S 1430 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PEgp4IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL \ 1430
BUILDING PROJECT IDENI IF'ICKITON lJ
BUILDING ADDRESS: � 1 LSN ♦ e � n*r-I'vV SANITARY NO. APPLICAd[OONN SUBMITTAL DATE
CW
OW F. :S FAME: go
PHONE: C RAC'TOR'S NAME: LIC NO: v�
NIC CON'f\kOL#
ARCHITF,CTIF.NGINEER: LION ADDRESS:
coN cr: rHONE: BUILDING PERMIT INFO
U G air, _3(0&2S53 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT EEE ��IT
I hereby affirm that 1 ata licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QZ with Section 9000)x[Division 31ffad Bmimessand Professions Code,mtdmy license is RESIDENTIAL
O in full I...candeftect PERMIT ISSUANCE
�UU 'ease Classy Lim.It �-, DN'L ❑KITCHHN REMODEL
APPLIANCES-kES UGN'1'IAL
ti ate Commmnr DITION El PLUMBING RE-PIPE
m ARCHITECTS DECLARATION PANELS MULTI-UNIT El STRUCTURAL
rz Zz I understand my plans.shall lie micas public retards MODIFICATION
O Z.-�p UP TO 200 AMPS
"�W Lie ens ed Professional El INTERIOR ❑CHIMNEY REPAIR
�. 201-1000AMPS IMPROVEMENT - SWIMMING POOLS
�.] OWNER-BUILDER DECLARATION
yy Q I hereby affirm that 1 am exempt from lire Contractor's License Law for the OVER 1000 AMPS ❑BATH RHLy,ODpF.UREPAIR L1DEMOLITION
X O L O fullawing re..on.(Semon](Y31.5,Rosiness and Profcssiom Codc Any oily ur county SIGNS ELECTRICAL ❑OTIIER N
yWOydwhich nNeire,if Pemtt .t t site,improve.deramlidn,id ar,am,say sbra ttre
0J
prior In its issuance,alsoq s the ppl'mantI h permitl file a signedshipment SPECIAL CIRCUIT/MISC.
Fmk, thoth licensed pursuant t theprovisions of the Contractor L L (Chapter9
W MO fie g 'thy. ]000) fU Division 3 fth B s cs ndP f ,Gtds)or s ET ER OR POLE INST. O 1
N tY e C that h i werapt therefromd th b si f thealleged ex pt A y rotation of x'� �y�DG/ADDITION �DEMOLITION
k m W Section 703 L5 by any.,,lial fora permit subjects the applicant to.evil penally of POWE 5S 'U1
Err not mom than Five hundred dell...(s5a). ❑p NAfF QUI (t ,TODD SERVICE
Z¢ I,as owner of the n IMPROVF,MEN 11N
OP
property, employees with SWIMMINCPo li TRIC
'will do the work,and the structure is not intended oro w do Tensile tax a(Se..7044,Business ❑OTHBR
uml 'and Profession,warns Gale:The improve,
l emr's Lind w Law does nal apply to an owner o[ OU'1'LL'TS-SWI'I'CIifS- X'I'URBS
G his 4oy who build,or improves tM1such i and who does such work deed or or through
his idle.If,emem,.he provided that such improvements arc not intended or offered for NEW BESIDES'1'IAI.ELECTR SQ FI'.
.r wners,however lhhave die bur en of ,int ithat he within one year i impletion,IM1e O O SQ,FI'.PLO EA S/SQ.fU'.
xwnacbaile).will havelhe burden of pmving that he did not build or improve for par-
},C po,e of sale).
