S 1861 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF:CrRICAL 1'13 IT NO.
BUILDING DIVISION AIIP1,ICA'rION/PERMI'rPLUMBING-MECHANICAL 1861
BUILDING PR0jR(TC IDEN71'IFICA'1lON
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMITTAL DAPI
21(02q 6Dwe" e 7 �($
OWNP 'S NA 11i: PHONE: ,�✓f CONTRA CAR'S NA M
. " IJCNO:
NIC CON'ROL p
L J'N7 11W`+ r ❑
ARCIII'IECI'IENGINEIiR: LIC NO: ADDRESS.
CONTACT: PHONE I B ILDING PERMITINPO
❑ Consultant Fees Paid by Applicant(Initial) RLIrG ELECT PLUMB MECH
�e let-C-0 s tv ❑ ❑ ❑
LICENSED CDN'I'RACr(IR'S DECLARAPON' QTY. ELECTRIC PF,RMIT FEE
I herchy mdirm that 1 um Rearmed under,meisiom of Chapter 9(commencing JOR DESCRIPTION
with Section 7000),u'Divixion 3offhcBmmare,and Professions Clde,aad my lieemc is RESIDENTIAL:
1+100 w' PF,RMI r ISSUANCE ❑SFDWL El KITCHEN REMODEL
Fly,
in full have and dlecl. 1
QUV License Class Lic.M �3 r2��/ API'LIANCIiS—RESIUISN'I'IAL ❑ADDI9'ION [I PLUMBING RE-PIPE,
hiUmc Cnnuucmt
FOy A ITECI'S UIiCLARAT]ON PANELS ❑MULTI-UNIT ❑SODIFIURAL
CATIO
'Z O N Z I unde...ond l,fy plans shall be used lax public mconfe MODIFICATION
OZ-- UPTO 20JAMPS C1 INTERIOR ❑CHIMN17Y REPAIR
Q�2^WUccrscd Peofc.asinnal 211-IINNLSMPS IMPROVEMENT DSWIMMING POOLS
ad OWNER BUILDER DECLARATION
C OVER 1000AMPS ❑BATH REMODEL/REPAIR E]DEMOLITION
C z Q I hereby off nn thus 1 an,exempt from the Comb.....'.L Iceose Law fin the
holowing reason.(Section 7631.5,Bosincss and Professions Calc:Any city or county SIGNS ELECTRICAL OTHER
,loch narrates.permit to,cadme,alma hnprnve.aenudixh,or repair any.finemre �L)
prior in IN issuance,also rcyuims the al,liednt for such patent to talc o signal statement SPECIAL CIRCLE UMISC.Ec
that he is liccnttd pursuannofhc prnvisonns of lM1C Comann/nJ.icem.xc Law[Chimera lei"
CCC, (cunnonence,wah Section 70uFof Division loffle l{uxiners and YnEc,,iom Ccde)nr TEMP.ME'1'ER OR POLE INS'I. COMMERCIAL:
Q.105 that he is exempt therefrom and the basis for the alleged evemplion.Any violation of ❑NEW BI.DG/ADDITION ❑DEMOLITION
^m
Section?031..1 hyany opplanal turn lwnoulnnbjectsfhcapplicanf to anvil larrah,ot 1'OWHR UI;VIC1iS TENANT ❑FOOD SERV ICE
nl more than live hundred dollar($560x.
fluei. OTHERVI!MENT
xQ wi I,mowmnt,and pelpemate nknot mendad ollatetr"their r,ole(See70m1.R m,, SWIMMING POOL ELECTRIC
�p.0 will da the won,Care:he Corsa iecor,andel a Low do fur sale(Sm.90an rose r of El OTHER
�'w
and property
whe s Care:The Conmhereo Ciccone Laws such
not apply % an owner of '11.LTS—SWITCHES—FIX'I'URLS
hi,,-a wheo,ce, or improves therms,and who docs sash work finnided oifor through
his own employees,provided that ouch impmvmnenls am nm imm�dnl nr oflereJ for Ew' F,SIUF,NTIAL r:LECHt SQ lel'.
sec If.however,the hailding or improvement is sold within one year it completion,thc SQ.ICL FLUOR AREA $/SQ.FI.
puter-builder will have the hurdnf of playing that he did not Wild or impmve for pur-
cut nalaJ.
L as owner of the pm,wr ,am exclusively contracting with licensed contractors to TOTAL:
y
mnuum the pmjcd Rev.9644,liminexx and Pint..ions C:aluJ Thu Contfuck Li-
nse law dues not apply to an owner of pmpeny who builds or improves thereon,and QTY. PL MG PERMIT FEE
whn corm rfs fm such Foto,with a euntmemr(s)Iiceawd punnum to Oe Gmm
fmnr:e
License Law. PrItsu'r ISSUANCE
I am exempt under Sev. ,B&P C fa,his reason
Owner Dere ALTER—DRAIN&VENT—WATER EA) VALUATION
K HIR
A]ION
RAI
. Wm under'SCOMI or"in,
D1?Ce tollo10N BACK FLOW PNOTECr.DEVICE
I hereby alarm under penalty ofperjury one of the following declarations:
ion.as and will for
Section iealeuf he Labor,
Cvdhnsurad Wrformace of be URNNS—I1.00R.R00P.AREA.COND.
