29119APPLICANTTO FILL IN INFORMATION
APPLICATION/PERMIT
�C �L•Gt"✓ . 9id
1 hereby affirm that 1 em licensed under provisions of Chapter 9 (aimmencing
�aZ wish Seniom 00mof Divisim.1 efthe Bnsinesa and Profes.emo Ccul,ondmy llcem, is
in full 1.6 and effect.
M�UV License Clms' Lic.if "
hG L Date Contractor '
,ARCHITIiCr;' DECLARATION
Z86,2 2 I understand my plans shall he used es Public reaeNs
OZ4- 't-
Fun It - Q Licensed Professional
b(f3 0WNER- BUILDER DECLARATION
WW, I hereby affirm that I am exempt from the Contractor's License Law for the
3 d U following revs.... (Section 7031.5, Business and Pmfessinne Code: Any chy o. county
LL I- which mature, a permit m consmun, alter, improve, demolish, or repair by structure
F LL'0 prior to its issuance. alse) mquims the applicant for suctipermitto Etc a signed smlement
17} that he is limbed pursuamunhe provisions efthe Commeme, License Law (Chapter 9
(cnnnnceriog with Section ,lgq)al "Division 3of the Business and l'nrlaaalmns Ctde)nr
thin he is exempt therefrom and he basis fur the alleged exemption. Any violation of
aX1 of Section 7031.5 by any upplicant for a permit subjects the applicant to a civil frosty of
not more than five noitued dollars ($5001. ,
n C ❑has owner of the pnnpeny, or my employees with wages as their stir, comp......:..,
3 wdl do Nawnrk, vnd theawmure is notlmendesl, oroRerul forsnle (Sec.9(W4, Business
G unit Professions Cut The Contractors License Lust does not apply m as owner of
"'p oiaty who builds m improves tbercmi, and who does such work himself or through
his own employees, providW that such improvements arc no. immmded nr offered far
'at..If, however, the building or improvement is sold within one year of rnmplccZ', the
owner -builder will have the burden ofpmving that he did not build or improve for pur-
ps st, f 1 7,
❑ I, as aware of the P pert' min c.o.,ively a.on,.to, ith beensW contractors 1.
construct d pro,ect (Sea 91144 Bu: rte.:.. ) Professions C d-, 1'1c Co macro. cerise L wd sn not apply t fpropeny who builds orimproves thereon and
who Contracts far such pnlee.s with ac:mbecous)licensed pursuant to the Cmanob s
License Lgov.
El I am exempt under Sec - ,B &P C hn idt"Zo/t
- USE BALL POINT PEN ONLY
BUILDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECT IIIENTIFICATH
;ONTRACTOR:S NAME: LI
M P, 46
IDDRIESS:
❑ Consultant Fees Paid by Applicant (Initial)
)TY. ELECTRIC PERM IT
FERMI "I'ISSUANCE - �t
APPLIANCES - R ESNIPTI'I AL
PANELS "
UPTO 210 AMPS
201- IIX0AMPS
OVER 1000AMPS
SIGNS ELECI'I C
SPECIAL CI li'IMI'
TEMP. MI: : R 1 -1, ST.
POWER DEVICE.
SWIMMING I.00LEI.. RIC
OUT LETS- SW1'rCHES -FI URES ,
NEW RESIDENTIAL ELECT R,
TOTAL,
TTY. PLUMBING PERMIT
WORKER;' COMPENSATION DEVLG¢APIOfI
1 hefehy affirm under penalty of perjury one of the following declarations:
I have and will mairmin a Ceniticam of Consent to evil Giosum for Workers Campcn-
sation, as provided for by Section 3700 of the Labor Cute, for the perf arommee of Ne
work f r which this penmi. is :camel.
❑ I have and will maintain WorLer's Compensation insurance, as required by�Seciion
3900 of 0r, Labor Code, ftnhe performance of the work lie' which Nls front is issued:
My Workers Compensation Insurance carrier and Policy number am:
Curler: Pont, No.:
CERTIFICATE OF EXL'MPHON FROM WORKERS'
` COMPFNSA'I'ION INSURANCE
(T1oaaectirn need not be completed Who Permit for one hundred dollar. $100)
or IesiJ1 certify that in the Performance of the work for which this permit is issued, T shall
of any person in any manner m acv becnm ,ith Ict In Ne Warlse. Cooper'
Q z salion laws of California. Date
Z Applicant
.N. NOTICE TO APPLICANT: ih afar making this Certificate of Exemption, you should
a become subject m the Workers Compensation provisions of the Labor Curie, you must
forthw hh comply with .och provisions or this permir shall he deemed revoked.
