S 1621 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILI)ING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIHNG-MECHANICAL J 1621
BUILDING PROJECT IDEN'1'IPICxr1UN
HUILDINJ)DDRESS:� n �: SANITARY NO. APPLICATION SURMI'ITAL JDDAATI
L
OWNP . �E: t P No CO M NO
NIC CONTROL#
-266
ARCHITECI'IENGINEER: LIC NO: A)D S / ❑
.... �r�I�'rn/
CONTACT: �rk� PHONE: BUILDING PF,RMff INFO
r-wi — L,%/<D��� ❑ Consultant Fees Paid by Applicant(Initial) BLDG F,I.E(:T PI.pM{l M
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ Bx Id��O(I
1 hereby alum that 1 our licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
�aZ ihtienian7axgnfDivivinnlofine BnLrnessnlndMifessionscMe,md my Bcarree, RESIDENTIAL;
FSO ntfullforeennde n PERMITISSUANCE
SAF- ❑$FDWh ❑KITCNF.N REMODEL
aUU Licen>e a. Lic.X APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F Z W Dae Curacao
sn6a
CHITECI"S DLCLA []MULTI-UNIT ❑STRUCTURAL
A
ZOrd
yz I undausland my plans shall be mcdca public records PANELS MODIFICATION
OZ4 UP'10200 AMPS I [I INTERIOR ❑CHIMNEY REPAIR
H4 Iz,U; Licensed Professions] 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
aW7d OWNER BUILDER DECLARATION OVER I(NX)AMPS
HiEC a
❑BATH REMODELfREPAIR [I DEMOLITION
Q 1 hereby ffirm mat I am exempt from the Co lum nr's Licem'u Low for the
U fidlawing reason(Section 7031.5.Business and Professions Code:Any city areounty SIGNS ELECTRICAL ElOTHF,
W ao-inwhieb ne,fines a pmout m call chat.improve,derrolLm,m repair may Immune
/A
0< prior m it.scsionce,also requires the applicant for such pimni to rile a xigneJ.cmical SPECIAL CIRCA D'/MISC. le-JII is
9999�;I. that he is licensed p...anuothe provisions of the Comractors License Law(Chapter l
WE (commencing with Section]1NID)of Division 3ot the Business and Prefessinrn Cadapn TEMP.METER OR POLE INST. COMMERCIAL:
66 aq that he is eaempt therefrom and the basis tin the nicest exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
wHQ^N Section 7031.5 by any applicam for.permit subjects lheupplimumdty ES ❑ ❑
mn a civil peof POWER DEVICES FOODSERVICE
t mora than Eve hundred dollars($500). IMPROVEMENT
Gy' ❑I,av owner afthe pmpeny.or my ennployeeswithwages us their nolecompencmion, SWIMMING POOL ELECTRIC [I OTHER
0Iy F'm will do the work,and thestructure is not intended modereJ for sale(See.70,16.Buinesa
send poile,dann,Cock. Ilia C'ammcmr's License Law docs not apply in as owner of OUTLETS—SWITCHES—FIXTURES
property who mi di or imposes thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered far ItESNENTIAL ELIECTk SQ FT.
sale.If,however the building or improvement is sold within one year of completion.the SQ.FT FLOOR AREA $ISQ,FT.
owner.builder will have the burden of proving that he did nm build or rotative for pur-
pose of sale.).
I,as owner m
of the ppeny,a xcl inavely contracting with licensed comrunors to TOTAL:
construct the eroman(Sea o an Business and Pndeho bei CMri The Cammeon,and
nseonwdmsnmapplyevis%invonmecony wearneddcorlmproves Contractor's
License
QTY. PLUMBING PERMIT FEE
who rommcLi for such pnnjc,m with a cuntrannn(s)IiccnseJ pursuant m the Cmnrucum's
License law. PERMIT ISSUANCE
❑lam exempt under Sec .B&PCfnr this reason #
AIXER—DRAIN&VENT—WATER(EA) VALUATION
Owner Dae /.
