S0001C0425 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LIN -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELELTRIG\L. 11, NO
BUILDING DIVISION APPLICATION/PERMPP PLUMBING-MECHANICAL SOOOI `T��
BUILDING PROJECT'IDENTIF'ICATIUN
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAFT.
//
OWNER'S NAME: I'HUNE:
CO NTR gOR'SN E: I.ICN �`
I N/C CONTR)L a
ARCHITECf/F:NGINF.ER: LIC NO: ADDRE.S
Aq
CONI'AC'L PHONE: 11 P_ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F TC'iPLUNIn MF.CH
❑ ❑
LICENSED CONTRACTORS DECLARATIONQTy ELECTRIC PERMIT FEE
1 hereby a0irm IM1at I con licensed under pmvisiona of Chapter 9(commencing JOB DESCRIPTION
ad0C)
W p with nBo
SMli 7fXXf`D.Vlslra3nf the Business and Panic....ns Cod•andmylicrn,res PERMIT ISSUANCE. RESIDENTIAL'
'
FWF in full force and dl'tt� ❑SFDWI, ❑KI'I'CIIIiN REMODIiI.
�UU Liccnsc Class Lick PPLIANCIS-RESIDENTIAL C1 ADDITION ❑PLUMBING RE-PIPE
�zwQ Date a7�� Cnntmdo
"� ❑MUI.TI-UNIT' El STRUCTURAL
y ARCHITECTS D Q�1' S PANELS MODIFICATION
OZ�Z Iundcmend my plant sM1allMusedo is record. UPT0200AMPS
❑IM'ERIOR ❑CHIMNEY REPAIR
F�FW Licenced Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODFUREPAIR ❑LEmod.ITION
6yx C Q 1 Inner,Minn dust I am ucntpt h'om the Cantrudnd,License Law ILt he
W L U following reason.(Section 7031,5,Emoiress and Professions Calc:Any city or mum, SIGNS IiLEC'FRICAL El HER
HER w -
uJ 3 u•�a which mimics a fK.it to construct,aver.improve,demolish,m repair an,structure
C' prior to it issuance.also requires the applicant for such pemrn to rile a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed lar naanuo the provisions of me Contremnes License laa(Chapter 9 COMMERCIAL:
icry�� (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INS'1'.
ic C.a chat he is cxcmpt therefrom and the basis for rhe allege)exemption.Any violation of ❑NFW BLUGIADDITION El DIiMUhI'fION
W NSection 9831.5 by any applicant for a Iwnnit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOI>SIiRVICE-
rn more than live hundred dollars($SOUL IMPROV EMEN'I'
20 ❑LasownernDlic property,army employee,with wryness,hei,sol,compensation. SWIMMING POOL ELECTRIC
will do the work.and the structure is got intended oroRered Ibnole ISec.9W4.Business ❑OTHER
~m
63 amt progeny
he b Calc:The Contractor's License Law dura nm apply himself Croom of OVI'L.IffS-SWITCHES-PI%IVHES --
his o nY who build,or improves thereon,and who rces such wote dedoror through 1 V R A
his own employees,Provided that such impmvemen¢arc not intended or offered for NEW RESIDENTIAL ELECT SQ lel'.
sats.If,how'ever,the building or imprnvemonl issold sahinone yearncomple.ion.thePl'.FL RA
owner-0uilbcr will have the burden rel'proving that he did nut build or improve for put-
pose ofsde.l. TUIAI.:1 JUL - 119 9 IUUI
❑1,as sm'ner of the pmp,ny,an'exclusively contrasting with Eeen,ed contractors it,
construct the project ISM.TBW.Business and Professions Code:)The Cmdranm's Li.
use La.dries moapplym-owner-of property who built,or improves thereon•and QTY" PLUMBIN hRMIT FEE
who contracts for such projects with a comrwtat(s)licensed pursuant to the Contractor's By
License Law. ,N&P C under,tenons PF.RMI'1'ISSUANCE 3 Dl
❑1 in exempt under Sec.
