S 1326 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLECnaC'E PEI rf No
RUII,DING DIVISION APP1.ICYVIONWERMIT PLUMIING-MECIANI,AL 1326
AMILDING PhilIDENTIFICATION "
BUILDINGADORI?SS: � - SANITARY NO. APPLICATION SfIBMITfAI.DATE
AL-LID, `3�--q S
OWNER'SNAME' I'H(1 ) CONII O
'RACR'S NAME 'LIC NO:
C - � NIC
CONTNOLM
ARHITEM)ENGINEERLIC NO: ADDRESS: 7-3
wu." G Zt
a)NTncT: 1 � ZONE: - "< `',BUILDING PERMIT INFO .,
JCOA,soImL' � rr&4% N (510-)q3o-96g6 El Cmnsullam Fees Paid by Applicant(Initial) BLDG IT PL PLUht13 MECH
),ICI III CON TRACTOR S OICIARAI ION QTY. ILECT1130'ERMIT,,,I ;=FEE
cny
I herof iter n t 1 licensed e p of Chapter 9 amm.re ng ,'' 1 _ 'l. '. -' - . 1 JOB DESCRIPTION
Amo win,Sea 70001tfD' % n 3nnhe e,irco,.nd lr f: ,:.Cn It,lint t, "ema,.'s 3�ff RESIDENTIAL.
W O PI I1MI'I RSI1nNCli
b W in Class ef!t ❑SI OWI. [I KITCHEN ItEMOD131.
aUU 1.ianse Class Ln, APPLIANCES—RISIDEN'HAI. ❑ADDIT[ON ❑PLUMBING RE PIPIT
F•Z W Dm. Cumactnr -
tn¢a ❑MULTI-UNIT OSTRIJCTURAI.
ANCIi I'I'hCI"S DL'CLAlinl'lI1N
OMhz Iunderstment,plum+hall bel used as public records PANELS - CHIMNEY
Z'4� UI"fO FW AMPS 2, 20 ❑INTERIOk ❑CHIMNEY REPAIR
Ias�jFW Licensed Prnfessimal 201-1000 AMPS IMPROVEMENT 0SWIMMING POOLS
al OWNER-BUIIDBR I)F.CLARATION
p'C4 W Q I M1erchy efEm1 that I nm exempt from the Convacun's License Law for the OVER 1000 AMPS 13AT11 REMODEhBI?PAlli ❑DEMOLITION
X�aV followingcounty ❑OTIIER
.)Sect ]III 5 H m I P :C d e Y ly Ire SIG451 LEC'1 RICA).
1- wt h 1 II t t h P demolish. P Y:t rent ..
J6J6 prix I I 1 req m ppl tf M1p fl 6 J'I le nv rt SPI'CIAL CIIICUII/NISC,
(cam I ' it Pms: a 'heP :nn if the Coal I License-
al 1' (CI prcr9 _
ZC, ammcncmgwilh5eaam70X))of Drvsion 3 of the Business aide nfes:m.+Ude)nr 'fIuU P.MIiIIiIt OR I'OhIjJ" 0NEWcomBLCIAI'
)hat he is exempt Ihcrel'rum unit the basis for the ullegttl exmnplion.Any vinlmion n[ ❑NEW BhDG/ADDITION ❑DEMOLITION
W,,,m Section 7631.5 by any applicant for a .at,subjects the applicant m a civil penalryof POWER DEVICES Zvi. O'I ENANF ❑1'001)SERVICT
FSGnm mm's than five hundred dollars(55(10), MPROVEMEN'1'
Ol.mnwner.f thepmlzny,onny anployccs with wages as their sole compen.amion, SWIMMINGPOOLEIJiCI'RIC
wdidnlhewomor
rk.omUheamuer.ix not inumealNTomd f.rsule(Sce.]644,Business El OTHER
W 3 and Professions Code 'Me Columbus,License Lax does not apply m an owner of oil'rT I:S-SWI'I'CHITS-Il%TURES
prnpeny who builds or improves thereon,and who does.such work himsell.r Enough
In,mcn can,imees,p ided th I.rich improvements am a.,-attended reoffered far NEW RI SIOIiNTIA1.HLEC'1'R Sp FI'.
ulc.11 t1 h ill b P I I I 'd' y f pl I t n.the SQ.FI'.FLOOR AREA S/SQ.FT.
as mer-hoolder willh the burden f provingtlrth did notbld or improvefelt put-
Earn.1 sale.
