S 0535APPUCANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDIN(: - ELECTRICAL
BUILDING DIVISION APPLICATIONAaRRMI•T PLUMB 1Nc. MECHANICAL
BUILDING PROJRCTIDENTiFIC'ATION
PERMIT NO.
S 0535
BUILDING ADDRP_SS:
I y9 1 fir-,\ ",A_C 4roc-
SANITARY NO.
APPLICATION SUBMITTAL DATE
^S
B'S A 'S 11: LIC NII:
OWNER'S NAME. Q \ PHONE: I (API)
G%?
919(11 _ARCHITECOENGINEER:
NIG
❑
CONTHOLp
LIC NO:
ADDRESS:
10 a -q 5 .��� coo S . J '
'ONTACT:j.5 PHONE:
3e.175❑
I�/q
61— /
Consultant Fees Paid by Applicant (Initial)
D I,DING PERMIT' INFO
HLDG ELECT PLUMB MECH
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LICENsEDCONTa C'IOR:S DECLARATION
1 hereby affirm that 1 em licensed under provisions of Chapter 9 (mmmcncing
'ItSection 7") of Division 3 ofthe Business and Professions Cade, and my license is
fe(force and eRec1.
LitesO.'s Cote//1377
LaneJbAL 9
ARCHITECTS DECLARATION
I understand my plans shall he used a public records
QTY. IiLECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑ SFDWL ❑KITCHEN REMODEL
[]ADDITION [I PLUMBING RE -PIPE
❑MULTLUNIT' CSTRUCTURAL
MODIFICATION
I ElINTERIOR El CHIMNEY REPAIR
IMPROVEMENT [3 SWIMMING POOLS
C BATH REMODEIJRE� CDF�fOLITI N
xy �J
HER
�r �7, C1,\
PERMIT ISSUANCE
APPLIANCES- RESIDEN'I N.
PANELS
UlIT02MAMP5
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9hd 2, .4
CC 0005GGG 6
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LL13 LLI�
Licensed Pride.... val201.IIXq
OWNI?N-BUILDER UECLARA'I'ION
I hereby anion that I am tempt from the Contractors License Lew for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which rtquires n permit m cmnstmd, alter, improve, Jemnlish, or repair nny sWcturc
AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIALCIRCUITtMISC.
O.
1�0;}
prions its issuancwalsomyuims the applicant for such permit to file a signed statenmm
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that he is licensed pursoam to the provisions ofthe Contractors License Law (Chapter 9
t+lap0
L .q
-.roty
�aY
F
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L3 ti
(eommencingwithsection7.1ol Division3ofthe Rusincsswd Professions Code)or
that he is exempt Imrtfrom and the basis for the alleged emmption. Any violation of
Section 70315 bywy app( icont for a permit wpjects thenppliewd to a civil penaltyof
nm mare than five hundred dollars ($500)
C1, as owner of the property, or my employees with wages as their sole compensation,
will do the wark,andthe structure isnot imenedoro8eted(nstale(Su. 7014, Business
and Professions Code. The Contractor's License Law dors not apply to an owner of
who builds or improves thereon, and who does such work It or in a E,
TFMP.SEE EDiR OR FLUE 'NIT.
COMMERCIAL
C NEW BLDG/ADDITION C DEMOLITION
CFOODSp VICE
IMPAWf*E,NT
J
❑OTHER4A s
POWER DEVICES❑TENANT
SWIMMING POOL ELECTRIC
_ `U`
OUTLETS-SWITCHES-FIXTD117
qa,
property
his own employees, provided that .such improvements we not intended or mitered for
safe. If, however the building or improvement is sold within one yew....trop........ the
NIiW RF.SIDI?NTIAL ES Q FT.
SISQ. FT.
SQ. Ff. FL(A%W17
a%metwilder will have .he burden of proving that he did not build or improve for pur-
PoneofsaleJ.
C 1, as owner of the property, um exclusively convecting with licensed contractors to
y
- TOT -1
uorotmct 0e pngect (Sec. 70,14, Business and Professions Code:) The Contractor's Li.
nse taw does not apply to an owner of property who builds or improves.hemon, and
QTy. PLUMBING PERMIT
who contracts for such projects with a contractors) licensed pursuant o the Contractor's
PERMIT ISSUANCE
License law.
