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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPE RTINO H1111.DING - ELECTRICAI.
BUILDING DIVISION APPIACATIONIPFRMITPLUMBING. -MECHANICAL
BUILDING PROJECT'IIIEN'VIFICATION
PERMIT NO,
Q 6 7 2
v G U L
2
BUILDINGADDRESS:
�1/0 S13 a �{jn 50." �4ve
SANITARY NO.
APP.ICAI'I(ON SUBMIT'ITALDATE
(T] 9
�V� � "' "
OWNER'S NAMic PHONE:
6QT NS lU 4
CON RA(TOR'S NAh11?: LIC NO.
0 s03Si
N/c
❑
conk rkoLx
ARCHITECAWGINEER: LIC NO:
ADDRESS:
COi PHONE:
BUILDING PERMIT INFO
37 h 75-1 A
❑ Consultant Fees Paid by Applicant (Initial)
a F.I.❑EM, PLUMB M❑ I
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Illus 1 am Eicamad under powniom of Chaplet 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
wish Srv6or7(XXHol ilivisinn 7of the Business send Podussiuro Code, and mylicenu is
in full f.rcemnd
RESIDENTIAL:
❑SFUWL ❑ KITCHEN REMODEL
APPLE ANCES-RES I DENTI A I.
Lic.
hicensusi - 9 Council
Dale mm�m h
[]ADDITION ❑ PLUMBING RE.PIPE
❑MULTI -UNIT ❑5'rRUCT'URAI.
El
El INTERIOR CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
ARC[ IITI!C'TS DIiCIAkATION
I understood my plans shall he used as public records
PANELS
Oil T02W AMPS
Llcenacd _Poi 'evxunOl
201-1000AMPS
OWNER -BUILDER )ECLARATTON
1 bemhy n07rnl that I am uaemp( ham the Contractor's License Law for the
following reason. (Swtlom 7031.5, It wn, and Il mssiore Code: Any cdy ur auntySIGNS
Ll BATH REMODEUkI?PAIR CUP OLITION
❑ GTHER
pVl31t IIIfM]AMPS
ELECT RICA,
which requite, a permit u, amswct. alter, Improve, demolvii. or repair any structure
SPECIA, CI RCUIT/MISC.
ioo its ivamce,al.urcquires the applicant for such permit to rile a. signed statement
prnsv
snann the provisions of the Contrecury License Law (Chapter 9
that he is licensed paru
(comencing with Section LXX) of Dlvisima 3 of the Business sad Pmfessinns Ctde)or
m
TEMP ME -1 UR OR POLE REST.
COMMERCIAL:
that he is exempt therefrom and the Tarim for the alleged exemption. Any violation of
11NEW BLDG/A DDII'ION ❑ DEMOLITION
Section 70315 by any applicant for a permit subjects the applicant to a civil Penally of
POWER DEVICES
❑TENANT ❑pool) SERVICE
not more than Eve hundred dollars ($500).
❑Las owner ofthe prupeny, or my anployees with wages a, their sale compensation,
will do the work, and the.arucmm is not intended or offered for sale(SeaIDL(, Business
IMPROVEMIiNT
❑OTHER
SWIMMING POOL ELECT RIC
EX?
and Professions Coda: 'I he Comuctor% License law dues not apply to an owner of
Oil 11ETS-SWITCHES -FIXTURES
NEW REMDI3N'T AI. ELECfR SQ IT.
progeny who builds or improves dancer, and who does such work himself or through
his own employees, provider that such impmvemems are not imende l or offered far
sale. If, however, be huildingat improvement is sold within one year of completion.the
FT. I' RARER
$/SQ. FT
mer4ailder will Ease the burden of proving that he did not build or impure far pur-
pose of sale.).
Fl I. as owner o(the pmpeny, a exclusively contracting wink licensed contractors to
TOTAL:
compact the pmjat (Sec. 7144 ITu.viness and Polm%slnns Code:) The C.nlrustal N I.1-
nseLawdoesnotapplyuanownerofpropenywhobuildsorimprovesthereon.and
QTY, PLUMBING PERM111 FFF,
who contracts for such projects with a enntmemr(s) licensed pursuant o the Contractors
PERMIT
License law.
❑ 1 am exempt under Sec. . H & P C for Nis mwmn
Owner Date
WORKER'S COMPENSATION DECLARATION
ALTER- RAIN&V13NT-WATI!R (EA)
_ �yVNAAIT(lN
!- �,{(y/��
PACK Iq.0 YfE :J Bk'1
herby alarm under pettmry influent, s:
one (lithe fns rrvior
�t�i��T
ofCor Worker a Coarser-
❑Ihave undwiaf.. by Se Ceolliencof the Lab m Codenmrcfor Worker's 'he
satimt, as pmvldcA for by Satinn i71N1 of Labor Code, for the performance nt the
vonk for which this pe nn it I, laud.
