S 2889 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
..1 'D•/,DSOII
A :RTINO -BUILDING-ELECTRICAL PERMrf NO.
..z HIIING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
BUILDING At SANITARY IS APPLICATION SUBMITTAL DATE
/✓ - 04 moi✓�/� C v AV c/
OWN[B'S AME: �� PH0O UNIRA R:1 NAME: �J-5 _ - LIC NgQ/ - N/C ^ CON'fHOLn
111FRCHITECf/E/ENGINEER: LIC NO: ADDRESS: 'C/�y��~ 7 ❑
CONTACT, P NE: BUILDING PERMIT INFO
le �, 2�� El Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El ®� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby ancon that I not Reenxed under,o.uiai"r,"f Chapter 9 m"na icuring - JOB DESCRIPTION
WOO with Semion)91B.f Division Sof Ne Husinesnentl Pr/nrecdonx�J5 r-dKa� RESIDENTIAL
F�� in full forte and caracc `� / / a�J PERMIT ISSUANCE
�UU License Cla11 /1 hic.p ❑SFDWh EI KITCHEN REMODEL
EZ Q6 Dae Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPIT
F,pti ARCHITECTS DECLARATION PANELS ❑MULTLUNIT []STRUCTURAL
Z Or-C I understand my plans abal be us,alm public records MODIFICATION
OZ-1 UP TO 200AMPS
Licensed Pmfosoo..I OiNTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARAI ION 201-1000AMPS IMPROVEMENT (]SWIMMINGPOOLS
O.CfJ Q I hereby affirm that I am exempt from the Cnntaam's License Law for the OVER IgIBAMI'S ❑BATH REMODEUREPAIR ❑DEMOLITION
fallowing reason.(Section I031.5.Business and Professions Cale;Any city or countyim ❑OTHER
u1 a W y 91
which requires a penult m construct,alter, SIGNS ELECTRICAL
F W O prove,demolish,nr repair any srucwre
yG prior to its issuance,also requires the applicant for such perm m file a signed statement SPECIAL CIRCUITIMISC.
fly Haat.is licensed arm.m tome be ComnMmFs license Law(Chapter v
X 00 (emtmenring with Section 7191B"fl)ivisi.n 3 it The Buainesannd Professions Gulc)ar 'TEMP.METER OR POLI:INST. COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Section 7031.5 by any applicant(",n permit subjects the applicant to a civil penalty of POWER DEVICES
notame, hon live hundred cod...($5a0. ❑TENANT ❑FOOD SERVICE
~SO ❑l,vs owner of Ne pro norm
IMPROVEMENT
pe y yemployees with wages as their sole asmpensaion. SWIMMING POOL ELECTRIC
I-` willdothew... anA theswcmre is nrn intended nrnReeJ for su1.(See 7144,Business ❑OTHER
63$ and Pmfessions Cade:The Contractor's License Law Ones am apply ,,nn owner of OIITLEIS-SWI'1''E-- FIXT'
pm,.,who huilds ar improves acre er.and who does each work himself or through
his own empl,res,provided that such improvements are so intended or offered for NEW RESIDENTAL ELECTR S
sale.If,however the building or improvement ixs.Id within one,evtuf completionT.
,the SQ.FT.FLOOR AREA $SQ,F
oxncrbuilder will have the burden of proving that he did not build or improve far pur-
pa rsu'rie2.
C 1,as owner of the property,am exclusively O n ow irg with licensed camracmrs 1. TOTA
construct the project(Sec.7144,Business and Pmfessionx Con_....Comncmr's Li-
cerwLuwdoesnotupplymanowner of pro,saoy who builds or improves diet and QTY. PLUMBING PERMIT PE.