ALTER-DRAIN&VISN'I'-W I' VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE ICE ��
I hereby officer under penalty of perjury one of Ne following decimations: J IO J
EIhave mMwillmainmina Cenificateof Conunnnself-insorefor Workees Compen- DRAINS-FLOOR.ROOF.AREA.GOND. STORIES TYPE CONSTRUCTION
it,as Provided for by Section 3700 of the Labm Code,for the Performance of the
0/11 work'if,whichthie perentos tied. FIXTURES PER TRAP
❑I have and will maintain Workers Compensation laeurance.as required by Section
3701 he Lith�osrt�Come,fynprt�he�ps�,for m,�unepcof the work flru�rr hic�h¢thi�iss Doon'titt is issued. GAS-ISA.SYS TEM-1 INC,4 OUTLMS OCC GROUP MIN
My Wo C I Yggn IJVII r-CY Nn.Yv�r_tiS��-^a`O GAS-EA.SYSTEM"OVER 4(EA)
Comer.. MY Y 1q 11[l IV
CERTE•TCATEOFE%EM PTIONFROMWORKERS' GRE:ASE/INDUSTRL WASTE INTERCEPTORCOMPENSA""PION INSURANCES BUILDING DIVISION FEES
Obi-cratinnced not be completed if Ne permit is turner,hundred dollars(S IUII GREASE TRAE'
I'hANCHECK igili
orlcaJ
I ccnily thus In thcpcdnrmanm of work for which Ibis permit is issued,lshall SLMER-SANITARY-S'IURM EA.201 FT.
not employ any l„mm in any mourner,g, rveD u� e Warko,"Cotnpcm 1C� ENERGY PEi?
o z saline L wsJ-y`Calil D,atc' [ WA'1'EH HEATER WNIiN'I'/ELEi TR V GRADING Mili
ZO Applicant,l(,��1—W r
N NOTICE TO APPLICANT:If,after making thin CrmOcae of Exemption,you should WATER SYSTEMfrREATING SOILS FEE
(-� become subject it,the Worker.Compensation penvisions of the labor Code,you must
Wforthwith comply with such provisions or this Permit shall be deemed marked. WATER SERVICE
0PAID
CONSTRUCTION LENDING AGENCY NEW RILSIDENFIAL PLMIL SQ.for p:nc R,c,PIA
UC) I hereby aBimnhatthem is a mn,nomie.lending agency fill the performance of
F the work for which this permit is issued(Sec.3099.Civ.C.) TOTAL;
0 U Timbres No. !1
Undoes Address A" D
�•" W 1 certify thus 1 have mad this application ordinate that the above information is BUILDING FEE
2" g TY. MECHANICAL PERMIT' FEE
IFr N building
1 agree let comply with all city and county ordinances and store Taws relating m Q SIiISM1fiG FEili
f) hnBdingcomvnet i r,md far
rep resenmtivcs est th6'city mercer upon he
shove-(We)agree
pto,ove for ioomil,i an Pkeep ha. PERM[ ISSUANCE ELECTRIC PI3E
(We)agree ts:save•indexpen and which
hay in anyway
n the City of against s against
ty
liabilnies.judgmems, as and expenses which may in any way teem,again,,said City ALIT:R OR ADD TO MIiCH. PLUMBING PEC
( con"turnecoft g tfthr%' 't.
APPLICANT I' 1P A S AND VILL .O LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.(41(1 CFM) MECHANICAL FEE
SOURCE . 1. N.
AIH HANDLING UNIT(OVER 10,000CFM) CONSBRUCr1ON'I'AN
SI rc of IPhcam/C t' Date E%HAUSI'1 IOODWIDUC11 IIOUSINGMHIGAUONFEE
HAMRDOOS MATERIALS DISCLOSURE
Willtbcapplicanl urfamm,hildin,nccup....true or handle limanka,mamrid HEAPING UNIT(TO 100.00 BTU)
as derined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10(1.(X0 BTU)
Core Section 25532(a)9
❑Yes1n�No VENT[LA['ION FAN(SINGLE RESID) PAID -
Dale R,ccipt M
Will Ilse applicant or hilum building owcupnnt use equipment or devices which BOLI Elt COMP(BHP OR 100.00 BTU)
mit hamNous air comaminanu as depoed by the Bay Arca Air Quality Management 'T( AL:
District? ((�� BOILER-COMXI P(OVER 100*0BTU)
❑Yes Whirr
AIR CONDITIONER ISSUANCE DATE
1 have read the az in, bons materials mquircmean 25.1 Chapter6.95ofthe Cdi-
htmin,doe n Sal Ct . ensu .255. and 25A1.1 a.mod,nd thin if m, NIiW RESNF:NTIAI.MliCll. SQ.pr
holding Jct:.n etc 'mmol. re hill,,tomni(ytc ltaupum
n[Ncrc is t Vl het d� ri colo Cid Ecatc nrOcetgmm:. /
Own an mil agcm Date TOTAL I ISSUED BY:
OFFICE \