S 1044 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEgMIT NO. 0
44
BUILDING DIVISION APPI,ICATION/PERMIT PLUMBING-MECHANICAL. CJ
BUILDING PROJECT IDEN"PIFICAT'ION
'1 ^ SANITARY NO. APPLICATION
,SUBMITTAL DAT
BUILDING ADDRESS:
1 �-f—I/
OWNER'SNAME: P E: CONTRACTOR'S NAME: LIC NO NIC CONTROL
V_ Le:ER:e N g73-I 3 i e El ARCHITECT/ENGINFLIC NO: A DRESS: A
IJ. ZG I Oi �M Pi-.'a� okv<.- C✓ nD
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG/ ELECT/ PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE CtY.dl'/
JOB DESCRIPTION
I hereby off..r mal 1 are beco d ender provisions of Chapter 9(eommendng
wh ecton IkrotDi.i.ion3af
itine Ba.mo.,one Pmfe%don.Code.md my license'(. RESIDENTIAL,
W p ZitSi7
PERMIT ISSUANCE
L full force and encu(. ❑SFDWL ❑KITCHEN REMODEL
Q,UV Liccnm Cle an -- Liu# ZAY� s APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF,-PIPE
E-z Da¢ Contra'
u,<y ❑MULTI-UNIT ❑S'T'RUCTURAL
ARCHITECTS DECLARATION PANELS
F y Z 1 unJccavnd my plans..boll be used as public rcatrJ. MODIFICATION
rzv4O UPT0200AMPS Ll INTERIOR [I CHIMNEY REPAIR
N��IsI Licenced Professional 2f11-100dAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER IWMI AMPS ❑R ATH REMODF,IJREPAIR ❑DEMOLITION
C$Q 1 hereby affirm that I am exempt from the Contractor.License Law for the
O Iy U []OTHER
following reason.(Section 7031.5.Business and Proes,00ds Code:Any city(11 county SIGNS ELECTRICAL
W 3 W ti which requires u permit to consumer,inter,improve demolish,or repair any structure a,yam
y 4
pcold,it,", mod,.1-mptude,-tit appl ' t forsuchp tt file a signed statement SPECIAL CIRCUIT/MISC.
9 }
that her,licensed......ne lu the prov,,acroofth Contractors L Law(Chapter9
(commencing with Section 71KK1)nf Division of the Bus'ne.s and Professions Cale)or TEMP ME'I'ER OR PULP I NST. COMMERCIAL:
mac C that he is exempt therefrom and the boas for the alleged exemption.Any Aulneion of ❑NEW BLDG/A DITION ❑DEMOLITION
B1;m not more 70315
foe hnmJreJtdollar,o185pM)nsuhjec¢the applicant nt ucivil penalty nl POWER DEVICES EI TENANT C FOOD SERVICE
2 I,as owner of the yeas In with wage.m their sole cont tion, SWIMMING POOL ELECTRIC 01 HER IMPROVEMENT
1
f C1worproperty, employees wi b IMnsi ❑Ol'HER'
F id Profs cion, a d: the Con a not intended Luerds, offered for a p,ly or 044,
tier of
3 m and Pmtcssinns Card: the Connector's Littnm Lvw Ancc nm apply m nn owner of OUTLETS-SWI TCHES-FIX'1'URP.S
IF pro,( had mild,is, P ,flarrocian.add who does such worklarawlf or through
hisown couploweds,provided Itr I such imponvements am not intended orofferod for NEW RES[DEN"1'I At.ELECTR SQ ET.
vl If,h tit laIJ 6improvement II 'thin Y' f plcfon pathe OOR.AREA S/SQ.IT.
.
owntrn 'Id will have m n d roti gEd,hra actin la improve ror r l�Vrth'll�ryV
pord af.ale').
