B0129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOQO� � '�0129
BUIIAINC PROJE.CTIDENTIEICAT'ION'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL])Alp
l9Fvo p ser 6_�'l .Q
OW R'S NAME: CC PHONE: CONTRACTOR'S yynnME:1 LIC NO:
d...,o ,�J d-y`j YL GpN / .aJ u�.q� /J [/ / NIC cf>,vruol.a
,ARCHITECII[NGINEE/VIk LIC NO'. py(IEQS7CC4N4I f/� ofa J f/ L/ ❑
CONTACD PHONE: HOLDING PERMIT INFO
��_� /�I LJOG ❑ Consultant Fees Paid by Applicant(initial) BLnc ELECT PLUMB MUCH
(% 6 I ❑ ❑
LICENSED CON']RACfOR S DE LI ARATIONQTY. ELECTRIC PERMIT FEE
MaZ
I thereby'Il m part 1 I' n,Wtrade,p ns of GtaE,r 9(urnms Ing JOB DF,SCRIPTION
W ScO 7000) fD n3 l he Bus :,and lnfsomos Codevndmy lac se RESIDENTIAL;
Fon in full force end cBal _ s PERMIT ISSUANCE D
,,V License Class Lie# 7/J�'4 3 ❑SFUWI, TCIIEN REMODEL
rFn6L Date -/T Carom-^•1C La APPLIA.YC6S-RISIDENTIAL [-]ADDITION C1 PLUMBING RE-PIPE
F O H ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
ZornZ Iunderxlnnd my plana shall M:used es puhlie records -
OZ 1-C UP T0200AMPS ❑INTERIOR ❑CHIMNEYREPAIR
F4 t:W Licensed Pode,simul 201-1000AMPS IMPROVEMENT ElSWIMMING POOLS
OWNER-RUEDER DECLARATION OVER I"AMPS ❑BATH REMODEL/REPAIR [I DEMOLITION
a a 6 1 hffim
ereby ol that 1 am exempt from the Carnation's License Law for the
X 3 d U following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL [I OTHER
W LL N which require,a permit to cororucl.alter,improve,denookh,or repair any stralon,
O� prim to it,k-nece,ek.oc'mm,the npplieom insnch peoniuo Elea,ignNstetemenl SPECIAL CIItCUI'DMISC.
L ray that he is licensrd peemam m the provisions of the Commeam's License hose(Chepter9
1y�00 (commencing %Il with Seen..7D of Division 3 of the Business and Profession.,Code)or TEMP.METIiR OR POLE INST. C-QSM ER I I:
d a e a that he is camp)therefrom and the bad,for the alleged exemption.Any violation of 9ENA�[i`
E\4 LG/AWITION ODE MOLITION
x_^,N Section 70}LS by any applicant 4aapermit subjects the applicant toacivil penalty of POWER DEVICES ❑FOOD SERVICE
Mol more than live hundred dollars($500). ROVEMENT
`=6O 01,o,owne,ot the prupeo,o,my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
k. will do the work,.nd themmome is angio,odedorolficod forsale(SaJ1144,Business HF
fail m and Profe ft...Code:The Contmetors License Law docs not apply to an owner of 5 OUTLETS-SWI'ICIiFS-PIX1 URES "
tl 3 property whit builds or improves Ihemon,and who died,such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.IL hanrvcr,the building or improvement is sold within one year of completion.the SQ.14.FLW 5/SQ.IT.