1,as he,of the property,am exclusively exploding with licensed ameraetom to
construct the project(Sec.]044,Business and Professions GsleJ The Countesses Li-
11.1,
i-c ,e Law does not apply to an owner of property who builds or improve%thereon,and QTY PLUMBING P RMIT FEE,
who contracts for suchprojects with a conu.cmr(s)licensed pursuant to the Convectors
License Law. PERMIT ISSUANCE,
❑I.me%.mplunder Sec. ,B&PCf..this reason
ALTER KT TER(EA)
Owner Date /w VALU �
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVIC (— IS G/_.
have
ereby andwll maiint under penalty of orCononeuflhefollmfor declarations:a _ +
(have and will for
maintain 37W of Ge Labor at a&inbar the Worker's Camper- DRAINS-FLOOR.ROOF,AREA, S'1'Ok1ES TYPE CONSTRIICI'ION
cation,as provided for so Ss kNu 3]fNl of the Lobar Code,fonhc peri'onnance of the
work for which tills maintain
is issued. FIXTURES-PGR TRAP
I have and will maintain he pial'S Compensation work
hi h respired t i Section
My of the Labor Code,fonhcperformanceof and
which this pemwis issued. OAS-EA.SYSTEM-1 INCA OUTLETS
My Wolds p.nsation Incur and Policy{Q�..��b��e{{��utn OCC.CROUP APN
CerriD� (INEX tvt Policy FROM
WORSE
GAS-EA.SYSTEM-0VER4(5A)
CER FICA'1'E OF'
EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASEAN DUSTRL WASTE IN]ERCEPTOR
('Ills section need nm he completed if the pemtit is for one himdmddallig,S 1 Off 1 G IVISIONFli
or less.) a GR5ASE'TEAP '
PLANCHECK
1 employ
any thatea thePerformancem n manner
so as
were for which this theForamW i,issued.lshall
en-
not clnplaY an SEWER-SANITARY-SI ORM EA.2fN1 FT
y,coon to any manner so as m beton culled m the Workers'Compcn- ENERGY
O z scion Laws of Culihtmiu.Date WATER HEATER W/VI3N'T/ELECTR
Applicant GRAD] FF.,
h NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you.should WATER SYSTEMIFRF,ATING
hceons subject to the Weaker,Compensation provinums of the Labor Code,you post SOILS FEE
fnnhwlth comply with such provleinnxxr this permit,hall be dcanmdmooked. WATER SERVICE.
Q
CON SONLFNDINGAGENNEW RESIDENTIAL IMNSQ.FTPAN] z I rewheffinn lbmthe.isaconstruction lending ageY fothepefimmance of
Date celpl#U O me work for which Ibis p.rodrs issued(Se.30].Civ,C.)no
w
OLender',Name
AL,
r CLI Lendcr'a Address
yy 1 teddy that l have read this apd,calm,and slate that the Andr information is BUILDING FEE:
U V] c rrext l agree m comply with a0 any and county ordinnnecs mid stole lows relating m QTY. MECHANICAL.PERMIT FHe
L) z buildinginstru.don,and hereby authorize reprw.nlmivcs of this sit,to enter uponthe SEISMICFE'
h+ abovo-mentioned progeny for inspection pur,oscs. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cxpuslinx against 51,ECTR1 F y
liabilum,judgments,costs and expenses which may in any way m.me against said City ALTF,ROk AUDTOMECH.
m,m,mace of the gr:ml Ing of this permit PLUMBING FE5
APPLICANT UNDERSTANDS ANI ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
E REGULAT ON. MECHANICA NEE
�AA AIR HANDLING UNIT(OVER IO,(100 CFM) CONST RUC
Stratagem ofAppltanl/C��f (nate EXHAUST HOOD(W/DUC) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle bmaNuus material HRA'I'ING UNIT(TO IW,WO IT IU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sir 25532(x)9 HEATING UNIT(OVER Flat H'TO)
0W ❑No
VENTILATION PAN(SINGLE RESID) PAN
Will the applicant or future bulldog ttxcupam use cyuipmtemt xr devices which Dale Rac.i p
mit bazardeu,air cunmummems a,defined by the Be,Arca Air Quality Management BOILER-COME(LHP OR 18,000 BTU)
Duche t9 )TA
E]Yes F)No BOILER-COME(OVER 100,000 BU U)
I have mad the hnzmdxu sande al.e mqultnmems under Choptu 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foram Health&Safely Code,Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.F-C
huiiding does narcotically have.scams,that it ism,responsibility to notify Ute cament
of the reyuirmoents which must he met prion issuance art Cxrafirme of Occupancy.
Owner xr authorized agent Date ISSUED BY:
OFFICE