S'1 OkIILS 'TYPE CONSTRUCTION
,tion,as hno ad,
for mi Station 39(X1 of the Labor Cala forad peAarmance of the
work for whish thin Isamu Ix —urd rker, I I%'IURLS—PLIi'rRAI'
El 1 have and will maintain .,cram Compensation Insurance,h hisoiree by Section g
3700of the Lubar CoJe,for, the perfornnnnreol'rhe work fnr which this permit is issued, GAS—EA.SYS'rl?M-I INC.d OUTLETS }: � OCC.GROUP AI'N
y
MWorks( fmpcnxminn cv r:mA Yolicy number are:
Camcr:�I Vy+�y��4ir�cc rtne Policy Nn: 2 GAS-1{n.SYSTEM OVER d(IiA) a
CI?H'1'IFICAfE OI*EXIiMITIUN PROM WO ERS'
COMPENSATION INSURANCE GREASUINDUSII(L WASTfi IM1TF,RCEPrOR
BUILDING DIVISION ty31?S _
frbiswtfl,n'lead nm hccoulderlllffhc,verna is Intone handreddollum($11X) GREASETRAP
or lcss.l V ALJ41IEUK`FEE
I ccnify than in lhcpurLfnnoummftNc work for which those permit is ixvucA.InhWl SEWER—SANITARY—STORM P.A.2W IT. lilll VI
not employ any person in any manner so as to become.object m the Workers Compen- ISNERGY FEE
ZZ nation Laws of Califeem.[)are WATER HEADER WNENT/ELECTR
Applicant GRADING FEE
rN-o NOTICE TO APPLICANT:If,after making Ibis Certificate of Exemption,you shanld WATER SYST ENITI'RLAI'INC,
I"t , beeomc whjecl m the Worker's Campersour,pans mors of the Imbor Code.you amt SOILS PEE
hardwitM1 complywith such provisions or this .it shall be deemed revoked WATER SERVICE
1
CONSTRUCTION LENDING AGENCY NEN'RESIDENEIAL PLMR. SQ.FI'. PAID
UQ I hereby aft nn thouhem is a conxuuail,n lendlny Roo,Ln theprrfornrmunl Umc miplp
the work For which Imit bis peris issued(See.3097.Civ.C.)
0 F" Lard'i s N....c TU'IAL:
V 1<ndcr'x Addax. TOTAL:
r y I eertifY that 1 have read this application and as c that the above infonnanno IN InfILDING Pili I
,F. Zf cormet.I agree tecomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z buildingeemfmcfion,and bembymnthoriee represenmfivcsoftM1i.s city unmet upon t he SEISMIC Fir
above awationed progeny fnr impecfion premises, PERMIT ISSUANCE,
(We)agree to save,indemnify and keep hanfdca the City of Collateral,agaimt ELECTRIC FIS
Iiabillece,judgmenls,come and expenses which may In any way acarueuguimt,moi Cify ALTER OR ADD TO MECH.
in emnscsucn a of the granting of this permll PLUMNING FEE
APPLICANI't1NDIiRS'TANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNI F(1010.00I CPM)
SOURCE REG1nl..PIONS. � ) MECHANICAL FEE
Q /\ ///._ AIR I{ARDhING I1NI1'IOVrIt II1,IX111C1M1 CONS]'RUCI'ION'IAX
$ngfumrc ofnla to entlCl,mr ter (I JDmc Izx HA EST 11001)(W/)IICr)
HAPARDOUS AI LRIALS DISCLOSUREHOUSING AIITIGAI'IUNI EE
Will,hen,dwant or future Wildia5sec,me moor handle hamntoo,mmxrial HEATING UNIT(TO 100,0110 B 11)
an defined by the Caperton Municipal Crates Chapter 9.12,and the Hcdth and Sat ety
Calc,ticalon 25532(u)? HEATING UNIT(OV ER I00L1100 BTU)
[:j Yes Fl No VENT ILATION FAN(SINGLE RESID) PAID
e Umc kcccipt p
Will due air contaminants
i futon building by the[l aseea Airnemordevircewroth
mithrnrdom air as defined by the[lay Arca Air Qualhy Management I{OILER—�UMP(IHP OR Ig1.IMN)BTU)
Distim9TOTA
[3 Yes E-lNn 1301LIiR—GDMP(DVEk 1(0,1)(N)B'fUl
1 have mad the M1manlous nnn¢rialx reyuircmente under Chapter CONDITIONERr 6.05 0l the Cali- ISSUANCE nDATE
fomia health&SaPery Calc.Sections 2550.5,25533 tied 25534.1 understand,hm if the NEW RESIDENTIAL MECH. SQ.FI', --7
muldmgdoes nartumndy haveu¢wn,dent if kanym,pa-inhey tonauld,twoccupanl b !/
of he asrianams which mus,M mel prior m imwama of a Car ifexre of fkcrpancy.
Ganem amthoriecd.gem Dale TOTAL: ISSUED BY.
OFFICE