B 0296APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO NUILTIN -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT' PLUMBING MECHANICAL
IIUIIAING PROJI?(-TJDF.MCIFICAI'IIIY' )11�:. -'
PERMITNOQ 0296
50001
Buff. LNG ADD ESS.
J
SANITARY N(1.
APPLICATION SUBMITTAL DATE
�'l10 ��
OWNER'SMi:R's6r 49L'1lC'NO:
CONTRACCORSNAMH: tyl "4.S3
v
N/C
❑
CON TROL#
ARCHITECT/ENGINEER: T/HNGINF,ER:
ADDRESS:
CONTACT: I'IIONF.:
i'_.+ !, "I"'BUILDING PERMIT INTO,. ,
BLDG ELF.C'r PLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
El,
LICENSED CONT'RACTOR'S DECLARATION
IM1 by R mtI coxed node p saf Chapler9 !comm) cog
wim5 i ](NKII I'D"' J fmc lfuei land ysln c. YLa.
in tall face n JcBull 'w 4 LL`y'
f- All if
QTY. ''' ELECTRIC PIiRhlll'- ' FEE �!
... a.. .. i '�"/ .�.I'.
JOB DESCRIPTION
RE
DWI. ❑KffCHFiN REMOIIIiI.
PHRMI'IISSUANCIi
APPLIANCES-RESI1adsU IAL
License.�Clu�.v� l��p Lic.#
DaleC DnrclorA J.
El ADDITION El PLUMBING RE -PIPIT
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
ARCHITItCPS DELL AT]O
, rordx
1 a ulto,und my plans shall he used as pu u
-
PANELS
UPT02WAMPS
Licensed Pnffcssinnal '
201-1000AMPS
O
I hcrchy affirm llWNPR-BUILDER DECLARATION
- tpl I nm excntpn from the Cantnmuds License haat far he
fallowing remon. (Section 7031.5, Brune,, and Professions Cade: Any city or manly
❑ BATH REMOUHIJREPAI DIJI:MOLwSr
Rfir'
OI HER R -/ ���—
OVER IfIlN1AMPS
SIGNS ELECTRICAL
which requires o j,cm it m construct, like, improve, demolish, or repair any mmcumcot
SPECIAL CIRCUI r/MISC.
poor to its issuance, also requires the applicant for such peroll Bleasignetl stetonent
that he is licensedpm u ni n. the pooriom of the Comrecu,rs Liccnu lsw (Chep'.
(commencing wish Semirn]OOOpd Divisi�n JoRM1e Nosiness anJl'rofe=(s C.vJe)or
that he is esemp( therTrrom and the bests for me alleged esentp(ion.Any violution of
TE-NIRMEfHRORPOLEINST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Seetiom7031.5 hyeny applicant for a Perini( subjects the applicant to a civil penalty of
POWER DEVICES
❑TENANT ❑ FOOD SERVICH-
unm0M(him l i.e lmndmd dollars ($50(b.
El I, as owner of the Property, ortoy employeeswill] wages as (heir sole compensation,
will do the work, and the structure is not intended modeled ]or sale (Sec. 70*1. Imoness
IMPROVEMENT
C1 OTHER
-
SWIMMING POOL. EL IC
and Processions Chile: The Contractors License Law does not apply to con owner of
OUTIJU S- SWITCH RES
NEW RESNENTIAL ELECIR SQ EI'.
properly who builds or improves thereon, and who dots such work himself .r through
his own employees, provided that such improvements arc not intended or oRered for
sale. If, however, the building or improvemen( is sold within one year of complaion,tho
SQ. .II - HAr.
$/SQ. EI'.
wnerfiudder will have the burden or proving that he did not hadd or improve liar par-
-
�pae0
❑ 1 f IM1 p t.'e'tr : IY m r y id :)Thud )macer
JUL 0 g ANS D
consumer d Ill Ib ]aw B .. a m r �:' n: Code:) TM1T crntmcu, 1
can La d l apply to fp peat h milds or improves theme d
who c tenets for such prtfec( with a commad,$) licensed pursuant m the Circulators
f., - - . .
QTY.•, r PLUMBING PERMIT 1, �' "FEET
s 'I_
GIIY Ur l urcn I HVU
'
PERMIT ISSUANCE
License Law.
1 nm exempt coder Sm. . If & P C for his naol
Date
AL I 17 -DRAIN & VENT- WAIIIR CA)
VALUATION
'
Own
WORKERS COMPENSATION DECLARATION
BACK FLOW PROTECT. UI!V ICF.