C I oro exempt under Sec. ,B&P C for this reason
Owner Dam
ALTER - DRAIN&VENT - WATER (EA)
VALUAI']ON
/ �D O
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I M1erehy tdl irm under penalty of perbry one or the following declamucns:
L
IM
I Ihwe and will mond ine Certificate of Conscmmseln-ireure for Worker's CmnPen-
cation, in provided for by Section 37M of the Labor Cade, for the Performance of the
DRAINS- FLOOR. ROOF. AREA, COND.
S'I ORI
TYPE CONSTRUCT ION
work for which this permit is issued.
FIXTURES - PER TRAP
C I have and will maintain Workers Compensation Insurance, in required by Section
37Wmnthe Lob nr Cade,tonhe perfnrnasweed the work div olowhthis permit is isaucd,
OCC, GROUP
AIN
CAS -EA. SYS TEM- I INC. 4 OUTLETS
My Wmkc s imp option I w r and Policy nu n
Came u Policy N..:—IST.k�a
GAS - EA. SYS'1'CM-OVIiR 41FA)
CEI TIRCATE OF XE IPTION FROM WORKERS'
\ COMPENSATION INSURANCE
OREASEJINDUSTRL WASTE INTERCEPTOR
N ILDING DIVISION IS
(This section need not bo completed if the Permit is for tone hundred dollars 1100)
or less,)
GREASETRAP
PLANCIIECK PP.
z
F y
Qforthwith
I certify that in the penman. esfthe work far which this permit is issued, l shall
sen crag.y any person in any man� m become subject to the Wnrkens' C.mpen.
sLemu l.ads of Culifi m o Dam C' m D `I
Applicam t C
SEWER -SANITARY -STORM EA. 200 Ff.
ENERGY FEESO
WATER HEATER WIVEN'VELF.CTR
GRADIN
NOTICE. TO APPLICANT. If. arm, malL this Cmificam of Exemption. you should
become subject to the Workers Compensation provisions of the Labor Code, you mus.
comply with such provisions an his peon:t shall he deemed revoked.
WATER SYSTL'MLTREATING
WATER SERVICE
SOIL
Ro
rte:
Ll �
o ULender's
tF1''s' W
CONSTRUCTION LENDING AGENCY
Ihertby affirm thauhem isamnsmc.ion lending agency for be performanceof
.he work for which this perm inia'J�(Sec.3097,Civ.C)
Name / s ••,
Lenders Addres l -
1 certify that I have read this upplicwion and stam In., the nMne information is
PA
Dam Receip,a
NEW RESIDENTIAL PLMB. SQ. Ff.
BUIL ING FEE
'f()IAI.:
U
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby urbanize repremmatives ofthis city to enter upon the
QTy, MECHANICAL PERMIT FEE
SEI IC FEE
PERMIT ISSUANCE
G 'C TRIC FEE
aMwe-mentioned property for inspenam purposes.
(We) agrc.to save, indemnify and keep harmless the City of Cupertino against
P UMBING FEE
Iiabili.ies.judgmems,costs and expenses which may in any way aurae against said City
in consequence of the granting of this peoniL
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 10.000 CFM)
CHANICALFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S tRREGULATIONS.
-
AIR HANDLING UNIT (OVER 10.000 CFM)
CO TRUCIION TAX
11Oy�� rr��/•N1a�
/11L
Sip turco ApplmaltsMimctor- Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HUGE(W2DUCT)
HOUSIN ITIGATION FEE
I ENUNC UNIT (TO 100,000 BTU)
J 1
Will the applicant or future buildingoc,mamsmrcor handle Iconic—mmedol
as defined by the Cupenina Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)4
HEATING UNIT(OVER 100.000 BTU)
VIINTILATION PAN (SINGLE RESIDE
C Yes ❑No
Will ous applicant or future building by one B sec ea Air u of M...s WIlgnomon
mit M1azartlous air contaminants us defined by Nc ray Area Air Quality Management
PAID
Dam Receipt 4
B011.ER'-COMP (3HP OR I(q.H(Id BTU)
TOTAL:
BOILER -COME' (OVER 100.001) BTU)
istncR
❑Yes r-1 No
Al I1 CONDE I'I(INER
I have read the laranlnas rnatedds mitmeemems under Chapter 695 of me Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand that if the
Id'gdoes not currently have o tenant. that it in my resrymsiladitym nmifyrne occupant
'tlaA quifs s�yJch must he and Prions i,esuance nfu Cnnilicme of Occupancy.
w OAl Um
_ ,[! r��11 .�('' (�
ISSUED 11 _
TOTAL
OwIlior au'han agent Dam
OFFICE
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