S 4339 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL ER NO. -
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 4339
i,I '"BUILDINGPROJECT IDENTIFICATION C fIH .J'l
SAN ARY NO. APPLICAfION$DBM11-I'AL pA'fF:
BUILDING ADDRCSS',
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OW e'S'AMEVP1RDOuU 1�ttJ, PHONE� _ CQIG SF'aSRQ.i11 I1A� LIC No I l NIC CONTROL Lf
.HITEC'1 GLNI31i ( 880: ADDCRFtiS `` n3 ❑ �/ Z
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CONTA�:CC PHONE: ii ' .BUILDINGPERMIT INFO:" ,,,.,..irI1 �� e 77, 1977 ❑ Consultant Fces Paid by Applicant(Initial) BLt sec/ ELE PLur✓ MECH,`,Q l DI ( 1L7L7LICENSED O EfRACOB1 DI CI ARAnoN QTY ELECTRIC PERMIT. I fFb 'I,I hereby amrm th t I 1 e. J de p r Chalne,9(comms e J06 DESCRIPTION
cton 7000)of'Ds on30Ilt Balim"and[nfe! Calc andmylcc i PERMIT ISSUANCEWOOfull!rw and ef[eet, x SPDWL ❑KITCHEN REMODEL.
a LieenseG k 3`70 /Y9
aUV APPLIANCES-RE.SNF.NfIAI. ❑ADDITION [3 PLUMBING RE-PIPE
yea g1C-- fsContracmr OMULTI-UNIT ❑STRUCTURAL
FCm AR BITE! SDEC A Af10N PANELS ]MODIFICATION
I M1e used as
uhlie rcmfds
C)O I unJersmnA my plans shat p W AMT'S ❑CHIMNEY REPAIR
O O UI'"m2 ❑INTERIOR
F.�'.f"LL1 Licensed Professional 201-1IX0)AML'5 IMPROVEMENT SWIMMDEMOLING TIONPOLLS
Yad OWNER-BUILDER DECLARATION OVER 1000AMP5 ❑BATH REF10D13UREPAIR DEMOLITION
C C Q 1 hereby affirm that 1 am exempt(rum the Conmemea License Law for the ❑OTHER
K
OW following following reason.IS¢ornn]0115,Business and ProlessinneCWe:Any city or county SIGNS ELECTRICAL
In w0 Fr/a� which requires o peril m coasmnet,ale,impnrvc,demolish,a 11P:ur any atmdme
Is, pdnnn ltsissaourac. lsompaires the applicant forsrich pe Iran a f le u signed Hummmnt SPECI AL Cl RCU FUM ISC,
thm he is licensed,..rano am provisions of the Contractor's License Law(Chapter9 COMMERCIAL,
W�GCO (commencing with Seetion 7")of Division 3 of the Business and Professions Cala of TH PMEI'ERORPOLEINST.
0.yx c y shot he is timing,therefrom and the basis far the alleged exemption.Any violation of ❑NHW BLDGIADDRION ❑DEMOLITION
W^ Sedion 7031.5 by any applicant far a permit suhled,facip,li,am,na civil penaiyof POWER DEVICES TENANT ❑FOOD SERVICE
Le
not marc than five hundred dollars 1$500). IMPROVEMENT
=O ❑ Las owner of the Nope-ly,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC []OTHER
d,t- willdothcwofk,andtbe..m... is not intended ornRereJ for sale(Se<.7M4,Business 6 OUTLETS-SWITCHES-FI%TURES 3 and Professions Code:The Contractors License Law does not apply to an owner of
property who builds or improves me o ,and who Anew ouch work himself or through
his nw,I employes,promisor that such mts improveenore not inorded ,,offered nor NEW RESIDCN'HAL 131.PATIt SQ IT
same.If,however,the buildinger iinprovement is sold within one yearafcomplNon.(he SQ.FI'.FLOOR AREA $/SQ.FT.
owner-builder will have the bode.of proving Nat he did not build or improve for par .� s0�
pass o(mlc.). - d 7
❑ I f be p perry, <I ly contracting wul licensed m t t
cou,nia,th f1IM
t ] 4BusinessadP t C la)End
Contractors Li-
TY f
sen I dp I rpt lyt fp p ty h 'Id p th d tQTY.tt r'f+i t'PLU MBINGPERMIT' 1 !t ,.