whoaontruets forsuch projects wirdocuntoumn,)lircnsedpursuant to he Ccuroadors
License law. PERMIT ISSUANCE
C I out exempt under Sec. ,B&P C for this reason
Owner Dam ALTER-DRAIN&VEST-WA'I'Els IRA) VALUATION
-
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following decbtndonx:
I have and will maintain a Certificate of Conscnt to self-insum for Workers Compco- DRAINS-FLOOR,ROOR AREA,CON). STORIES TYPE CONSfRUCt10N
sol.n,as provided for by Section 3700 of the Labor Code,Us the performance of the
work for which this peaven is issued. FIXTURES-PHR TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
3900ofthe labor Cade.far the prrfonn..crunh,work farwhi,li lh'e'comi is issued GAS-It.A.Sys TEM-1 INC.4 OUTLETS -----OCC GROUP APN
My Worker n asation lnsun ce comer and Palicyyyy bet
Cnrier Policy Ntry'� GAS-ITA.SYSTEM OVER 4(EA)
CERT I;IGAI'I" FRXIiMPI'IONFR \ 111ik.'
C(. PENSATIONINSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION_FEES
(ITissection need not he completed tribe permit is Entine hundred dollars is ME GREASETRAP or Ic") KI.'E
I certify Nat in Nc performanceofNe work far which this permit is issued.]shut]
not employ any petnnn in any asno rso as to become subject the Workeri Cam SF,WIiR-SANITARY-STORM FA. FT.
Z ration Laws al'Caliliania.Date I pen li GY F
zApplicant WATER HEA!ER W/VIiNT/ELIECfR GRADING
tti N NOTICE TO APPLICANT.If,after making this Certificate of Exemption,yon should WATER SYSTHMITREATING S
a become subject m the Workers C.mperoaini provisions of the I'mar Coda you mast
W foahwiNcomplywithsuchpmvisionsor NispennitshallbedmmedmvokN. WATER SERVICE R
tCONf1ONLENDING AGENCY nNEW RESIDENT AL 'LMBS f
PAID
U 0 Na hemisacovtionlending agency for the performance or
Dae Reeeipts
W Fhe wars for which this real is issued(Seae3099,
Civ.C)
O Lenders Name TOTAL:
r PV Lenders Address TOT L.
fy 1 cenily that 1 have re:W his upplicminn and sore that the aMrvc information is BUILDING ME
IA correct.I agreemcomplywith alleity andsountyordinnnces and state lawsrelo6ngm QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives of Nis city to eataruponthe SEISMIC -ME
ti abuvo-mcntioned prnpeny for inspection purposes. PERMIT ISSUANCE.
(We)agree to sine.indemnify and keep harmless Ne City of Cupertino against ELECTRIC FEE
hibilitics,irdgmems,cs¢und expcnsn which may in vny way uccme vgaimtsaiJ City gLTF:R OR wDD TO MIiCH. PLUMBING FEF.
79,
in consequence"f the granting.E this pemtit.
APPLE TNT It ER TAN S NO WILL COMPLY WITH ALL NON POINT AIR HANDLING UNI'TfI'O IO.Hq CPh17
SOIL 'z RE AT M1' MECHANICAL FEE
�j AIR HANDLING UNI'f(OVER I0,000CFM) CONS'TRUCTIONTAX
Signvmre of Appal vnVComncmr ( male EXHAUST GOOD(W/DUCD HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant a,future buildingoecupa"t smremmu le baeUAousmten.1 HEATING UNIT(TO 100,0910 BTU)
as defined by the Capacitor.Municipal Cole,aspic,9.12,cast Health and Safety
Coda,Seaton 25532(u)'! -,6 - HEATING UNIT(OVER 100,000 BTU)
C3 y,' C s VENTILATION BAN(SINGLE RESID) PAID
Dam Receipts
WIII the applicant in furore nodding by the D use equipment ll devices which BOILER-COMP(3HPOR I00,(DO BTU)
it ict? s air contaminants az definM by the Day Area Air Quality Management T
Disvim7 /
❑Yw BOILER-COME'(OVER 10,(911 BTU)
�f
C
I have read the hazardous materials requirements under Chapter 6.95"fine Cut. AIR CONDITIONER ISSUANCE DATES
humin HeaIN&Safety Cala Sections 25505,25533 and 25534.1 understand that Cow, NEW RESIDENTIAL MECH. SQ.PT.
ofthn "snot ii' haven mmtnt, tit is my responsibility utility the rccupam (� f
ohth which vt nn ismyrespon Cility recti
m at TOTAL: ISSUED BY:
OFFICE
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