30942 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY `
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL.DATE
/a 7s A/ /67
OWNERS NAME: PHONE: - CO ACTOR'S NAME: LIC NO:
AldoLS21//J S � jD NIC CONTRQL#
ARCH](ECT/ENGINEER: LIC NO ADDRESS: �� �.tl - -r - ' ❑
CON'I'ACI': PHON Ii T _ �4. BUILDING PERMIT INFO
/ nL,� zY�t�'OZ�_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MI CH
( ❑ ❑ ❑
10ENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby (firm dta 1 am licensed under p...vision,of Chapter 9(mmmendng JOB DESCRIPTION
OMZ with Section 7")of Division 3 of the Bucincssand Professions Code.and my license is
W00 i PERMIT ISSUANCE RESIDENTIAL:
FW mull force vnd effoW D &-///O' ❑SFDWL ❑KITCHEN REMODEL.
dUU IIice so Cla.a _ _ Lia# APPLIANCES-RESIDENTIAL ❑ADDITION ED PLUMPING RH-PIPE
y I Lu Date Conwc /I/I e- -e--56w;
S
F. o) ARCHITEC'S DECLARATION pgNELS ❑MULTI-UNIT ❑STRUCTURAL
Z 0 rn Z 1 undcrsmnd my plans shall M octal us public mcorJs MODIFICATION
OZ�� UPTO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�E'ul Licensed Professional 201-IWOAMPS it IMPROVEMENT
q:C C Q Bar I in exempt
nn ue C anna OVER 1000)AMPS ❑BATH REM .1 ?PD1 DEMOLITION
1 hereby affirm the.1 am exempt from the Contmcmrs Licence Law co th<
au3 6 U following massa(Section]onstru Business and improve.
demolish.
Code:Any tiny or county SIGNS ELECTRICAL (]OTHER
W 0 y which to issuance,
n permit m m the alter,improve,demolish,m repair any stmnum
F-�'Od prior to issuance,also"timeshc applicant for such Permit file esigned xmmmrnt SPECIAL CIRCUIT'/MISC.
ft2} that he is licensed Lamomntto the provisions ofthe Centalx License Law(Chapter 9
la: (cummencing with Section]000)of Division 3 of the Business and Professions Cde)of TEMP.METER OR POLIi(NST. COMMERCIAL:
d q m K thea he is exempt therefrom analthe basis Iim the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant fern Perini[subjects ate applicant fo a civil pe.all,of POWER DEVICES ❑TENANT El FOOD SERVICE
ns[atone them five hundred dollars(551X).
F Z Y IMPROVEMENT
xd
will
Los owner ,the pmpereme is en imendeswi[hwngcsoc theirsolet,14,Bmion, SWIMMING POOL ELECT RIC
W F.O will dothework,and the he CotranotsLfc,mceLow does of apply
o]oan thorniness ❑OTHER
I+ql�m and I'rofesninns Gdc:The Contractors Liccnx Low does not apply m an owner of OUTLETS-SWI'TCITES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such invemennx anot intended or offered for NEW RESIDENTIAL E
tpmare LECTR SQ
sale.If.however,Ne building or improvanem is sold within one year ofcompletion.the SQ.FT. Q{t AREA $/SQ.PT
owneobuilder will have the burden of proving that he did not build or improve for put-
,.of
ut-
pose of sale,.
