S 1312 1 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LEC'IRICA], I HSIINO. 1312
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL \V
BUILDING PR(1,IEC1innec•IF'ICATION
BUILDING A DDRESS: SANITARY NO. AI'PLICAT'IDN SUBMITTAL DATE
OWNERS NAME: PHO ^/�-grjy) C( LIC NO:
VHV NIC CONTROL If
H LITE GIN.F.R: LIC •0:.1/; ♦ AD FS
RS: ❑
CONTACP �5 rz5,.` 1�RIi41/'NF 7BUILDING PERMIT INFO
/ ,•^ �i .n&4000 Consultant Fees Paid by Applicant(initial) BLDG iI.EGT PLUMP MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herchy w'fir.a mm 1 am heeaxnd nadir Provisions of On ler 9 bannmenciag _ - JOB DESCRIPTION
Opwith Satlon 00(nof Divlsimm7of thetluxiness and Pnotenxeons Code,nnA tiny license is RESIDENTIAL:
.nmu n,ree inn effect. PERMO'ISSUAbi ❑SMWL ❑KITCHEN REMODEL
TUU License Chew La,If APPLIANCES-RPSI DENTAL El ADDITION ElPLUMBING RE-PIPE
F�W Dom Canhamm
ta, ARCHITECT'S DECLARATION C1 MULTI-UNIT ❑STRUCTURAL.
c-D an PANELS MODIFICATION
Z O j2,6 ]understand my plain shall be used es public records
OZ-.Q UPTO200AMPS El INTERIOR C1 CHIMNEY REPAIR
i__W Licensed Professional 201-1000 AMPS IMPROVEMENT 0SWIMMING POOLS
aYJ OWNER-BUILDER DECLARATION OVER lad AMPS ElBATH RHMODEuREPATR ❑DEMOLITIO
P4 6 I hcmby infirm Ihar I am exempt from the Codman's License Law for rhe
56�6V following reamn(Smion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL CI OTHER
tD�+LL no which requites a permit to consumer,alma improve,dent or.pair any sdai
^LLOS onialoiniix......Imreburesthaupplic.nt finsuch pc.am fileasignedsatement SPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the positions ofthe Cuntecmts license Law(Chancre
0 (commencing with Section 7001)of Division J ofhe Business and Pndessions Code)or TEMP.ME717R OR POLE INST. COMMERCIAL:
4po e C that he is exempt therefrom and the bwix for the alleged examprim.Any viNmion of ❑NEW .DG/ADDITION ❑DEMOLITION
Section 1031s by aayapliicont far.permit subjects fee applicant to a civil Penalty of POWER DEVICES ANT ❑FOOD SERVICE
4411 not more than five hundred dol tuts(5500).
IMPROVEMENT
C�G I,as owner(if thcroert,or employees with woes as their side cors tion, SWIMMING POOL ELECTRIC
0.j' O ❑ P P T' Ye P Y 6 pinna
vol I do the work,unit the structure is not intended or offered hostile 1Sce.?044,Datums 000THER
F m :ted Prinn"vions Codd:The Contractors Liceree Law does not itplily to an owner of OUTLETS-SWITCFII!S-FIX'fllltl!S
prnpany who huilds or improves therm.,and who does such work hh"sulf nt though
his own employees,l ovided that such improvements me not intended m onited I'nr NEW RESIDENTIAL It 'T"
sale.It,however,the hudding or improvement is sold within one year ofcmnpldian,d¢ SQ.FT.FLOOR AREA SISQ.FT.
owner-buider will have the burden of proving mat he did not build or improve for pur-
pose inside.).
I,as owner of the popery,a exclusively contracting wird licensed csentmm
ers to TOTAL'
construct the project(Sea.70,14,Business and Pmfessimw Cale:)The Contractor's Li-
cense, aw dies not apply to an owner of properly who builds or improves therm.,and QTY. PLUMBING PI7RMIT FEE
whocontmens for such projectswitha mnhucmgs)licensed pursuanuo the Commend s
License Low. PERMIT ISSUANCE
❑I am exempt under Ss. .B&P C far this reason
ALTER-DRAIN&VENT-WATER IRA) VALUATION
weer Dine
WORKER'S DECLARATION BACK FLOW PROI'IiCT.DEVICE oOo
1 thereby woff rte under,penalty e,ofCononeofthemlaaving deeWorker's
Continue
I] Ibrve andwill for byneCion 37 cofCe Labor Cde,f tris Wnhdx e ofhe DRAINS-PLODR.ROOF,AREA,COND. OHISS TVYE ONSTRUCfION
anion,to Provided for by Section 37W of the Labor Code,for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑ 1 have unit will maintain Worker's Compensation Insurance,as required by Section
380 of the Lubor Code,Or the perfo"n.nce of the work for which this permit it issued GAS-EA.SYSTEM.I INC.4 OU'T'LETS OCC,GROUT' APN
My Worker's Compensudon Insurance carrier and Policy number tire
.
