99110139 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
[BUILD[N
Y OF CUPERTINO BUILD ING-ELECTRICAL E n .o.
UILDINGDrvIgIpN APPLICATION/PERMIT PLUMB:NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
C RESS: /I �� tiANI'1'ARY NO. APPLICATION SUBMITI"AL DAT
1024 MYJ F F -9S-
^WNHR'S NAME: • 2J 2 J J CONTRACTORS 'AME LIC NO:
V N/C CONLEN.st
RCIIITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMITINFO
K-s!v 21 2 —33
7- ❑ Consultant Fees Paid by Applicant(Initial) BEDG/ ELLM PLUMB MECCH
LICENSED CON rRACPOR'S DECLARATION QTY ELECTRIC PERMIT FEE r✓I� L!7 a�J/
1 hereby affirm me 1 am Eaemcd miner FxwWon,of chapter 9(commencing JOB DESCRIPTION
0000
GmZ withSection]IX0io
)oLLh,isn3o0m Bucinessand Profession.Code.and mylicene is RESIDENTIAL:
PERMIT ISSUANCE
F_. in full force and effect. ❑S OWE, ❑KITCHEN REMODEL
aUU Fare eClms CoLilnn APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PLPE
hnC III Use Commaor
F7m ARCH,IPC rS DECLARATION PANELS C1 MULTI-UNIT ❑STRUCTURAL
Z O VI Z I understand my plans shall he used as public mcowN MODIFICATION
OZ 1-C UP Or 200 AMPS El INTERIOR ❑CHIMN17Y REPAIR
1=�L a, Licensed Professional 201-1000AMPS IMPROVEMENT EjSWIMMING POOLS
1f OWNER-BUILDER DECLARATION OVER I/NO AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
y tY tY Q 1 hereby affirm the 1 am exempt from the Contractor's License Law for the
5(3 d fullowing rensvn.(Section 7031,5,Bmincse vnd I'mftWon,Cod,Any chy m county SIGNS ELECTRICAL OTHER
u1 u.y which requires a permit m construct,alter,improve,demolish,or repair any stmemm
Q prior to in l..oanu:,also require,the applicant fnrsueh pennam flu a signciloarewunl SPECIAL Cl RCU I'F/M ISC.
===M that he is licensed pursuant the provisions of the Connear's License Law(Chapter 9
ge 0 (commencing with Section YtHXBof Disi inn 3 ofthe Business and Prnfessio-Cmepn TBMI'.METIiR OR POLE INST.
E.a G M that he is exempt thereliom and the hasis for the alleged exemption.Any violation of ❑NEW D N LLP '
0
WZ>im Scainn'IOJLS by any vpplicam fora pcmnit subject..the upplicem wncivil lxnahy of POWER DEVICES 'IFNANT ❑FOODSI:RVICE
Nan five hundred Jolles(8501).
of
F 'n re IMPROVEMENT
❑Q - Lothe work.thepesaactnr mycmntended es offered
fosalei(Sec.rampen.vminn, SWIMMING POOL ELECTRIC ..-
W O will Probework.and the shrvemrein tots License ow do s it.,apply to an H.,a O IiR
6 3 w and Professions Cato:The Contractor's License w Law does not apply to.. owner n OUTLETS-SWITCHES-FIXTUNES
property who bull.s or improves thereon,and who ices each work himself or throng
his own however,
building ohm such impms sold w are not inlander or phare.for NEW RESIDENTIAL ELECfR P
sale.IL M1owever.the building or improvement is ntltl within one year of campletioo,eM SQ.FI. 1OOR ARBA 3/SQ,FI'.