❑ I,as owner of the property,am exclusively contracting with hemnsed commede,m 9,-//37
A ^' ��
construct the protect(See.7 .Business and Pmresaonc Code:)Toe Contractors Li- '//, (r] 6
cease Law does not apply to an owner of property who builds or improves thereon,red QTY. PLUMBING PERMIT FEE
who contracts for such pm)m(s with a wnoacmr(s)licensed pursuant to the Contractors /d
License Law. PERMIr ISSUANCE (�
❑Inas exempt ad,,Sao, ,B&P C pairs reason
ALTER-DRAIN&VENT-W "R ) VALUATION
Owner DNC
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVIC
�❑ have
hereby nl mai under Cennityol perlmyeneofthefollowing decWorker's
Ihnvc and will mnmeinnCenifente ol'Can,cenl mt.celLinwre for Worker's Qtmpen- DRAINS-FLOOR.ROU1414A ND, NT IES TYPE CONSTRUCTIL
cation as provided for by Section 39 W of the Lohor Cada,for the perfnmm�ec of Thu
work for which this Permit is ismool. FIXTURES-PER TRAP
❑1 have and will conedur Wo let's Compen,alion ha,mance.as required by S tion
37Woflhe Labor Cade,forthe pererr roof the work for whuhthls pemtius issued. GAS-EA.SYSTEM-I INC,40UTLGTS tKC.GROUP APN
My Worker s Compensation Insurance carrier and Policy number arc:
Comer; Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTI FICATE OF F,XEM PTI(IN FROM WOR KERS' GRA,ASE/INDUS"1'R I,WASTE I NTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ThisNtion neednothccnmpleand it the Pennui,h michundedidollms($HHI) GREASETRAP
or less.) P AN22 FEE
ioy any perm in performance o[thest has for which this the W rkl 'Cd.Lthvll SEWER-SANITARY-S'IORM EA.200 FT,
not employ any person in any mtmncr so vsmbemmesubjecuathc Wnrkuo'Gtml>en- L '
sZ .cation Law..f Califomiv,Date WATER HEATER W/VENT/ELECI'R
zApplicant I GRADING FF,
.y y NOTICE TO APPLICANT:If,after making this Cenificam Of Exemption,you should WATER SYS'TEMOKEATING
become rater,to the Worker's Compeo.mion movisinn,of the Lahot Cade,you must SOILS PPT-,v
forthwith comply with such pre,vamnxor this permit shall he dccmcdrevuked WATER SERVICE
Q
UZ CONSTRUCTION uINGAGENCY NEW RESIDENTIAL PLMR. SQ.PP PAID
Dale Receipt
I hereby affirnt there isuc :wnlcaser nn lending n6cncY lietbepMDnce mmnl.
m(M1
the work far which thtsypg�� 1 (Seo 3119].CiVQ CJ
OP Lender'.Name 1 %Ai..ue)L�AihSO1i <' L'
r {U Lender's Address D A
a I canary that I have recal this application and nate(list the above nomination is
BUILD[ 'C PEE
fn correct.I agree to comply with all city and county ordinances and stare laws relating ue QTV MECHANICAL PERMIT FEE
U ,Z building construction,and hereby authorize representative%of this city to enter upon the SEISMIC h:
idev-nmintened Empty for insPeclion P-1-11, PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the Ciy ofCapeti n.agntn', ELECTRIC S
livhilitir,usolgmcnls,cnnsundex,volaw whichomy in any luny accord against said City ALTER OR ADD TO MECH. PLUMI .F
to n,,,a,ncc of the 6ronfag of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,100CPM)
SOURCE REGULATIONS MEC NIC .FEF.
✓)/ < zz AIR HANDLING UNIT(OVER I0,000CF1,) CONSTRU ION TAX
Si�ofAppli . Conwmor EXHAUST HOOD(W/DUCT) HOUSING. TIGATION PETE
HAZARD TERIALS DISCLOSURE
Will(he applicant or fume building wcuptml store Or handle M17yrdouc material HEATING UNIT(TO 1311,000 BTU)
u.defined by the Cupertino Municipal Code Chapter 9,12,and tiro Health and Safety
Code,Section 25532(x)4 HEATING UNIT(OVER 100,001 BTU)
[3Ycs F1 No VENTILATION FAN(N INGLE RESI D) PAID
Dale ueipt p
Will the applicant or fuere building occupant use equipmenl of device,which
at air contaminants u.defnod by the Bay Area Air Quality Management BOILER-COME(3HP OR IIMI,IKKI BU) TOTAL'.
iarieC BOILER-COMP(OVER I OPS)BTU)
❑Yes [D No
I have read the haaallous materials (s under Chapter695 of the Cali- AIR CONDITIONER ISSUANCE DATE
re,2
fomiv Hmah m come Curie.Section t,that,25533 and 25514.1 understand that it the NEW RESIDENTIAL MECH. SQ.tT.
building Jscs mol currently M1uveaenanl that it iv my nwynnxibility mnmify the o¢upam
of the which must be met prior to issuance of a Campcae of Occupancy.
�• ' L.
Owner nr uulM1nnud agent Due T L° , ISSUP.D RY:
OFFICE