31049APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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CITY OF CUPERTINO
QTY.
BUILDING - ELECI RICAL -
-
- PERMD NO.
`
6UILDING DIVISION
APPLICATIOWPERMIT
PLUMBING - MECHANICAL
API'LIANCFS- RCSIDCN'flAl.
O
'
PANELS
UP TO 200 AMPS
I UILDING PROJECT IDENTIFICATION
Licensed Hnfessional + _
", s notIa amorp,IiRDECLARATION Li
1 hereby nffinn that I nm exempt fr.m the Cosions Coda: s License ty o fonhe
following rwxr n. ($cation ]onsum Business trod ova, de in li h. or Any city or county
which rcyuires a pemtit to amswa, titer, improve, demolish, or repair any swcmre
piton. itslssumtce, als�requiresthe�pplicantfmsochpermittofileunigncdstmcment
that he is licensed puauan in the provis ions of the Contractor's Licenic Law 9
(commencing with Soilam](KKl)af DiAmmi J of the Business and Pmfessians Coca) or
that he is exempt Nerctrom and the basis for the alleged exemption Any, o1w nn of
Section 7031.5 by any applicant for a Permit subjects the applicants. a civil penalty of
not 1,asooan five hundred
I re
,vart, arsyemployee, m '-
property, Urmyainabrdmeficagesasa1jiSac sole 70j B.nt ion,
will Jn the work, and the ntruemre ix not imendvd or alldred for sole (Sec.7(94, Bminess
and Pafessions Cade: The Cambodia's License law does not apply to an owner of
nolwrry who builds or Improves therum, and whit does such work hinrself or through
his own employee, provided that such improvements are not intended or offered for
nulc.lf. hnweva, the huilding or intpmvctnem lx sold within one yovrofc.nt'Iglon ,that
overear-builder will have the burden affirming that he did not build or improve forpur-
prom• of sale.).
R its owner of the properry, am exclusively contracting with licensed contactors t.
c smtruet the project (Sec. 7194, Business and Professions Colin) The Cmduce is Li-
tense Law does not apply to ant owner of pined, who buildsmimpones thereon, ad
whocontrnets fersuch projectswith amuterror(s) licensed pursuant) the Contacmr's
License law. I r
I Um exempt under Sea ,B& 1' C forthis reason
201- IOWAMPS
BUILD IZADDRESS:
OVIiR 11100 AMPS
SIGNS ELECPRICAL ;
'
SANITARY NO.
APPLICATION SUBMITTAL wal
e-
TfMP.M= -R OR P IN
�
COMMERCIAL: <
❑ NIiW BLDG /ADDITION ❑ DEMOLITION
❑TENANT' _O FOOD SERVICE '
IMPROVEMENT
❑OTHER
"-
tt)WffA��jol'S NAME:
�1_
f{+�54�.�'HONF:
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COMI'RACTUR'S NAME: LIC NO:_
SWLMMhYG POOLELECTRIC
OUTLETS- SWITCHES - FIXTURES
N/C
CONTROL N+'
�ARCIIITIiCT/ENGINIiCR:
li� aS
-
❑'
Y
��1 "
NO:
ADDRESS:
$/SQ. FP.
CON'1'ACI':
11IIONE:,v
BUILDING
PERMIT INFO
J
"
�1CI1: ��S
CP)99G•Oi12
❑Consultant Foes Paid by Applicant (Initin)
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1 hereb affirm Thar I vn licenxd under ' V .�� f Chn mr 9 (armmencin
y provis;n.x. p g
th Scct
in falf Class d'O �Dlvish 130 tire Bnsinesc and l'rofcssionx Code, and my liwnnc is
.full force
co,b La'M
Dam Command.,
QTY.
ELECTRIC PERMIT
Fli
•'JOB DESCRIPTION
S DWL ❑KITCHEN REMODIeI,
❑AUDITION El PLUMBING RE -PIPP
❑MULTbUNIT . ❑STRUCTURAL
MODIFICATION
.El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
El BATH REM DEUREPAIR ❑DEMOLITION •,
'D OTHER �
`
PERMIT ISSUANCE
API'LIANCFS- RCSIDCN'flAl.