ut Ears 1. - ly
[] 1,as owner of the pmpeny,alit excll usely contracting with licensed contractors to TOT'
con....to the pr i(Sets 7014,liminto and Pedewinm Code I I ne Comment'si- ,• • y L, y�r
Ise Law dues nut ply loan owner ofpmpcny who builds or improves thereon, QTY. PLUMHINGPERNIT � 'FEE
ap
who contracts her such projects with o corrections)Iieenscd mentionuo lbs Can..wbas /
sL�ic•m'n.+e Law. PERMIT ISSUANCE
I and exempt under Sec. ,B&P CI.rlhis reason 00
AC ER-DRAIN&VENT-WATER(IIA) VALUATION
OwnerUalc _r
WORKI;R. COMI'1!NSATION f iC.AR61'ION RACK FLOW PROTECT DEVICE1-6-2- ) ry_Q �•
I hereby affirm under Penalty.f pe jury one of the following declarations: l\VJ/VVV
❑ I havmmd w ill nmialmn it Cenifcmc of Cnnvmn to svl(-inmm for Wnrk,'x Compam DRAINS-FLOOR,ROOF,AREA,COND. STORIES I TYPE CONSTRUCT ION
sari..,as provided for by Section 3700 of the Lat or Cede,1'.r Ne pcdiumunce.1 the O
work barwhvirflus pannills isxned, Z. PIXTURES-PER THAT
1 have and will maintain Workers Compensation Ipsoancu xx requited by Section 11
- :3706.1'the[,be,Code.fe,relxrformmnmnf the work for Ts Nero l hislwnnit is issued. OAS-ISA.SYSTCM-I INC.4 GO G.FI'S OCC,CROUP APN
My Worker's Conpereatem Insurance carrier and Policy nounber ore:
Carrier Policy Nn.: GAS-EA.SYSTEMOVER 4(PLA) _
CERTIFTCKIT OF EXEM17ION FROM WORKERS' GREASFIINUUS'1'RL WAS'1'F.INTERCLpI'OR
COMP') SA'IION INSURANCES O111L ) [BION IgiFS
Cm-eotinn need not be vomplcte4 iOhe pemtit is far one hundred dollars(51110) GREASEIRAP
orles.a.) PLANCHECK IFE �,
toy any tlet in in anymnuneeo as t work fa wuhrod 1.IlaW ixissuN,leholl SLWRR-SANITARY-STORM F.A.2010 P1'.
not employ any person in any mannenn arson become suhjed lolhe Wnrkeci Cotnpen- - ENERGYREE all � .
7.1 enIt T lawsof Cllifomiu.Ours WATER HEATER WNEN'I'/ELEUTR
Applicant - GRADING FEE
NOTICE TO APPLICANT:IL aenr making this Cendican,of Exemption,you should WATER SYS'M-MG7RIYTINO
F " beunae subject to be W.tkers Compensation provisions of the Labor Cole,You nmsr SOILS PLL
Iomhwllh comply with such provisions or this pamnit shall be deemed revoked. WATER SERVICE
LL44 Q
CONS'I'III ICTIUN LENDING AGENCY NEW RESIDENT AC)'LMB, SQ.I'I'. PAID
VQ I hereby affirm that hem is a construction lending agency arthe performance of )Tem Rccen M
tire wt)rI Int which)his pcnnil is ixsuud(Sea.31197.Col.CJ
Y. Lenders Name IO1Al.
{UL) Lcrder's Address A
fy, 1 cenify that 1 have read this application and slam that rbc above information is BUILDING 17 �k
umc,a.I ugme lo comply with all city teal eomnY nrdarierea and sate haws relating os QT'Y. MR:1 N CAL PERMIT. 3,' FEF.
C.J z building construction, m
stion,and hereby eah. e represenmtives o [,)enter city enter uptmthe - - "1- SEISMIC PLIn'
abmomemic ned prepcdY Iia inspection purls'scx. a1)
(We)a m save.indo11mf d keep harmless the Cit f'Cu nt,a t I'CRMI'I'ISS _ ELI:CTItI O
goo yen p arcane
peni gains
liabilities,judgmenl+.costs and expenses whish may in any any seems again.a said City ALTLR 'IO MI?CII, r�'�
PLl1MItIN' .U; V
' �nnscyucnce ufrhe granti11g.[this permit. - 1 VV /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR la ) I ( UINI�Tvk'O4F)III Pb ) MLCIIANI L THE o
SOETICE REGULATIONS.
AIR))ANGLING UNI'TOVER 10,000 CPM) CONS'I'RUC'ION TAX I
Slgnatureof AppliceaVGourector Date HXHAIS'114000(W/DUCT) HOUSING MITIGATION FE,
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant.mom Buildingmeuponl,malshandle hozallous...head H EATING ONE'1'('1'0 100,000111'U)
ns defined by the Cupenbm Municipal Code,Chapter 9.12,unit the Ileahh Imd Safety
Code,Section 25532(x)'! 14E l INC,UNIT(OVER 100,kx)ill'U)
❑Yes ON. PAID --�
VLN'I'ILA'I'ION PAN(SINGLE kESIU) Doc ltacei #
WIII the applicant nr furore bnilJLrg.mvpanl me ryuipnanl or Ju....which
emir hazardous air containments as defined by the Bay Area Air Quality Management TOILER-COM)'(311P 011 I60,fXX1 B'fU) - 'roi AL:
Divinm^
Fos BOILER-COMP(OVER 100.000111U)TU)
] ONn
1h:we read the har,ndnuv madmiaN minirements under Chapter 6.95 ofre hCali AIR CONDITIONER - ISSUANCE DA'I'S
Room Health&Safely Code.Sections 25505,25533 and 25534.1 millennium]Thal Ville NEW RESIDENT IAL MECH. SQ.FL
building docs 11111 Initially have it mmv:E that itis my resp rsibdityt.notify the recle nl
of Ibe rexryiremenu which most be met pAr,1.issuance of a Clird icam of Occupmcy.
Owners aathnrized ugenl Date TO'T'AL. / O ISSUED BY:
OFFICE �'