performance of Rdcelptk
the work for which,his permit is issued(Sec.3097,Civ.C.)
0 U Lenders Name TOTAL:
Lender's Address 'TOTAL:
firs a 1 cenify that 1 have read this application and state than the above information's BUILDING PER
correct.l agree in comply with all city and caunty ordinances and state laws rending to QTY. MECHANICAL PERMIT
U nuiWing amstmmion,and herehy authoiim repreeettewcs ofthiaci,y men,erulsn the SEISMIC FEE
tlehve-mentioned property for inspection purpnees. PERMIT ISSUANCE!
(We)agree to save,indra mify and keep bloods,the Cay of Cupertino against FLI!CTRIC FEE
piobiliden,judgment,comand expenses which may many way a<cmcagaim..,it City ALTER OR ADD TO MECIL
to seyuenee of the gaming afthie perm,. PLUMBING FEE a
AP e LI 'ANT UND STANDS AND WILL COMPLY WITH ALL NUN-POINT AIR HANDLING UNIT(TO 10.010 CP
S( IP:EREGUL IONS. MECHANICAL FEC
'1�I/_4 AIR HANDLINGUNTT(OVER 11 pI1 CPMJ CONSTRUCTION'p'AX
Signature of ApplisC Contmcmr r Dam EXHAUST H(IOD IW/DDC HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURli
Will the applicant.,future builiingsncuientsmre m handle hasnnlous matedol HEATING UNIT(TO/11-x)BTU)
as defined by the Capone.slums,pnl Code.Chapter 9.12,and the flealth trod Safety
Cale,Section 25532(x17 IIRA'I'INC,UNIT ER 101)g)I 11'I'll)
El Yes ❑No VP,NT]LATI FAN(SINGLH RESID) PAID
Dam q!51(I
Will the applicant
ar or furore building occupant use equipment or devices which BOILE -COMP(7HP OR IIp,000 BTU[
in,hneardous air conmminama os JcOnN by the Bay Arca Air Quality Management TOTAL:
DishlcIt I ,ER-COMP(OVER 1100,0110 BTU) _
❑Yes 17 No
I have mad the htomilm.s materials requirements under Chapter 6.95 of the Cali- AIR CONDIITONER ISSUA CIi UNIT
f0mia Hcaah&Softy Cole,Sodium.that i 25533 and 25534,p understood mut if the NEW RFSIDIiNTinl.MECII, SQ.FT.
see Havidsn SafetycomeCode.Sections
25505.
ait is53ory res it 2553llty uderfy td that IpareToa
of the tequimmenrs which must he mer prior to issuance of a Cenificam of Occupancy.
Owner or autnniacal agent Data ITOTAL: ISSUED BY:
OFFICE