O CONS' I'RUCYION LENDING AGENCY" -
1 hemhy affirm that hem is a construction lending agency for the performance of
the wok for which this perm) l is lssued(Sm. 3197, Ci v. C.)
Q U Lenders Name
tG: Lender's Address - -
I certify that I have read this application and smte that the above information is,
V!)i corbel. l agree to comply wile all city and cman, ob inance: and state law'x relmi.g m QTY,
l.7 building construction, and hereby authorize representatives of this city to enter upon 'he
above. (We) ed propery lnr iosp ft' an Purposes. - (We) agree n,. cove, indemnify and keep harmless the y ac o anoint against
ibotlw,mcdeofthe nand expenses which may in any way aceme against said City
• in consequence of NC grunting of this pemit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI NON -''�tA1NT
SOURCE REGULATIONS, . //a, _
HAZ RDOUS MATERIALS DISCLOSURE 4 , -
• Will the applicant or future building occupant smut or handle acandous material
of defined by me Cupertino Municipal Code, Chapter 9.12, and the Hedll and Safety
Crate, Seerinn 25532(e)'!
❑Yes,
No ,
Will Ne applicant or filaiv building occupant use equipment or devices which
nit h:vmdous air contaminants as defined by the Hay Area Air Quality Management
1Okincfl s
El Yrs Fl No
I have read the he ... due, materials re".r6c is under Chapter 6.95 .(,he Cali-
human Health & Safety Code, Stations 25505, n533 and 25534.1 understand that if the
mildimg does am carten0y I.... a turnm. that it is my real msdiihty to re fy Ihr ocuapam
of the nomination. which at be met prim m ismarec of a Ceriifiewc of Occupancy.
PERMITISSUANCE
ALTER - DRAIN & VEN
BACK
DRAINS
DRAINS - FLOOR, R
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I D
GREASETRAP
SEWER - SANITARY -STO 1EA T.
WATER HEATER WNENT /IiLF.Ci'
WATER SYSTEMNREATING
WATER SERVICE
NEW RESIDENTIAL PLMIL. "SQ. EL
•MECHANICAL TERM IT
PERMIT ISSUANCE
ALTER OR ADD TO MP-CH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER Iy"CFM)
EXHAUST HOOD OVIDUCT
HEATING UNIT (TO R1000 BTU) ,
HEATING UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE RISID)
BOILER -COMP UHP OR 100,000 B'M
BOILI7R - COMP (OVER HIT" BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ.
r '
OFFICE
PERMIT NO,
29119
SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
12'L'1�'S
JO:
NIC - O T a
1
❑ BUILDING PI: MIT INFO
BLDG ; ELECT y% IT EST Imo• MECH'
FEE LrS -G,/ JOB DESCRIPTION
WL' �❑ KITCHEN REMODEL
IiJADD[TiON ❑ PLUMBING RIPIPF.
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑ INTERIOR - ❑ CHIMNEY REPAIR
IMPROVEMENT) n
❑ BATH REMODEL/REPAIR '❑ DEMOLITION
.�OTHHR
w
�ntAl pRi 11 n 9J9 7
Comm _ '
❑NEW BhDG /ADDTION( -t'b OF,MOLITION
i 'OTENANT " tEl FOOD SERVICE
IMPROVEMENT
❑ OTHER
GRADINVEN
`SOILS FEE
J,
PAID
'Date RceeiPtp
TOTAL:
FEE SEISMIC FE
ELECTRIC FEE
PLUMBING PEE
PAID "
Dam Receipt a
'TOTAL: .. s
SSUANCF A
P
SSUED BY:
SQ, FT FLOOR AREA
&'fkaSQI
FEE
LGAT I N
- - STORIES
1'
TYPECONSTRU
OCC.GROUP
APN
In ILDIAIC( UI .ION ITiCS
GRADINVEN
`SOILS FEE
J,
PAID
'Date RceeiPtp
TOTAL:
FEE SEISMIC FE
ELECTRIC FEE
PLUMBING PEE
PAID "
Dam Receipt a
'TOTAL: .. s
SSUANCF A
P
SSUED BY: