S 0202 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEUTRICA1 P15ITNO,0202
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANIGU. V`
BUILDING PROJECT IDENTIFICATION
li EANG 0) LS/ �A S SANITARY NO. APPLICATION SUBMITTAL DATE
Sol
F. 'S MG:40 A� 90Nit? , CON7y}S(T'Q M / "� LI NO
w�� [lJl�///•/�T^•A• �o 7 ' NIC CONTHOLM
ARCHITECr/ENGINTEE,R: LIC NO: AD R�,SSS �yw ' ❑
5/ya .r D , �rmk>
CONTACT: / PHONE: BUIhUING PERMIT INFO
*�=,r 11 ,� O 7?q y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ' 'C PLUMB MF.CH
W l ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION visionsof
QTY ELECTRIC PERMIT FEE
I hereby affirm that I am license.)under provisions of Chapmra(commencing JOB DESCRIPTION
Z with Sarco ite)of DivixionJof the Business ane ProfessionsCMe.and mY license is
X00 PERMIT ISSUANCE
RESIDENTIAL:
erve la and cBunb_ / 9 DSFDWL [I KITCHEN REMODEL
Q Z U Dittos Cla• �V)a�-O�—A Lic.p
vFiQL Dale APPLIANCES
�TSDITCr ti% T� ❑ADDITION CISTRU URAL PIPE
� HITE(.T$DIiCLARATION ❑MULTI-UNIT' DS'rRUQ'URAL
Z Oy',Z„ I oli
1 a hallbcuned as Ii c ds PANELS ODIFICATION
UPT02MAMPS
�ot.r ofcs a U� ❑INTERIOR IMNEY REPAIR
201-1000ANIPS IMPROVIiMENT SWIMMING POOLS
c OWNER-BUILDER DECLARATION
OVER land AMPS D BATH REMODEL(REPAIR ❑DEMOLITION
1 C W se re y affirm that 1 am exempt form the Courtrai Liccns Law for the
�3 Y6.FU- following reason.(Section 703 IS.Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER
m which requires a permit in construct.alter,improve.demolish.m repair any smclme
.F+^�� Prior it its ixsuunce.nlsn requires The applicant fia,mh ppnrin,,files,igned vmtemanl SPECIAL CIRCULI'/MISC.
d;�.. that he is licensed pursuant provisionsthe provisus of the Contracm Liu:n9
/s se Law _00 (eommencingwhM1 Smtinn 9(XIB)o[DEvisinn9 nfthe Businesu and Pmfcvsinm Cale)or TEMP.METER OR MOLE INS" COMMERCIAL:
C,6 o C that he is exempt therefrom and the basis for the alleged exemption.Any vinlation of - D NEW BLDG/ADDITION D DEMOLITION
X m_u. Section 7031.5 by any applicant for a pcmiit subjects The applicant to a civil penally of POWER DEVICES
W mof more than five hundred dollars(ESIX)A ❑TENANT ❑FOODSERVICE
F'=< I.as owner of the rt,or emloas with woes as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
al O ❑ tripe Y Y p Y € tensa
willdo fie ime,C d thehe Ciro is nor mmnded crise L lwe edi does sale(Sec.too
a o is, of
[]OTHER
6 3 ro and Professions calor The Conl theresa License Law does nrl apply m an owner rf OUTLETS-SWITCHIiS-FI%Ti`RES
propertyhis own who builds or tided that
Karan,and who dix_s.,n work ded or'ooredbrought
far
his own employees,provided Thal such improvement,sold thin onl iyear ofv or peered for NFW RESIUEN'1lAl.HLECfR "Ff.