❑L as owner of the pmpeny.am exclusively contracting with licensed rnnwnnn to
c r arun the project(Sec.7044,Business and Profession..Cade:)The Ci n nexamr's Li-
c se Lew does not apply to an owner of property who builds orimptovesthcreon.and QTY. PLUMBING PERMIT FEE CIryUr '���-��
who comrm
as for such projects with a emanations)licensed in rsunnno[he Conwcuv's
License Uw, PERMIT ISSUANCE L(J(••
Iant exempt under Sec ,B&PC for this reason CH��
Owner Dae ALTER-DRAIN&VEST-WATER(EA) ULUATION
�
WORKER'S COMPENS ANON DECLARATION BACK FLOW PRO'rECI'.DEVICE ��
I hand w arm maintain
under pcnafi c of perjury one of the followmoure mg decWorker inns
❑.have and will main mina Certificate Cc Labor Coden(a,Oterarf..Comce of tar- DRAINS-FLOOR.R(7UP.ARPA,COND. S TYPE.CONSTRUCTION
cation,ax which
Bu for by Ss ion JIIXI of[hc Labor Code,for Ne performance of the tt
work for which[his permit is i orN. FIXTURIS-PER'BAP I r Vr
37 I have end will mainmin Worker's Co ce ofthe w lasumnce,as fequirrm by Section VVI''
J]oo of[he laMr Csde,for Ne performance of the weak for which Nn Permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS DEC.GROUP APN
My Worker's Comixotoomnl urate carrier and Policy numbs
Cartier: . Policy Na.:no "
Carrier: GAS-FIA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEb1PT10N FROM WORKERS'
COMPENSAI[ON INSURANCE GREASE/INDUSTRL W'AS'TE IN'rERCEPTON
(ILisxemion need all he tompated it1
l6c is for ane hmtdrcd claim's 1$I IW) GREASE TRAP BUILDING DIVISION FEES
ur less.) PLANCIIECK PF:C
I clarity that in the performance of the work for which this Fermin is issued.shall SEWER-SANITARY-STORM EAFT.
.20(
not employ any pe^sn any manners[tam become subject to the Workers Camper- ENERGY FEE
0 Z sn[iun Laws of California.Date WATER HEATER W/VENT/ELECfR GRADING FEE
Z 2 Applicant
rp NOTICE TO APPLICANT:If.after making this Cearifiene of Exemption.you should WATER SYSTEMITREAT.NG
a ; become subject to the Worker's Compensation provisions of the Labor Cale,you must SOILS FEE
forthwith comply with such provisions or this permit ilea..In,deemed revoked. WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
7 ') thereby if,.that wlen
hem is a cormction dmgngency for the peffnmpmrof [).to Receipt
V Pthe work but which this fail is issued(See 3097,Civ.CJ
Lender's Name TOTAL:
V Lenders Address TOTAL:
l31
I cmify that 1 have rcuJ this application and nate[hat the aMve information is BUILDING F'i
Ln correct.1 agree m comply with all lily and tautly ordinances audible laws reln[ing m QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby ootbodre mpm.wnmtivecofthis tiny menterupnt the SEISMIC E
above-mcntioncd pool for inspersion purposes PERMIT ISSUANCE
(We)agree suave,indemnify and keep harmless the City of Cupertino against BLE 1 t
laibilinies,judgmcros,co sandexMascawhich mayin any way accrue against said City ALTER OR ADD I'D MECH. PLUMBING r
inconsequentggqqqofthe tinting of this pc
AI' 'qUN t5 NDSA WI(I MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TT)10,000 CFM) MECHANICAL FEE
OR [L�`D` IONS.
_ AIR HANDLING UNIT(OVER to."CFM) CONSTRUCTION TAX
lig mare nl' Aplin Cn Tact Dam EXHAUST HOOD(WIDUCTI HOUSING MITIGATION -E
H RD US MATERIALS DISCLOSURE
Will the art or race building occupant store or handle hazardous material HEATING UNIT(TO 100d001)BTU)
as defined by the Cupertino Municipal Code.Chapter 9,12,and the Health and Safety
Cele,lection 255320)? HEATING UNrI(OVER 100.000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building [sac [or devices which Dae Receipt#
PP dbytheB cqui Air
BOILER-COMP CHP OR UMI.000 BTU)
Dist hvallous air contaminants an,defined by the Bay Area Air Quality Management TOTAL:
District?
C3 Yes
ta rut❑Yes ❑No BOILER-COMP(OVER I OBIXIO BTU)
I have rend he mianloucmaterials mgsiremcnia under Chapter 6,95 of the Cali- AIR CONDITIONER _ ISSUANCE DATE
s mia Health&SafeD Core,Salle s 255115,25533 and 25534.1 undexamnd that if the NEW RESUHiNr1AL MECII. SQ.M.
M1uilJing does ani curu,0y btvc a mann[,[M1:n I[Is my rc�mcihili[y w null ly the xcupam
�Rnhe myuimmenu which man M met poor to isctmncc of a Ccnificate of[hatpw¢y.
TOTAL:
Owner or uuthonxeJ agent Dae ISSUED BY:
OFFICE