S 0794 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO Bull DING-ELECI RICA], Prg`MIT No.
BUILDING DIVISION APPLICATION/PERMIT rLUnIBING-MECHANICAL v 0794
BUILDING PROJECT HEKN'MFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
W Z 2-
WNEj<'S NAME: L PHONE: Z�-Z O TRACT(1R'.SLsN�;MH: S k'1'x�C LICN G NIC CONTIi(ll.p
AR ITECT/ENGINHER: eNO: ADDR' ❑
6 wl p}o
CONTACT: PHONE: ` B ILDING PERh11T INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELISCT PLUMB - MECH
El El
• LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT - FEE
1 hereby union thin 1 am licensed under provisions of Chopler 4(nanomncim, _ _ - JOB DESCRIPTION
OMZ adlin Sxlinn]IIB(1)af Division 3oflhe Business nnJ Prolession.Code,andmy license is
W O PRRMI'i'ISSUANCE.
F W F in full force and eRe SFDW'L 0 KITCHEN REMODEL
�UU I.icen: Class Lie.p APPLIANCI'S-RESIDENTIAL ❑ADDITION CI PLUMBING RE-PIPE
NQ 6 Dale Cantncl
FOy ARCHITECTSI CLARXI' N PANELS [I MULTI UNI'T ❑STRUCI'URAI.
y Z4 1 understand my pans se use
d plans be, as public records MODIFICATION
oz , UPTO200AMPS I El INTERIOR OCHIMNEY REPAIR
h..4�; Licensed Professional 201-100SAMPS IMPROVEMENT' E]SWIMM INC.POOLS
t65 J� OWNER-BUILDER IIIiCLAItA'1'ION OVER I0110AMPS ❑BATH RIiMOOI:IJR1iPAIR 0DEM011.ITION
1 hereby affirm that I an exempt Ron the Commences License Law far the
'ipC,06 U following reason.(Suction]0315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHI?R
tY 3 LL which requires a permit to construct.alter,impose,demolish,or repair any structure
F'�O� prior to its isuance.also requires the applicant for such vand to file a signed statement SPECIAL CIRCUI'UMISC. ol
fly that he is licensed pursuant o the provisions ofthe Contrumurs License Law(Chapter 9
ENE (commencing with Section 7WXdof Division 3 ofthe Businessted Pams Citable TEM('.MISTER OR POLE(NST.
E y a E that he is exempt therefrom and the huffs for the alleged exemption.Any violation of [I NEW BLDGIADDITION ElDEMOLITION
iC I+.
Section 7031.5 by any applicant for a Fermi t subjects the applicant to a civil penalty nl POWER DEVICES ❑TENANT ❑FOOD S1iRVICIZ
ul y rnmnrc than five hundreddalWrs(S9ll). IMPROVI;MEN"1'
d GL.sownef of thepropmy,ormyempinymn wllh wugesasnheif,nle cnoponsmlon, SWIMMING POOL ELECTRIC
will da the work.unitthe structure is out intended nnORem fm em(Sec.]f Wt,liunincss C1 OTHER
.ad Professions Cask: Gm Commuters License Law Joe,not apply man owner of OUTLETS-SWITCHES-FIRT'URES
63^ pinpeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however the building or improvement is odd widurtmoe yemofsompedon.the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build ar improve far In,
pox.of sale.).
0 1,as owner of the prnpeny,am exclusively contracting with licensed cnmmchas to TOTAL.
rostrad the project(Sec 70OU Business and Proleavons Code:)The Carriacou,o Li-
cnseLowdoesnotapplytoanownerofpropertywhohaildsorimprovesnhereon,and QTY, PLUMBINGPERMIT WEE
who contracts for such projects with a contractuds)licensed pursuant o the Con factor's
Llcensc law. PERMIT ISSUANCE
0 l am exempt under Sec. ,B&P C for Nis reason
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICH. / y O
I haffm0
ereby under penalty of perjury nuc of the ofteaintinns: ( (gdeelemV 1V
❑ Ibavo eudwill lnuinulinnCenifma of Cnnscmmrclf insure for WorkeLv Colnpcm DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECe1NSTRUCTION
,adieu,as provided fur by Section 3700 of the labor Code,fur the parformlumu al"lift
work for which his pcandtl,issued. - FIXI'UR17S-PER'I'RAP
0 I have and will maintain Workers Compensation Insurance,as required by Section
37Ml fthe labor Code.far the performance.fthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OLTLli'I:S OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy Nn.: GAS-E.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRfiA51%INUUSTRI.WASTE INfERCIiPIOR
OIIILDINO DIVISION IOGBS
(This section need not be completed lfthe pencil is nation,hundred dollar,5100) GR17ASII'HRAI'
nr Icssd PLANCIIHCK PEIi
Icerthylhm In Wu Performance ofthe work fur which thispprmitis Issued,Lshall SEWER-SANITARY-STORM PA.21X1 PT.