ARCHI'I'ECI'SDF,CLARATION
IunJernanJ my plans shall as puM1lic records
PANELS
UP TO 200 AMPS
Licensed Hnfessional + _
", s notIa amorp,IiRDECLARATION Li
1 hereby nffinn that I nm exempt fr.m the Cosions Coda: s License ty o fonhe
following rwxr n. ($cation ]onsum Business trod ova, de in li h. or Any city or county
which rcyuires a pemtit to amswa, titer, improve, demolish, or repair any swcmre
piton. itslssumtce, als�requiresthe�pplicantfmsochpermittofileunigncdstmcment
that he is licensed puauan in the provis ions of the Contractor's Licenic Law 9
(commencing with Soilam](KKl)af DiAmmi J of the Business and Pmfessians Coca) or
that he is exempt Nerctrom and the basis for the alleged exemption Any, o1w nn of
Section 7031.5 by any applicant for a Permit subjects the applicants. a civil penalty of
not 1,asooan five hundred
I re
,vart, arsyemployee, m '-
property, Urmyainabrdmeficagesasa1jiSac sole 70j B.nt ion,
will Jn the work, and the ntruemre ix not imendvd or alldred for sole (Sec.7(94, Bminess
and Pafessions Cade: The Cambodia's License law does not apply to an owner of
nolwrry who builds or Improves therum, and whit does such work hinrself or through
his own employee, provided that such improvements are not intended or offered for
nulc.lf. hnweva, the huilding or intpmvctnem lx sold within one yovrofc.nt'Iglon ,that
overear-builder will have the burden affirming that he did not build or improve forpur-
prom• of sale.).
R its owner of the properry, am exclusively contracting with licensed contactors t.
c smtruet the project (Sec. 7194, Business and Professions Colin) The Cmduce is Li-
tense Law does not apply to ant owner of pined, who buildsmimpones thereon, ad
whocontrnets fersuch projectswith amuterror(s) licensed pursuant) the Contacmr's
License law. I r
I Um exempt under Sea ,B& 1' C forthis reason
201- IOWAMPS
OVIiR 11100 AMPS
SIGNS ELECPRICAL ;
'
SPECIAL UI SC
TfMP.M= -R OR P IN
�
COMMERCIAL: <
❑ NIiW BLDG /ADDITION ❑ DEMOLITION
❑TENANT' _O FOOD SERVICE '
IMPROVEMENT
❑OTHER
POWER DEVICES
SWLMMhYG POOLELECTRIC
OUTLETS- SWITCHES - FIXTURES
NEW RESIDENTIAL ELIiCTR 5 FT.
-
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SQ. FT.FLOORAREA
2`59w:
�{.p
-
$/SQ. FP.
T
QTY, PLUMBING PERMIT
FLEE
PILAMY ISSUANCE
AI' - RAIN &VENT -WATER EA)
n
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VALUATI(lN
(� L0�'�
2
WORKER 'SCOMPENSA'FIONDECLARATION I
l hereby affirm under penalty of perjury one ofthe following deMaations
I havesnd will maintain a Certificmeof Cunsato sell texture far Worker's Compnt.
cation, as provided for by Section JAM of the Labor Code, for the performance of the
work for which this verbals issued.
❑ I have and will maintain Worker's Compensation Insurance, as ramified by Section
3](Nl of the LaMrr Gde, fonhe per(.rmuncc nfthe woik lire which this permit is ixsued,
My Workers Compensation Insurance carrier and Policy muddler are:
Cartier:" Policy No.: -
CERi' IFICAI'EOFEXEMPTIONFROMWORKERS'
COMPIiNSXGON INSURANCE . -
(Passcaimi need.., bccompleed ifthe permit is(.tune hundred J,,[].(SIM)
entire.) - - -
ury any,haromin performances as xorkfce,.1t.1 the Wikb,,'C Issca.
not unl'Iny anyreson in any manner sit asroh ¢r the Worker Coln'
ration Laws of California. Date one
Applicant -
BACK Iq. OTECT DEVICE
DRAINS- FLOOR. F,AREA FIND.
STORIES
- s
TYPE CONSTRUCTION
FIXTURE AP
GAS - HA.SV .40Ut'.[TS
OCCGROUP
ray
IUYi• \aj
APN
( .
GAS -EA. SYSTEM-4E (I
-
GREASFANDUSTRL WAS'IT3INTERCEPPOR
I I, i
IVISION FGCS
-
GREASHTRAP'
SEWER - SANITARY- STORMEA.2WFT.
ENERG\
WATER HEATER WNLNT/ELELTR
GRADING FEE.
!
NOTICE TO APPLICAM: IL after making this Car ificnie of Exemption, you should
forthwith comply Vr the Worker's Ction, or this permit ions.(, he Labor Core, man run
forthwith comply with such provisions or this pcmri, shall ledcemeJ revoked.
CONSTRUCTION LENDING AGENCY ..
I.,w effrn that here lssued(uuui0lending agency for performance of
the work for which this permit is issued (See. 709], Civ. CJ
Lender's Name
WATER SYSTEMITRENTING
WATER SERVICE
SOILS FP.Ii
PAID
Data Ra
n
Ir
NEW RESIDENTIAL PLMB. SQ.IrI'.
t
+I
I <ndelI Address
BUILDING FEP �
e�
1 cenily ,lens 1 have read this applicminn and rata rhm the nbase informmien is
correct. l agree to comply with all city and au fly ordln ... esandstsm laws adaling us
buildingeonnructiaii. udhembyautha rizerepresenme ¢pn
tiv.fthisci,y,oenrun,he
Howe -cream Ned property for inspection purposes. '
(We) agree to save, indemnify and keep harmless the City of Cupctino against
Iiabilitiesjudgmenu, costs and expenses which may in anyway accrue against said City
nseyuenceofthegramingofthispermit .'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU E REGULAT ONS.,
, G/I Z/4 .�
QTY. MECHANICAL PERMIT
FEE
SEISMIC FEE
a I'
PC IT ISSUANCE
ELIiC ( F.E
AIJERORADDTOMECH. -
PLUM N 1 Ti
AIR HANDLING UNIT (,010.000 CUM)
MECHANICAL PEG
AIR HANDLING UNIT (OVER 111,RfN1 CUM)
_
CONSTRucPIONTAX
S' matumo( Apt,ficanVCmdactor - Mate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous nuneriul
as refund by,he Cuficombs Municipal Cale, Chred, 9.12, and the Hwlrh and Safety
Code, Section 25532(a)Y
Cl Ye. ❑Nn
Will the applicant on future building by the Bay equipment it devices which
emit bne,udoua air contutninnn(s as dellnul by the Bay Arcs Air Qstmlity Management
Dixtncr] - ❑
❑ Yes No - r
I have read the hazardous mamrials rouiaencals under Chapter 695 mthe Cali.
q p
faffi Health & Safety Code, Sections 25505. 25573 and 255]4. I understand that if the
huilJing dares notafety Code, Semnns 2550 it leery and m 34.1 wneistandeat if am
.the regairemmts whieli must be a, 'nor to issuance 'if. Ceni fiene of Occupancy,
17XHAIJSI IIOOD(W /DUCT)
HOUSING MITIGATION PI'.P.
j
HEATING UNITG`0 IM ME) BTU)
HEATING UNIT (OVER 100,(X10 BTU)
PAID
I
VENTILATION FAN (SINGLE RESID)
Dave Recei "M
-
HOLLER -COMP pHP OR 1 W,W(1 BTU)
TOTAL:
- 100,000 L
BOILER COMP I000 BTU) _
-
AIR CONDITIONER
ISSUANCE DATE
/ _ /7
lV0 ii
ISSUED BY:
ryF.W RFSIDIiNTIAI. MECH. SQ. IT.
Owner ar authonud .gem Data
OFFICE