S 0320 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO , HUIIAHNG-ELECTRICAL Pii5IT NO,
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL NJ 0320
' BUILDING PRO]ECTIDENTIFICATION
IIUILDING nDORIiS4 7NANITARY NO JAPPLICANON SI/11MITTAI.DAT:
aoq� 8 Alves Dia ei o \-�
OWN int"i Mli:-Fo�1 .PHQNIi: )NTRACI'O NAhtli: LIC No.
�qIL NIC ///C///ON���TROhp
Clu rECf/ENGINEER: LICNO: AI 'SS ❑
CONTACT. PHONE: - 'BUILDING PERM1iI'T INFO
•6 � ❑ Consultant Fees Paid by Applicant(Initial) HIyI>0 ELECT PLUMB MECH
NSI D CONTRACTOR ICI ARAT QTY. 17 t r FLECTRIC PERMIT;� t CE ss r�J[` ❑
I n er R that fi w 1 p ' I Chapter it(eamrnen ng - t t• _ .TOB DESCRIPTION
��Z crabs i ]BIXB fD"s an 3ofthe Husmc: dPn fcsstnm Cade and my license is - RESIDENTIAI:
W PERMIT ISS F in full force and effect 0SEDW1, K" :N REMODEL
�UUU License Class Lic. pPi'LIANChS-RESIDENTIAI. I'I'ION MIiING RE-PIPE
F-ZW [)ate Cmarunor
mQ6 [I MULTI-UNIT ❑STRUCTURAL
F+�y ARCHITECTS DECLARA'I'[ON PANELS
1 undentnnd my plans shall he mcd as public records - MODIFICATION
^z-Q i Oil 10 2g)AMPS TERIOR El CHIMNEY REPAIR
F 41'm Licenser]Professional 201.1000AMPS IN 'ROVEMENT D SWIMMING POOLS
-{ OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RE V1-1YEPAIR 7DEMOLITION
C W a 1 hereby affirm that I am exempt from the Contractors License law for the f�kk
06 U
following reason.(Section 7031 5,Business and Professions Gyle:An t maul ❑OTIOR ltak
iqqi55 gar Any Y SIGNS ELECTRICAL a
H+3 4Im¢"
which rnpnires u permit to ennxvnn,Wtei,improve,demolish,or report any structure Oft
NJprn
ion its issuance.also requires lheapplicant for such pi or file aligned drmbeat SPECIAL CIRCUI'UMISC.
;s. that he is licensed punuam to Ne provisions of the Core ramofs License Luse(Chapmr9 R
Gy sic
(mmntencing with Section 7").f Division 3oflhn Business and ProfescionsCde)m THMP.Al OR POLE,INS'r.
m C that he Is exempt Ih mfica t sed flat,basis rot the alleged exemption.Any vmmaon of E BLDG/ADDITRVli%(,W DEMOLITION
^lNL Section 70315 by any applicant for a permit subjecu the applicant o a civil penalty of POWER DEVICES - aaT�VV// '' VUI'U. [3 FOOD SERVICE
ps not more man five hundred dollar,($500). �/�ai1PRbVEMFNT
L=eo Lmnwner of the pmpety,nnny ampiny swith wages as their sale m.inspirtion, SWIMMINGPOULELECTRIC
will do the work and the drucmre isnot intended m offered for vale(Sec.]1144,Rosiness ❑OTI IIiR
{�]3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWI'I CITES- 1%TLRES
p' .. property who huddx or lutpmves tbcreon,and who does such work himself or thnmgh
his own employees,provided mat such int unbcomms vie not intended or offend for NEW RESIDENI']A EC'1'R SQ EI'.
sale If,however,the bu Id ng or mpmve rc t is sold within rte yelorm orsopletima.the SQ.FT.FLOOR AREA SISQ.IL
uwnerhtldc,wll havods,burden oflonvin,that h Ibi polh IJ or anionicfor p D
ye"Yeaten). � 3z
I sow er of the Sec.7 y am exclusivelycompleting lh I 1 t e n t
mmct theproject
not apply 7M4 litsrmpr dP 1 builds 1 ) pr v t t I' f'
censeurwd,forstapplytoan ith aof pmpertywcensdormpr he thereon and QTY. ' "PLUMBING FERMI' / n(,FEE'j m
who nmtrac¢for such pmjee¢with v contractors)licensed Punvam m the Cnnwnots
LiecmcL A PI?RMII'ISSUANCH
El1 c empt t der Ss!
LA TER-DRAIN&VENT-WATER(IIA VALUATION
WOR FR'SC P:NSAIIONDECLARAHON HACKITLOWPROI'ECI'.D
' EVICE
w Ihereby Or and under penalty of perjury one of the following dedamtions:
7 l have and will mainwin a Certi ficate of Consented self-inmm for Worker's Compen- DRAINS-FLOOR,ROOK AREA,CON . / STORIES 'I YPy CONSTRUCIOP
smian,as provided to,by Section 3700 of the Labor Code,for the flit n..malc of the
work for which this permit is issued. FL%TURILS-PFR''-A'
1 have and will maintain Worker's Compensation Insurance,as required by Section y�y
37M Athe Labor Core,lir the perramtancn of the work for whiahanknennit is rested. CAS-EA.5YS'rEM-IINC.40U'I'I.H"IS DCC.GROUP {1PN
My worker's Compensation Insurance carrier and Policy numher arc: AAA111 I
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(G) _
CF.RTI FICATE OF EXEM PTION FROM WORKERS, "
COMPENSATION INSURANCE GREASIMNDUS'I RLWAS'IT INI'ERCEPTOIt EU N IVISII iS
IThis.aninnnttJ nor be connple¢Aif the pemrit is for ono hundred dnllan(SI W)
or less.l ' GREASH"TRAP PLANCIIT:CKI /
I certify that in lhepedomwnceofine work far whahlhispetoul is issued,Ishall SEWER-SANITARY-SORM IIA.21q FIL
not employ any Flood in any manner so as to become subject to the Workers Compen- IiNERGY FEE
OZ action Laws of California,[)are - WATER 1117NI Ell WIVENIIELECl'R GRADIN
Z Q Applicant
P
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IRF,ATING
FA
bemnm subject the Worker's Compensation provisions of Lnhar GMe,you must SOILS
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLMN. SQ.IT. PAID .
.U� IherchyafErrablthem is v cnmerrctinn lending agency fill w
r lire perfmnuce of Ont Rcceipta
QF the work for which this permit is issued(Sec.NA7,Civ.C.) TOl'AL:
U IenJtts Name
Lender',Address
T..� I cedify thio i have mad this application and state that the maws infantilism is - r BUILDING FIJI
i--i Zicorrect.Iagmenrmmply withall cityand county ordinances and atom lows relating QTY. MECHANICAL PERMIT EIiF,
U � mildingc�nstructi�n.andhereby nmhorh.c reprtunurlvesnfthiscitywenterupon me s r '1 SHISMICFE
above mentioned property for inspection purposes. 'IiRMI'1'ISSUANCE
(We)agree to love,indemnify and keep harmless the City of Cupertino against Iii,ECTRIC
Iivhilllics,juJgnmms,en sls and ex coxes which may in any wny uecmargalnst said City AI:fP.R OR ADD TO MEGA.
nscyuence nfthe 6mmin hisp...a6 - I'IAMIIINC PIiIi �.
of •DANT UNDP:RST WILL COMPLYWI'i'HALLNON-POINT A HANDLING UNIT(TO IO,IXMICPM)
S URCE R'GUIlATION MECHANICAL TLE
AIR H DLING UNIT(OVER 111,11(X1 MI CONS'IRUCTION'I'AX
Signauaof Af can ' tractor Dar li%flpllST D(W/DUCq HOUSING MI'1'IGA'fION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING IINITI M.(XW U)
as Joined by the Cutwi ico Municipal Code,Chapter 9.12,and the Health and Safety
Codc,Scclion 255320)? 1 IFATINC,UNIT(OV E ,001)III U)
El Yes ❑No VENTILATION PAN(. GL, SID) PAID -
Dae Reccimx
Will the appllcmn or frump building occupunl use cyaipmem or delicts which BOILER-COMP POR I00'(gd
it l a oodou.s air coulaminanls as defined by the Bay Area Air Quality Management TOTAL:
Di.drid^ BOILER-CO 'LOVER 100.000 BTU))
❑Yes _J No
Ibave rrvdmehasadntonsitedalsrt u under Chaner6.95 ofthc Cali AIR ONE TONER ISSUANCE DATE
mmm� p
Tornio I Icvhh&Sufaty Codc,Sestinas 25505,25533 untl 25534.I unAcntvnA that if the NEW MSIDENTIAL MECH, SQ.ET.
buildin6 Asea not correctly have a tenant,thw it is my respnnviblliry In unify me aecupam
of the n,mbements which must IN,met prior to issuance of a Cer ifiend of Oksol mly. -
Owner or aur' tanned agent - Dam - 'IY)TAL: ISSUED BY:
OFFICE