31461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. 21 A
BUILDING PROJECT IDENTIFICATION 61
J 1'7 J-
R.DINOADDRESS: SANITARY NO. APPLICATION SURMITTA,DATE
l000k il. lotto MAri hls. Av< (l l 4� 1114
111VNVS NAM` PHONE: CONTRACTOR'S NAME: LIC NO:
I L41 Aw` 'Joy SI- NIC CONTROL
tRCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONIC BUILDING PERMIT INFO
❑ Consultant Fec9 Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Fa f" ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
Z 1 hereby affirm that 1 an license([Bu under id From
of as
9(commencing is JOB DESCRIPTION
thSmciz�re and
ion3of the Husineas and Prnfeseions Cole,and my license is RESIDENTIAL:
Fir Nrfull force and effort. PERMIT ISSUANCE
RuU ❑SFDWL ❑KITCHEN REMODEL
aFUV License Clan C.m APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
N<i Dap Contracmr
E.Dw ARCHITECrs DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
zpnZ I understood my plans,hall be used aspublic.,ads MODIFICATION
OZ—p UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
FBF.W Licensed Prnfessbnal 201-100MAMPS IMPROVEMEN,
,Xx; OWNER-BUILDER DECLARATION OVER]"AMPSREMODE PAIR ❑DEMOLITION
C C Q I hereby affirm that 1 am exempt from TH
the Contractor's License Law for the
XO6U following Mason.(Section 7031.5.Business and Pmtensions Cole:Any cityur county SIGNS F,LECfRICAL >0 OTHER
g,3U,F' which requires a permit to con.Wcl,alta,imprrve,demolish,.,,,,all any Imemre
0 pflorwiwlssuutire,alsorequire,t ett,iicanl for,uchinamom fileaslgned.omemeut SPECIAL CIRCUIT/MISC.
cccc;!(y that he is licensed pursuant o the provisions of the Contractor,License Low(Chapter 9
W 0 (commencing with Section]0010 of Division 3 of the Business and Professions Codd or TEMP.METER OR P01.11(NST. COMMERCIAL:
Q.1 e that he is exempt therefrom and The basis for the alleged exemption:My violation of O NEW BLDG/ADDFFION ❑DEMOLITION
XI Section 7031.5 by any applicant for a permitzubjects the applicant)a civil penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZ
an
Bve hundred dollara(55001. IMPROVEMENT
pO' sawn,of Ne property,pnny employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
IfCC••.. 11 do the work,untl Nestrunura i,not mtenJCJ uroll'crcJ far sole(Su:.9144,Buxinwx THEN
W m i d Pndesxions Code
The Cnntrecmr's License Lme it 'not apply m an owner pf LETS-SWITCHES-FIXTURES ITL
a";.. all
who builds or improves Netenn,and who does such work himself or through
his own empm n
employees.provided that such improvements aot intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
ale.If,however the building or improvement is sold within one yearofcompletion,Ne SQ.FL MOOR AREA VSQ,FT
o nerbuilder will have the burden of proving that he did not build m improve Por put- gag p I
poseofsvle.), l A
❑ 1,as owner of the property,an exclusively contracting with littnad contmemrs to
onsWct he project(Sec.](44,limine.a and Professions Code:)The Comma,-,
cerise Law does not apply to an owner ef proparty who bunids or improves thcomm.and QTY'. PLUMBING PERMIT FEE NOV 18 X996
who commets for such projects with a contacto r(M un licensed pursuanNe Conmachers
License Law. 1 PERMIT ISSUANCE /�
❑ lam exempt and ,B&PCfsr this a CITY Ur
ALTER-DRAIN&VENT-WATER(EA) VAI 11ATl
Ow
ne Date
WORKER'S COMPENSATION ATI arm
DECLARATION BACK PLOW PROTECT.DEVICE
I hereby abate under penalty of ofCon ane of Nc following declamsCo lJl/
.fit .
as ausida forbynvCeri37W pf Com ate msare,for for Workers Cumpcn- DRAINS-FLOOR,RODE ARW,COND. � L STORIES TYPE CONSTRUCTION
anon,m'pmvidhi for by Semina 3]110 of the Labor Cole,for he performance of the R
work for which this permit ix issued. IgXTURF.S-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Suction
37W of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Worker's Compensation Insurance caries and Policy number not
Carie, Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi meimn need mot he complecd ifthe ponir is faun hundred dollars SIMI) GREASEIRAP
nr las) PLANCHECK FEE
I certify that in the performunecofthe work for which this permit is instiad.LNdl SEWER-SANITARY-STORM EA.200 FT.
nee emaploy any f ax,in any manner sons to become abject m NC Workers'Compen- - ENERGY FH
OZ anon lawn of Callfomiv.Dac WATER IIEATER WNENT/ELE(ZTR GRADING PEC
O Applicant _
NOTICE TO APPLICANT:IL after making this Cenifleam of Exemption,you should WATER SYSTEMRREATING
F '�^ become subject m the Worker's Compensation provisions of the Labor Cole,you must SOILS FEE
W4vohwiNcomply withsmch pmvisinns.,,his permit nhallM deemed revoked. WATER SERVICE
7Z CONSTRUCHONLENDING AGENCY NEW RFSIDENTIALPLMB. SQ.FT. PAID Date Rc<iprp
U 0 Thereby affirm that is vconswctinn lending g agency for N<peAormance of
f-' Le work for which this permit is issued(Sec.3097,Civ.C)
U lander,Name TOTAL:
Landers AJd,es )
I ccnify that I have read this application and state that the oMve monomania is 50 BUILDING FEE
F"y C...I vgrccm comply with all city and county ordinances and nam laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize repremnutives of Nis city to enter upon Ne SEISMIC
above-mentioned property for inspection purywes. PERMIT ISSUANCE
(We)agree to ave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitiesjudgmem,costs and expenses which may in any way acemc agaimt said City ALTERORADDTOMECEL
PLUMBING HE
APPLICANT PLIC pe sof the UNDERSTANDS
of this permit.
SOURCE
REGULATIONS. AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL ITS
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTA
Signature ofApplicant/Contmctnr Date EXHAUST HOOD(W/DUCT) HOUSINGMITIGATI NFF.E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stere orhancile hazardous material HEATING UNIT TO 0.000 BTU)
as defined by the Cupeninr Municipal Cade.Chapter 9.12,and the Health and Safety
Cada,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
❑Yeas ❑Nn VENTILATION FAN(SINGLE RESID) PAID
lit. Rett M
Will the applicant or future building occupant use equipment or devices which
it humrdous air contaminants as defined by the Iluy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) 'illl
Drsmn? BOILER-COMP(OVER 100,000 BTU)
N 4
❑Yes ON.
I have reed the harardous materials requitement,power Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE.DATE
humin Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.IT'.
honking does not curcmdy have a lemanl.chat it is my res,ntsibility to notify the occupant
.[the requirement,which most[at met pnorm issuance,to Camfiea,of Occupancy.
Owner or authomel agent Dae TOTAL: ISSUED BY: kn Sa a`
OFFICE
i
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