S 2957 —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINC-ELECT RICA], PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT - PLUMBNO
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAT'IONSUBMITTAL DATE
1,1 1011(0 Carol Lee �)r r
OWNER'SN Mi: PHONE: ON TRACT[Ii'S NA IC NO:
no S uavc! 4t?4 251-0319 � � �1has 431 NIG GONS RD1.a
ARC[ITECTI'NGINF�R. LIC NO' ADDRESS: �4 ❑
117GLUI h. 90I1 UK l l012 _9[50 Shaun . �a1Ul�llo q430(,
ERMIT INFO
CONTACT. PHONE:i L 0 BUILDING P
El 11 y`13_ 61-9 Consultant Fcca Paid by Applicant BLDG(Initial) HC umB Mrc,
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FIEF �O
I hereby affirm that I am 1leensed ander provismm of chapter 9(etumnenelmg JOB DESCRIPTION
��z wim S¢tion 7NN).f Id isiom3ofthe Basinessand Pmfnsiuns Cale,and dr,Iwanseis a<--D RESIDENTIAL,
ENTIAL.
CO of a 43 "'2 P[RMI'1'ISSUANCIi ❑SPDWI. ITCHEN REMODHI.
111 lame a d a q
aQU Licen la Lica 3 APPLIANCES-RESIDENTIAL 3r L O ❑ADDITION ❑PLUMBING BE PIPE
zL Da¢ - CIadnscmr
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL
z atz Iunderxmndmyplansshulik.,,Iaxpublic,ec.M, PANELS MODIFICATION
Oz�2p UP TO 20)AMPS ❑INTERIOR El CHIMNEY REPAIR
1=+,N-,1-'Ia1 Licensed Professional 201-10N00AMPS IMPROVEMENT SWIMMING POOLS
•] OWNER-BUILDER DECLARA9'ION OVER 1000AMPS
❑PATH REMODEVREPAIR El DEMO{.ITION
W�W C se I herehy afir that I am exempt from the Contractor's License Law for the
043 L following reason.(Section 9031.5,Business and Pmfessiutn Code:Any city or county SIGNS ELECTRICAL ❑OTHER
fU 'F.m which requires u permit to construct.aIle,improve,demolish,or repair any structurele Ir P 0 ow
I�"�at primlo n,i.....ae,also requires the.,licant farsuch pennino filea signet statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contraemi s License Law(Chatter 9
.Cg (a,mmm�cing who Seminn](Ibfllnf Divininn3of ma Businuxs read Pndcssionv Cndc)m 'rEMI'.MHTER OR POLI?INST COMMERCIAL:
6 i ea K that he is exempt therefrom and[lie basis for the alleged exemption.Any violation of ❑NEW BLDGIADDILON ❑DEMOLITION
iYfl 4•
Section 7031.5 by any applicant for a person subjects the applicantt)a civil penally of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
F�,y am ore than live hundred ddlaa(S5(Xp. IMPROVEMENT
_ w
G
< L] 1.osnnerof Ibe pmpeny,or my employees with wages as Neirxnlecompensation. SWIMMING POOL ELECTRIC
gaFwill do the work,and me succam,is not intended or offered for sale(See7014,Business []OTHERW an I Professions Codm'1'he Ctna,,I is Licensa Law docs not apply to an owner if OUTLETS-SWITCHES-FIXTURES 1 a
property who builds or improves rbereon,and who does such work himself or through
his own employees,provided mat such improvements arc net intended or offered for NEW RESIDENTIAL ELELTR SQ FT.
sale.If,however.the had ding or i mpeavement is sold within ane yanof campletinn.the SQ.FT.FLUOR AREA ESQ.ET.
ver builder will have the burden of proving that he did not build or improve for par-
pose of ads.).
FJ1,as owner of rhe pmperty,am exclusively contracting with licensed commemrs to TO L:
construct / 13
the project(Sec](H4,Business and Professions Code:)Um Contrucmdx Li-cerise Use docs not apply to an owner of progeny who builds on improves mereon,and QTY. PLUM GPERMIT 71zFEwhocameos farsuch projects with a Cmra lmun licensed Pursuantu,meconu-acmr's
License Law. PERMIT'ISSUANC
❑ I am exempt ander See. .B&1'C far this reason
-
Owner Dnm ALTER-DRAIN&VE - TIiR(EA) x 3 n VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DE � y' 0&
A O
l hereby ann fiunder penally of perjury one of the followingd ..n (l
ecl... .
s: U
y ❑ I have and will maintain uCertiRcamet Consent to selfinsumfor Worker's Compsn. DRAINS-FLOOR,ROUE AREA.0 D, STOR S TYPECONSTR CHON
satin..es provided for by Sceiion 3]00 of the 14Th,,Code,for the perforunce of the y 61
/ -
rk for which this peril is issued. FIXTURES-PER TRA !/ter (/1/
A(1 have and will nmimaim Worker's Compemation Insurance,as required by Satin.