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Iherehy ul0rm underrynaby of perjury one oY the following dedarminm: swv�I✓
IIn...it will maiamin a Cemili,atc of Consent ms elf-i:mrefnr Wmker's Compen- DRAINS—IlOOR,RIX)F.AREA.COND. 0 TYPE CONS'1'RUCTION
,alba as provided for by Section 37M otthe Lobar CMe,far the performance of the STORIES
which this permit is issued. FIX'rURES—PER TRAP
I have and will maime.Wacker',Compensation Insurance,as required by Section
llllpafthcI Mn CMe,father!", mice
of Ilia work far which this pe lis issued. GAS—EA.SYSTEM- OCC.GROUP APN
My Work n Cast
wrier m l Policy nwYfae o,.)4
Carrier: N(G Policy No.: f.C.CI! GAS—EA.SYSTIfV .(IEA A
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRI EINTERCEPI)R
COMPENSATION INSURANCE 1_1 in BUILDING DIVISION PIiLS
('Mis,elionnadnolbecamplemdlfthepnmif is for one hundred dollars($IW) ORFSE.]*RAPIle — —
or less.) PLANCHECK FEE
Iartlfytheintha ad,trachar ahcwarkfnrwhiuhth].#maWtikers'Co.,.--I shallSEWER—SANITA STORM Ea 20017.
nm elnpiny any person in any runner m as,.no become subject a the Workers Cpers- ENERGY IRE
cation Laws of California.Date WATEk H13AlER V. IF.LC:CTR
z 0 Applicant GRADING FEE
NOTICE TO APPLICAME If,after making this Cenificaa of Exemption,you should WATER SYSTEM(
I-' 5 hecome subject to the Walker's Cormemsutien pmvimars of the LAmm CMe,you must SOILS ME
{a11 s�•1 forthwith comply with such provisions ortbis#smut shall he daemed revoked WATER SERVICE
Q
CONSTRUC TION LENDING AGENCY NEW RCSIDIENTIAI.PLMO. SQ.IeI'. PAID
V Q I hereby aRrm That there is a comodction lending agency fortelscrhommnce of
One k p
the work for which this patient is issued(Sec.9097,C .C.)
fL h nder's Name OTAL:
Le
T..J
M. Latium,Acidness TOTAL:
s�" RJ 1 certify thin I basement this application and cma the the...we infismmtion is tlU1LDING FEE
t E
fA coned]agree tocomplywith all city and county ordinances me cute lows relating QTY. MECHANICAL PERMIT FEE
U Z building construction.and unci hereby amhoriu represenWlives til this city to enter atm the
SEISMIC FEE
above-memioncd p.,my for rustication purposes, PERMIT ISSUANCli SO
(We)agree m cava,indemnify and keep koalas,the City of Cupenino against ELECTRIC FIFE
liabilitics,judgmenm,costs and expenses which may in any way scene against said City ALTER OR ADD TO MECIL
PLUMBING PEE
in consequence of the granting of this permit.
APPLICANT UNDERS'fAN DS AND W]Lt.COMPLY WIT]I ALL NON-POINT AI R H ANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEF:
SOURCE REGULATIONS.
AIR HANDLING ON]](OVER 10.000 CFM) CONSTRUCTION'I'AX
Situation of ApplicanVContmmor Uaa EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
IIAVARDOUS MATERIALS DISCLOSURE
Will theapplkae or Icor,bnildintnccnpum.brm nr handle baaardomorderin HEATING UNIT(TD IOL00)BTU)
as defined by One Cupertino Minnie' ale,Chapter 9.12,and the Health and Safely
Code,Sccnior 255321a)T HEATING UNI"T(OVER Im%gd0 BTU)
❑Yes No VIENI'ILATION FAN(SINGLE REMD) PAID -
1 Date Receipt#
Will We applicant or from building aem,mor use equipmem or devices which
it broader, it comtterma ox ed by the Bay Area Air Quality Management BOILER—COMP UHP OR 100,(")BTU) i
Y ) Ye, BOILER—COMP(OVER 100,000 BTU) /`
I have mail the hamadmic materials requiamenm under Chapter 6,95 of the Cvll- AIR CONDITIONER U ISSUANCE DATE
famiv Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the i NEW RESIDENTIAL MCCH. SQ.IF,
briddingJces Ecu lyhaveut cant,nhatitismyresptmsibilityus Xiff�y the upam /
ofthc requi n•ma at compoormismanccofm Cc a ,Ir pT�c (/�(j/./�
Ow ora mimd again 'Date TOTAL: ISSUED BY`22 '
OFFICE ��/