1 hereby aRnnantler penallty of perjury one of the following declarations:
STORIES
'1'YPii CONSTRUCTION
Workers Compel
netion 3700of Ce Labor Code, for
❑[have and provided
smirk, as pmvlJhi fpr by Section 3]1X1 of the Labor Code, far the penommnco of the
DRAINS - II,OOR, ROOh.ARIiA, GOND.
fur this permit it issued,
FIX '1'UHF.S-PfiR TRAP
1 have and will olle,f n Worker's Compensncoccofthe w rk bar me, i required by $action
01 .,,,I
J]Il(lotIn, 1,nMn Cade, far the per the work lirr wM1ich this permit is ismnl,
GAS-HA.$YSTEM-I INCA (Il]TLETS
OCC. GROUP
ANN
- GAS - EA. SYSTEM-OVIIR 4IEA)
My Worker's Conmcnamlon Insurance cagier and Policy number are:
Carver Policy Nn:
_
GREASFANDUSTRL WAX[ E INTERCEPTOR
CERTIFICATE OF EXFMPr10N FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION IFES
(Thissemiollialor heemnplend ifthe permit is: sr enc hundreddalfos($100)
nr leas]
GREASETRAP
PLANCHECK FGIi
SIiWIIR-SANITARY-S'IYl,MEA. 20()FI',
-?NEHOY
PEIi
.I))oily thin intoe punfonvanccol(he work forwhlch this permit isisauul, IahuO
abjggy.W oWorkun'Cnmpmt-
not employ any person in any manner a, yy t_hecsu
WAFER HEATER W/VENT/ELECTR'
GRADING IFF. '
cation Laws of Cut ,ria. Da I/
1 Applicant
SOILS PEE.
NOTICE TO All . -ANT: If, at,,, making l tis Certificate of Exemption. you should
become subjem n le Worker's Compensation positions of the Labor Code, you most
WATER SYSTEMITREATING
WATER SERVICE
finhwith comply with such provisions nr this permit shall be deemed revoked.
CONSTRUC'I'ION[.ENDING AGENCY
Ihereby a0irmthat them is a commc0on]coding agency for the performance of
NEW RESIDENTIAL PLMB. SQ. 19',
PAID
Dam Re)oip#
-
_ TGIAI.,
' the work for which this permit is is ... it Sce. 3097, Cls. C.)
Lenders Name
Leaders Address
I
BUILDING PBG
1 can ly that I have rem( this application and slam that (h bo interaction is
1 sorrc ( I'6 to comply with all city and county ordnance. unit.tat laws relating t
h(ild'ngc(rsr-c( n, and hereby mhorm represema:vosof till, cityt luuP,t the
., l _ ,, r
QTY.; Ili t'�� MECHANICAL PERMIT ) FEE r
,SEISMIC FEE
FERMIT ISSUANCE
ELECTRIC FEE
above hornJonul pmperty far Inspm(ion Inmems.
(We) agmT to save, indemnify and keep harmless the City rf Copemno against
PLUMBING PIi13
liabiblies,judgmems, costs and expenses which may in any way accure against said City
in asequenceofthe permit.
AC] ER Oil ADD TO MECH. '
AIR HANDLING UNIT ('r01(I,Wp CFA1)
h1HCHANICAI. FEE
O
RSTAN Sthis
APPLICANI TANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNI'I'OVER IO,gq CI'M7
CONS 'PRUCTIONTAX
Signatmeol'A,hrant/Contmcnr, Data
FXHAUSTHOOD(W/DUCT)
HOUSINGMITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapp]icarn orfminclailiingocchpant susreorhanJ]Thazardousmmedal
as defined by the Cupertino Municipal Code, Chapter 9.12, end are Health and Safety
Code, Section 25532(.)?
HEATING UNIT (TO IIIO,f BI U)
HEATING UNIT (OVER HEODO BTU)
VENTILATION FAN (SINGLE RESHIP
❑Yes No
PAID Unto Receipt#
BOILER - COMP (3HI' 012 IIX),OW BTU[
Will the appliceld or future handing mcupant ase Tympment or devices wldch
' callhamNohs air contemplates as defined by me Bay Arca Air Gouty Mam(gement
9'O'fA L:
DinridO Ycv ❑No
BOILER- COMP (OVER 100,000 BTU)
-
,
AIR CONDITIONER
1 have read the hazardous materials re9tiremems (coder Chapter 6M of the Cali-
ISSUANCE DATT3
NEW RESIDENTIAL MECH. SQ, PI'.
folia Health & Safety Code, Sections 25505.25533 and 25594. 1 understand that it the
building doesnoomortly hove(in,; n6that itis my rex.rodllity n, n od"Iteouuprot
.
m the agmorecmis which moat be nsan prior m issuance of u Ccmfieate of Occupancy.
ISSUEDBY:
TOTAL: ♦
Owner.. ... barred .gan, Dam
OFFICE