who contracts for such pon,ect,with. nt ctur(s)larmsed pu atve
n o the Contractors - ' -r
License Law. - PERMIT ISSUANCE
1.m exempt ands,Sec. .B&P C far this reason
ALI PR-DRAIN&VENT-WATER TA) VALUATION
Owner Date �j ^7
WORKER'S COMPENSATION DECLARATION BACK FTOW PROTECT.DEVICE '1 < O /\
•. IhembyafW.under penahy of perjury one of,he following hoelootions: �/ J tl
I have and will maintain a Cetificam of Cousennoself-Insure for Workers Counter- DRAINS-FLOUR,ROOF,AREA,GOND. STORMS TYPE•CONSTRUCfIUp
ration,as provided for by Section 370X1 of the Lahnr Coda,for the performance of the
work for which this permit is issued. FIXTURES-1'17R'T RAP
❑ I have and will maintain Worker's Campensadon Insurance,as required by Section
3700411he labor Cale,for erfomtnnee of the work for which this permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP AI'N
My Workers uo ser ce a cemd P01icy nu ber`a
Cartier: " m Policy No, 1.z✓'-� GAS-EA.SYSTEM OVER 4(EA)
CEIG I FICATE OF EXEMPTION FROM WORKERS' GREASFIINDU S'TRL WASTE INTERCEPTORCONIP17NSATION INSURANCE BUIT.DING DIVISION FP,F:S
(This section need not be completed if the pcnnit is forme hundred dollars($100) GREASETRAI'
PLANCHECK PEP
or less]
(certify that ithe pe,fommncc a alishe ork Wiliam
suich jett in'he ut Worker'
ed,I shallCoopr- SEWER-SANT"I'ARY-STORM EA.200 FI'.
oat employ any pmsnn in any moron,sit ns mm lrocunm euhject m the Wirkus'Canpnm- ENERGY FEE
,Z smina Luwsof Culifmni..Date WATER HEATER WNENTIELECI'R GRADING FEE
Z O Applicant
NOTICE*1O APPLICANT:If,after nuking this Ccnificue of Exemption,you should WATER SYSTEM/REATING SOILS FEE
F N become mbiect m the Workers Coni,acumtion previsions of the Labor Cade,you must
fonmwhh comply with such provisions it this permit shall be deemed revoked WATER SERVICE
Q
d
CONSTRUC'n(IN LENDING AGENCY NEW RESIDENT(Al-PLMII. SQ,FT. PAID
in RccciptY
V p
(hereby affirm don them is a constructionlending agency for the performance of
the k( b'b t1 .his ed(Sec 3099 .C' C.)
OIs Lend,,, Na /
V Lc f ,ALJ 90 1 eL41
Z, jigv
y I nfy that llure mail tl': ppm ]"am lost thh information q t ' l,c Etter t I1UIhDING PI-i
y tj correct lagree mcan plY itit llcty and tY d' dstt l It gt ;QFY. . 'I� F,MECHANICAI PL'R]11Tj ,� FNN t
VZ b�ldingconswction.and]rebyauthourerepresmnaivesofthucitytocateruponthe SEISMIC FF. 3 Q
abuse mentioned property for inspection purposes. ♦PERMIT ISSUANCE ELECTRIC -E e33
(We)agree to as ,indemnity and keep harmless the City of Capetian against
liuhllhics,judgmenb,costs tad expensrn which may In any way aeras...insts.id C'ny ALI IIR OR ADD TO MECIL PLUMBING FE'
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL WTH ALL NON-POINT AIR HANDLING UNIT(TO 10,100 CFM) MECHANIC&F
SOURCER .LATIONS. S-
- � AIR HANDLING UNIT(OVER 10,000 CPM) CONST 1 . TAX
S namreof AppllcuMContf or Date EXHAUSTHOODOODUC'ry HOUSING ITIGATION FEE
HAZII{ ODS MATERIALS DISCLOSURE
Will the applicant of future building occupant store or handle mountains material HEATING UNIT(TO 100,000 BTU)
as defined by the Copmon Municipal Cade,Chapter 9.12,and the Health and Sudety HIiA'fING UNI'('(OVER 10h.000 BTU)
Cads,Norden 25532(.)!
El Yet, No VENTILATION PAN(SINGLE RESID) PAID Dam Receipt -_
.
Will the applicant or future building occupant use equipment or devices which BOILER-COMP QHP OR 100.01)(1 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Dianieto. BODER-COMP(OVER 100,100 BTU)
❑Yo ❑Nn
I have real the hmadaus nucrials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCES, A'GB
tbmin i{ulth&Sof Cade,Sections 25505.25533 and 255 d- and the if the NEW RESIDENTIAL MECH. SQ.14. - ( A/
Wild dines no rently have u1enun4J{m itis pf mfilff�un mli[ytmenccupara
of mh q m"pi hit xl'INc nnctt�� m t6 aofu E(i air.of Oecupwmy.
q411 All rT 42
O m unmarred agent Dam I I T ISSUED BY:
OFFICE