3]00ofIbe[..bar Cocafarthe uNrfamdiceofrho work for which box Ismon,is issued GAS-HA.SYS' NC.4 OUTLETS OCC OUP J
Cmy arr r:me�+GrrWePslyrinsgnce come and Policy nuR,bec'ax:lb GAS-PA.SYS M-O ///(/It
S T to Polis No.: 56a a rf� 3 xP_ Z
CERTIFICATE OF EXEMPTION FROM WORKERS' U
e.
COMPENSATION INSURANCE GREASUINDUST S R TOR
(This section need not be completed ilthe t is forene hundred dollars BUILDING DIVISION HES
hsn°t GREASP.TRAP
or less) PLANCHF.CK FEE L z Z Q
I cenify that in the performance of the work for which this peril is issued.)shall SEWER-SANITARY-STORM : .
not subject employ any person in any manner so us to become subjeco the Workers'Compact. ENERGY FEE O
zstation Laws oI California.Date WATER HEATER WNI?NT/ELECTR
C
Applicant GRADING FEE
NOTICE TO APPLICANT':IL.Re,making Ibis Cenificam of Exemption you shoal] WATER SYSTRMITREATING
F hecome subject to the Worker's Compensation provisions al'the Luber O1r.you must SOUS FEE.
Wfonhwithmmply withsvch pmvisimenrmkovaraildell W ilamedrevoked WATER SERVICE
� z CONS]RUCTIONisacGNLtion lending agency
NEW RESIDEMTIALPLMB. SQ.F'T. PAID Receipt
V l forwhichrthmlherc issued(Sea 3097ndiag agency fritrhe perli.mancc rel
(••' the work for which his permit is issued(sec.31N].Ci,C.)
Dn Lender's Win,c TOTAL:
V Leader's Atabass
'� ❑d I cenify that I have read this application and nam desire above infrnmau m is F BUIL 1 'PEE
a
o-Fi N mitran.1 agree to comply with y city and county ordinances and sant rows miming m QTY. MECHANICAL PERMIT FEE y�-�s
V �
building conxwetinn,and hereby authurisc represunmtiva of this city In enlcnrpon the SEIS CFEE (90-
(We)
t/
aMv-mcmioned property fur inspection purposes. PERMIT ISSUANCE -78
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELF., RIC FEE
liabllitiea,judgmems,consaad expenses which muy'm any way r1cma...inusrid City ALTER OR ADD TO MECO a Sly
in consequence of the granting of Ibis peril. PLU ING FF,F. IIJJ
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHA, ICAL ME 3
SOURCE?REGULA'I ONS.
!1 AIR HANDLING UNI'f(OVER 10.00N1CFM) CONSTRUCTION TAX
Signature alApplianVContntmur Data _1 EXHAUST HOOD(WIDUCI) HOUSING MITIGATION HE
HAZARDOUS MATERIAI S DISCLOSURE
Will the applicant or future Wilding occupant store or handle haurd.us minimal HEATING UNIT(TO 100.000 BTU)
as ddfned by the Cnparano Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 255320)'1 HEATING UNIT'(OVER 100.000 BTU)
0 Yes NN. VENT ELATION PAN(SINGLE RESID) Date Receipt#
PAID
Will sapplicant or furore huilding occupant use equipment or devices me
em [countries,
air conmminanss as definni by the Bay Area Air Quality Managemcntnt BOILER-GQMP(3HP OR IW,(KKI BTU) TOTAL:
District?
11 Yes DrNo BOILER-COMP(OVER 100,0001 RTI])
2 Q
IM1nve read the M1aeallous maerials reyuircments under CM1apter(.95 of the C.li AIR CONDITIONER ISSUANCE DATE
Terni.Henith&Safety Code.Sections 25505,15593 and 25534.1 undcrsmn i mat if the NEW RESIDUE TIAL MECH. SQ.FI'. l
Wilding does not curmmly have a tenant.that it in my responsibility to notify the receptor
rements h¢h onto prmr
x maceofa Ceblicmeofoccupancy.
` Icl-4
denied agent Dam T AL: 1 ISSUED BY:
OFFICE