Carrier: Policy NO: GAS-EA.SYSTEM-OVI!R 4(EA)CI!RI'IFICATE OP EXEMPTION FROM W(IRKERS' ORCASGINUUSTRI.WAS'll!INTERCRITOR
COMPENSATION INSURANC17 BUILDING JIVISION FEES
(This aconin need not W completed if the commit is fun
nnme hdred duflus(5110) GREASE TRAP
or dew) PLANCHRCK FI!F
/17
teriflythmin the pcmformenre of the work forwhicM1 nhisrymmit is isxuedlshall SEWER-SANITARY-STORM EA.210 TT.
and employ any pees m in any manner so M to become subject a,the Wmkcrn'Cmr,w- ENERGY PER
Z
saties Laws of California.Date WATER HEATER W/VF-NT/ELECTIR
z Q Applicant GRADIN
in NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEMUREATING
h ; become subject ho the Wmecer Compensation provisions of the Labor Code,you most
SOILS E
{ail tti forthwith comply with such provisions or this permit shall M decided revoked. WATERSERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FIl PAID
L)0 Ihereby.ffmmhatthe.is.consumed..liming agency forme permmmnce of )etc Recciptp
F he work for which mit permit is issued(Sec.3097,Civ.C.)
QLender's Name
U
WU Lcndeh Address TOTAL: ^
y 1 unify thin I have read this application and state that the above nomination is OU .uNG Flili KJ
y cornet.l mercers comply with all cityand county tomences and stem laws refiring m QTY. MECHANICAL PERMIT' FEE
U{� WifEngeonstmcrion,and hereby authorize mpmxemvrives of this city um enter upon the ISMIC ITE
Move-mnaioned pmpcny for ne"tion fumpoitw.
(We)n lace m save,indemnif d keep homeless the Cit f Cu lino n•nbrst 1'I!RMIT ISSUANCE: ELECTRIC In E.
b yes p Y o Pe' b
incmmwijucr of
ends Setting expenses pewhich may in any way came against said City ALTER OR ADD TO MIiCII.
' � nseyucna of the gmntlng of nbix permit PLUMBING FEE
APPLICANT GOITERS pA N US AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO UtaOCtlost)
MECH ICAI.I FI
SOURCE!REGULATIONS. Q
AIR HANDLING UNITIOVI!R 10,80 CFM) CTIUN TAX
Signature of ApplicanoContmcme Dat. EXHAUST HOOD(W/DUCT) HitlIPSING,loffIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future Building«cupant store or handle hamNaus"internal HEATING UNIT(TO I011,100 It'TO)
w defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health.ad Safdy
Care,Section 25532(a)? HEATING UNIT(OVER 100.000 BIG)
El Yet (3 No VENTILATION PAN IS INGLE RISID) V� PAID -
U m ccipt N
Will the applicant or future building occupant use equipment or devices Which-
"tit hameloux air conmmin:mts as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 1101.1001 11 RD
Disuict't
p Yes C3 No BOILER-COMP(OVP.R IfX1.IXX)P"f l-0
I have mmol the haeurdnus mmmlWs requirements minder Chapter 6.95 of AIR CONDITIONER the Call- ISSUANCE DAT jYI
mein Health&Safety Code,Seeions 25505,25533 and 25,.94,1 uarestand thin if the NEW RESIDENTIAL MECH. SQ.RR ^'7 ^ ZC.
1
ull0ing doem s ncurrently have o tenant,that it is my responsibility to amity mmrcupant _ Li
of therequhemcnrs wbchnnot W met in,to issuance of a Ceniliate all Occupancy ,t _
Owner or au0mrized agent Dam TOTAL A
ISSUED BY: — v� /
OFFICE