not employ any pcwminor,manners..,to became.amjecno *Worker::Comlca. ENERGY FEE
z ,Z sation Laws f at oro Ua WATIiR HEATER WNENT/ELECI'R
O Applicant kyaa GRADING FEE
NOTICE TO (CANT:IL alter makin6lhix Certificate of Exemption,you should WATER SYSTEMC REATING
become subject to the Workers Compensation provisions of the IaMm Code,you must SOILS FEE
f.rhwithcomply with such provision.,or this pencil shall he deemed revoked WATER S17RVICE
Z) z0. / IV/
U0 CONSTRUCTION ue aliaGAGENCY NEW RIiSIDENfIALPLMB. SQ.FT. PAID Date
L1 k for
na this ad perant a lnsued(Sec.30 len ding agency nor he porfnrnnlnccof TM1
the work for wM1ich this permit i,issued(Sec.3114],Civ.C.)
Y. lenders Name TOI'A�: I T
U Lenders Address TOTAL:
y1 W� 0
(-. I certify that 1 have readat
Nis applicion nnJ stem ohm the above information is BUILDING PER 0
W coout I.'ammc.mplywith allchymale.umyonli...resandstamlawsrelmingto QTY MECHANICAL PERMIT FEE
V building construction,and hereby awhorize representatives ofthis city to enter upon the SEISMIC PF.Fi 0
above-mentioned propcny for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep hannlmx he City of Cupertino against ELECTRIC FEE
dibil ides,judgmems.mals and expenses whichlnuy in any way gimme ngainxt...id Ci ly ACI'ER OR A DDI'0 MECH.
in mqu
eenca an
of The granting of this permit. PLUMBING hili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM(
MECHANICAL FEE is
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IILIMM)CFM) CONSTRUCTIONI'AX
Signanre of Applilif.00mmcmr Dan EXHAUSTHOOD(WMUC) HOUSING MII'IGAI'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building vacated store or handle hazaldou,material HEAD NG UNIT(TO 100.000 BU)
as dented by The Cupertino Municipal Cade,Chapter 9.I2,and The Health and Safety
Code,Section 25532(00] 1 HEA'T'ING UNIT'(OVER IT d ,d B'I'it)
O Yes L3 No PAID
VENTILATION PAN(SINGLE RESID) Doe Receiptk
Will the applicant or future building occupant use equipment of devices which
emit lermadmis air cmumbitats as defined by the Bay Arca Air Quality Management BOILER-COMP QHP OR IW,IIIXI BTU)
TAI..
District? BOILER-COMP(OVER 1(10.1100 BTU)
G Yev EJ No
1 have real the huvaNnus e' s mquiremems under Chapter fi 95 of flue CONDITIONER c Cali. � ISSUANCE.DATE
lian'n Heri&54, CnJe Sedam, ,505,25993 and 25534.I undemum l Nal If the NEW RESIDEN'T'IAL MECH. SQ.FL p
building smactemaily scalers that It is nym,urabifly to nobly licaula, L
of the cut l ainsuararol a Cerific ofOeuv
Z,2 _
Owner thor ms!agent Dae^ TOTAL: ISSU[D BY:
OFFICE
415 Yfi'v
r `
606$ 2zrs:
rN ?ATla OL .. DJq
-6FFIL8" •
- -'71YO FAMIL-f. FNM
�RoRaSEn pix4Do5ED
ROMEO
DAy wii'JoDWs PATIO o q5Y 3$
Eo6$= )COX.
TD Me ET LV•4ae;g gf2
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