UNAINS - I O,R (ARI?A, C(IND
STORIES
TVI'.CONSTRI1Cf1(lN
FIXTURES - -WRAP
and will maintain Walker', C'umprnsation Insurance, as regabed by Section'
J 00.fnkc l.aMmCade, for the perliumumceol(m work fill w Inch this permit is,,mral.
My h.
TP�PnlioyNn.y e
CarrWieosr Fr`)hC)an scmmiom u,ataGmierad pone
UCC. GROUT'
3'
v
6� APN
V
GAS-I!A.SV" dINC. l ".
CAS-EA.SVMVIR4(:A1
OREASI%INDI15'I'kL WAlI'Ii INT'IiRCF.ITOR
CERTIFICATHOPEXEMP"HON FROMWORKERS'
COMPENSATION INSURANCE.
ItUILDING UIVIS
ION rilN
ITtiescc(ion need not he a rpletcd'dthe pemul is far one hundred dollars ($100)
or less.)
GR17ASI: TRAP
PLANCHECK FI?U
I certify that in the per&mance ofthe work forwhich this permit is issued,[shall
nm employ any person in any manner no as to become subject m the WorkersCompen-
SEWER-SAN]TARY- STORM P.A. 21X1 FT.
FNURGY ME
WATI7R TIME ER W/VENT/ELECI'R
GRADING FEE
s ni.n Laws of California. Date
Applicant
NOTICE TO APPLICANT,Enact making this Cettificam of Exemption, you should
hcomc studied to the Worker's Compensation previsions of the labor Code, you must
WATER SYSTEMO RP.ATING
SOUS IEE
forthwith ca.,,Iy with such provixiomur this permit sial[ be deemed revoked
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I humbyaf0muhanhcm isxcnt,lantion lending agency(orthe perfmrmars.1f
NEW RESIDENTIAL, PCMB. SQ. R.
PAID
m Receipts
the work for which this pe omit is issued (Sec. 1097, Ci, C.)
Lender's Name
V TOTAL:
Lenders Address
TOTAL
BUILDING ITE
I certify that 1 have read this application and sum (list the abase information is
QTY. MECHANICAL PERMIT FEF.
SEISMIC FE13Nli
correct. 1 agree in comply with all city and county ordinances and spite laws relating to
building completion, anti herchy authorize representatives of this city Jointer upon the
PERMITISSUANCE?
ELECTRIC PEI.
aMwe-men(iunetl prnpeny rim in.slection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD' In MECIL
PLUMBING Itis?
EiahiEities,ludgmcros,costa anti exp(:nacs which any in troy way accuse agains(suid Clty
amvegannep of (be granting of This permit.
ADR HANDLING ONE ('1'O 10,000 CFM)
MLCIIANICAI.IEai
APPLICANT UNDERSTANDS AD WILL COMPLY WITH ALL NON -POINT
SOI.t .kUGI1LA'I'IONS.
AIRHANDIANGUNI'I'(OVHR 0.000CPM)
CONSTRUC'I'ION 'i'AX
)�
"44
SignN re of Apply n/Conmamr ate
li A%ARDD MA'I'URIAIS DISCLOSURE
EXHAUST' HOOD fed/DUCT)
HOUSING MITIGATION VER
BEAT' INC, UNI' I'G I01000 TO 1' 111
will tho? plieum or tout •hm1i ingoccupvmsmm,a handle haz.Nnas momrial
as defined by (he Cupertino Municipal Gulp, Chapter 9.12; and the Health and Safety
CNc, Section 25532(m)'1
1IHAI INC. UNIT' (OVEN I00JXXI If EU)
VF.NTILAI'ION PAN (SINGLE kIiSIU)
❑ Yes ❑ No
PAID
Dam Receipt x
'
P(OILER - CONI' (31 H' OR 100,003 HTO)
Will the applicant or future building by the B use equipment of devices which
emit hmard.us air ronunninama us JehncJ by the Nay Arca Air Quality Management
Di.aricf!
❑Yes [:1 No
TOT Q
BOILER- COMP (OVER 100,00i
AIR CONDITIONER
I have maul the hvnrdouenaRuialk requireomma under Chapter 695 of the Cali
ISSUANCE DAT13
NEW RESIDENTIAL MECIL SQ. PT.
folia Health & Safety Cole, Suetions 25505, 25571 and 25534.1 understand that if the
build tg sea not currently have mount, Iha it is my resptmxihility to notify the.ccupam
\�
nfth ammety which nwa bnnmt prlo iamocc of a Ccnificam of Oce
At"t' �x
ISS BY. 3-31-4 9
TOTAL:
woe r out .rimed age Uae
OFFICE