iwoc -
builder will have the burden of proving that he did not build or improve for puT-
Qof
TOTAL:
L as owner or the property.en exclusively contracting xsxim licensed contradomi m
instruct the project(Sec.7044,Business and Professions Code:)Hat Conoacmry Li-
«nse law does not apply to an owner f properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who cornacd for each pnnjea,with a cmiracwr(s)licensed purwanrto the Contracam,
laccnsc Law. PERMIT ISSUANCE
❑lam..enspo and See B de P C for this reason
)wncr Date Finmim r EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O/\I,Qy�
Ihe- am u
RTnder penalty ofps:aflury one ofihe following declarationf�1
C3Ihave an ill maintain aCenifcute of Cnnsem m4f-insure for worker's Compen- DRAT ,40ZQnCOND. S ORIES TYPE CONS'I RUCTIO
.onion,as presided for by Suction 3710 of the Labor Code,_.the pudnnnavice of the
work for which this permit is issued FIXTURES-PER TRAP
n 1 have and will maintain Worker,Compe.onion Insurance,as required by Section � �
37M ofthe LuMr Calir th
Cale.le performance of Ne work for which this permit is issued GAS- E ( TLETS OCC GROUP —3 APS
My Workers Compensation Insvmnce canis and Policy number an: ..D
Carrier. Pol icy Nn: GAS-EA.SYS'I'EM.OV ER 4(EA) -
CERTIFICATEOFEXEMPfIONFROMWORKERS' Q
COMPENSATION INSURANCE GREASFANDUS'IRL WASTfi INTERCEPTOR
BUILDING DIVISION IBES
(This section need not be cnmplemiftbe permit isfonme hundred dollars(SI00) GkEASETRAP
or less.) PLANCHIiCK hF.E
I certify that in the performance ofthe work forwhich this permit is issued,)shall SHIVER-SANITARY-STORM CA.200 F,
ma mnpiny any pi in tiny manner o,as m bwnnn subject m Ne Workers'Compen- ENERGY 176E
Z ®don law.of California.Date WATER HEATER WNENTNLECTR
O Applicant ( GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,von.should WATER SYS rEMI REATI.NG
? became subjea us the Worker,Compunwtin I provisions of the Labor Code,you mast SOILS FEH
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
� z CONSTRUCTION L1iNDINGAGENCY NEW RESIDENTIAL PLMB. SQ.fifi, PAID
UO l hereby affirm that inert-is a construction lending agency for the performance of Di.�Recefl'g
the work for which this ps t is issued(Sec.3(1 Civ.C)O U mi1<aders Name `("'� �n LIbTAL
Lender's Address TOTAL:
(r't a 1 cenify flat I have mad this application and.culd,ol the above information in 11 IhO1NG F8
to correct.l agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE J
U 'Z building construction.and hereby aalanie representatives of this city to enter upon the SE SMIG
ulrove-mentioned property for inspeaimn purposes. PERM]"F ISSUANCE
(We)agree to save,indemnify and keep humble, he City of Cupenim anst gaitil. ,'RIC FEE
anilities.judgmen4,costs and aspens.which mayit any way accrue ngvino,i id City ACIER OR ADD I OMECH.
consequencein of the gmating of this permit. I'I. 7{NG FEE
APPLICANT'UNOHRS'IANDS A U WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 1(11X10 CFM)
11E IANICAI:IFE--
SOURCE REGULATE ONS.
AIR HANDLING UNIT(OVER IO.gN)CPM) CONSTRUCTION-TI'llAX f I 1..,,�
Sig tum sfAppliern/C� our Date EXHAUST HOOD(W/DUCT) IIG(ISING MITIGATION FEE'S Ill
HAYARDOUS MATERIALS DISCLOSURE
Wilhhe vpplictmt or future building nccopennIom or handle as.Lnlnm nemdal I IHATINC,UNIT'(,0100.000 it'I U) U ��
es defied by the Cupertino Municipal Cmc,Chapter 9.12,and the Health and Safety
Cede,Section 255JNu)? I[FATINO UNIT(OVER 103.000 BTU)
0Yes C]No
VENTILATION FAN(SINGLE RESID) I ID
Will thea applicant or future Wilding occupant use a ui 1 or devices which Date Rsrenpf p 1.
pp g pan q it Qu BOILER—COMP CHP OR IIX)"BTU)
7huildingdcenineurnntiyha%eailenani
it hazardous air ammminamn as defined by the Bay Area Air Quality Management Y y;VTAL
striaf:'
E]Yes FjNo BOILER—COMP(OVER 100,1X0 BTU) /
I have Toad the IS M .s materials ne uiremcnos under Cha 6.95 of the Cali- AIR CONDITIONER
Chapter ISSUANCE I)A'17i ^ �y
nia Health.S Surety Cme,Sutimns 255 ..25533 vnd 25534,1 unda,mm Nal if the NEW RESIDENTIAL.MECH. SQ.FT.
at if is my responsibility to notify the overarm
thcrcyui nren lsw hast MtprionoufM1nrix'J ugem Dam TOTAL: ISSUED BY:
OFFICE