owner will have the burden of proving thin he did Mat build fir improve for pur-
,e coL-le.). -
1,re nwner of the p,.,ny,am cxcic ively contracting with licensed cnmmeme,t0 IA
c...Me,the project(See 711W.Intiones,and ferefesaiuns Cral Mac Contralto',Li-
reuselasedoesnot apply toanowner ofprogany who builds or improve,thereon.and QTY. PLUMBING PERMIT FEE
seho contracts for such projects with a contractur(s)licensed pursuantto the Committees
License Law. PERMIT ISSUANCE
❑1 am emmpt under Sec. .R&P C fn mit reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Duro
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE \ �kO
IherebyathnnunderNnalty ufperjugoneofthefollowingdeclarations: C/ C/
I have and will maintain a Certificate of Conant to self-insure for Worker's Compere- DRAINS-Fl. R.RWF,AREA.COND. STORIES "IYPF.CONSTRUCT ION
union,as provided for by Section 37M of the Labor Code,for the performance of the
wark for which this pemet I,i.woil, FIXTURES-PER T RAP
f�1 have mil will atainmin W..far,Conmevralk la-ranee,as required by Section
}7W ofthe Lnhor Gvlu,fonhe perfurmanec of the workhn whaddo,eurliei...ed. GAS-EASYSLiM-I INC4OU'H.I?TS OCC.GRaUP APN
My Work s C. Pan 4ca Indtwe vain 1 11 d Policy nu
Carries 1,L L P'Uv"(r Policy No.: U�G�Or GAS-BA.SYS'I'Ehf-OVERa(IiAI
CERTIFICATE OF r XEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi,action.eed mabre i ipletWifla"renis is Poronchundreddollan(SI00) GREASE'I'RAP
Miles.) VhANCHECK THE
I comity that in the erfornoncc afire work forwhich thispemut i.si,sncd,I doll MSYS'l
ARY-STORM E\.2W FT
not employ any perom in any manner u)as m become subjem m the Workers Co.,.- ENERGY FIJI
Z -lion Isms of Califon ia.Date WNENTrELE , - 4PAID
O O Applicant \
�' NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should /IREATINGbecome subjm m the Worker,Cum,sa-trod provhinrv,of the LaMa Coda you must forthwith comply with ouch Provixian.fir tis permit shall be decmcdrevok,d.CONSTRUCTION LENDING AGENCY 'IAL PLMB. SQ.IT. .� aU O (hereby sin.that there is aummtmetion lending agency fmthe perhnmanreof �. .�the k f h h di pe t yyl/ 30 1 C' C) III 1 `��Lend .N TIIIAL'O V TOTALreW0. Led/:A IJ :. GI I'ty f 11 h d d I fi I dao th l lh mamn i,V] corrcct.lvgrcct.comply with all c'ly ad county oN nooses and-lms l -rel ting to QTY. MECHANICAL PERMIT FEE
V Z building cunmmetion.and hereby aathone,representatives ofthis city to enter upon the
aMve-mentioned pmpeny for inspection porpoises. PERMIT ISSUANCE EL[GTRIC P[C; Q OI
(We)agree,.save,indemnify and keep harmless the City of Capetian.against
Iialidnie,,judgmentt,sou¢anlenpense,which may many wayacemeugaind said City ALTER OR ADD TO MECT PLUMBING FEE
-in ceaw"con's,ul the gran if of thw �t
APPLICANfJk NDER NDS I. WILL COMPLY WITH AI.I.NON-POIN"r AIRHANOI.ING UNIT(TO I0.0(X)CFM) MECHANICAL FEE
SOUS/. C AT1 S.
AIR HANDLING UNIT(OVI3R 10.000 CEM) CONSTRUCIION'1'AS
Signature of ApplicanVComrannr Date EXHAUST FOOD(WMUCI) HOUSING MITIGMION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or lumre building ocemmid slum or mndle haennlous minimal HEATING UNI L(TO 100.000 If 1'U)
as defnW by We Copaibas,Mu Opal Code,Chepmr 9.12,and the Health and Safety
Code.Section 25532(a)1 HEATING UNIT(OVER 100.000 li'TU)
El Yes KNo VENTILATION FAN(SINGLE RESID) PAID Date Raeipla
Will the applicant or future wilding occupant use equipmem or da'ice,which BOILER-COME(3HP OR IIkDMO BTU)
t ba7arduas air c.ntuminanu as defined by the Buy Arca Air Quality Management 'IO
bsmmp 1
0Yet G(N BOILER IfMl,flgl N'DU)
AIR CONDITIONER SSUANCI�J)ATE^
1 have noel Ne hate Se roam' quircme.t,un53 Chapter h 95.E Lha Cali" 11 lT%/'/'i �'(
luddiHealth 'afety C .Sttuu '_ 05.:5533 nm12553a.i understand that if the NEW RESIDENTIAL MECH. SQ.pr. 6, ( \v
building tine cumem , te that it is my rcsponnibilirymnmify the occupant IIYY
u'u enlaw ' at hcl apdor to issuance ofa Cem roof Over y
/l- OF,.
Owner ur oil nrizcd agent Datc TOTAL: ISSUED BY: L
OFFICE