xaleJfEnable, ell have
he bng oder of pumenlidam hewithin
a ,build ni improvelfor the - SQ.ET,FLOOR AREA
eof saldcr will have the buhden of proving that he did not build ar improve far par- j
prscofmlw). P d I D
❑I.as owner of the property,.B exclusively contracting with:)The C contractors i- '[(dly
' mnarveT The project(Sec.9PW.Haziness and Professions GCdC:)The Conlmelofe Li- `
cnreLawdoesnorapplylnanownerofpmpertywhobuildsor improves thereon.and QTY. PLUMBING PERMIT -'
-.DUN 24
whocnnvans mrsuch projects with aeonmostags)lic sed pursuant Irmo Conwclnrs / �[(IoD
License Law. 19iRMIT ISSUANCE 11�{I
I am exempt under Sec. .B&P C Tor this reason
Owner Use ALTER-DRAIN&VENT-W'ATER(EAI ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
1 hereby a1Rmi under penalty of perjuryone of The following declwnions:
D l have and will maintain a Ccnificam of Consent o self insum for Worker's Compri- DRAINS-FLOOR,HOOF.AREA.CON❑, STORIES 'I'YPEC(ONSTRUCI'IOD
scion,as provided lilt by Section 3]0)of the labor Code,for the perfannance of the
work for which this permit is issued. 19%'I'URES-PER'T'RAP
D 1 haveand will maintain Wnrketa Cunmenavtinn bromanca n required by Sec
3700ofthe Labor Code.for TM performance of the work for which this permit is tomIS. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP MIN
My Work nm ration Insurance cunicr Policy
Policy
Cardec Policy No: GAS-EA.SYSTEM-OVfiR 4(EA)
114pA��ERTIFICATE OF EXEMPTION FROM O K RS' GRF.ASFIINDUSTRL WASTE INTERCEPTOR
-^^IMk/COMPENSATION INSURANCE BUILDING DIVISION PIliS
(This section 7.'m be complcld if the Permit is for one hundred dollars O l TXA GRLASF,TRAP
or less.) � LPLANCHECK 19717
vitt any Ihn in the anymannrof Nn wnrkmewhich thio savol.Co shalli ect mTM1e Wnrken SEWER-SANITARY-STORM P.A.ZIIU PII GY PF.F
not employ ter person in any manner ar aamnai become comper-
O Z, Sudan laws of Calimmia.Date WATER HEATER WNENT/ELECTR
O Applicant
GRADING
y NOTICE TO APPLICANT:IL after making this Cisions of of Exemption.you should WATER SYSTIiM/I'REATING
become subjat to TM1e WarAeh Compensation Provisions of the Labor Code,you must SOILS FEE
W fnnhwithemnEd,wilh suchpmvisionsnnM1ispormit shall bedecmedrevoked.
WATER SERVICE
C A
� Z CONS'I'RUCfRON LENDING AGENCY N17W RESIDEN'I'[Al.PLMB. SQ.IT PAID
V Q thereby atfina that there is acandmclion leading agency lknlheperfmmance of Dam R,eci,I#
W F+ the work for which This pennil is issued(Sce.3092,Civ.C.)
O U Tsndcr's Name .I.OTAL:
Icnder's Adlrew 'rOrA1.:
I ccnify that I have read Nis application and slam that the above information is BUILDING FEE
(n correct.I agree In comply with all city and county orNnanms and state laws relating in QTY. MECHANICAL PERMIT FEE
LJ rZ building epnzlmetion.and hereby aothmife representatives oflhis city To enter upon the SEISMIC FEE
above mentioned property,for inspection purposes.
(Win)agree lo save,indemnify unit keep harmless the City of Cupeninr against FF,RMIT ISSUANCE L'LIiC'rRIC FtCli
iabilities,jadgmenoIn cn.as and" Pro whichniayin any wav accrue against said City ALTER OR ADD 10 MECH,
onsequenm ofN Tingo Ifs T. PLUMBING PER
APPLICANT A ' 'A 'J WILL COMPLY WITH ALL N N-POINT AIR HANDLING UNIT(TO Hf0R CFM)
SOURCE G11 T /� MECHANICAL FIiIi
1T AIR HANDLING UNIT(OVER 10.010 CFM) CONSTRUCTION TAX
Signa re of ApplicvnVC Imdnr Dale EXHAUST HUGE)(W/DUCT)
/.AR000S MATY,RIALS DISCLOSURE HOUSING MITIOAfION ItiE
plicate nr future bu iliingoccapantelarem handle hmaalous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(()? HEATING UNIT(OVER 100,IX0 BTU)
D Yes DNo
VENTILATION FANS INGLE RESID) PAID
Will Ne applicant or future building occupant use T or devices which Date Receipt M
pun ea Air n BOILER-COMPDHPOR IW.0008TU
mit hazardous air contaminants an define)by the Bay Area Nr Quality Management )
L
'Tared.:
s DNn I1011.ER-COMP(OVIiR IINI,1100 BTUI
read the hat—dour ordered, AIRCONDITIONER
reyuiremenls under Chapmr fi 95 of the Cali- ISSUANCE DA'I'S
&Safety Code.Sections 255(15.25533 acid 25534.I and_in it TIoT if the NF,W RESIDENTIAL AtECH. NQ.IT.
ei,that it isposihTonwify theacupamtants which must be met prior as ksatnce of a Certificate of(kcuparmyhnrneJ vgnu Ume 'I UTA h:
ISSUED BY:
OFFICE
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