S 1747 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LEcTRICAL Pli ITNO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-.'sIF.CiIANICAL 1747
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
/0:5179 6410 l C 2_y,�,
OW'NER'S r4AMI11 I'HONii: CONTR CTOR:S NAME: LIC NO.
W3 ,40 7 /O NIC CONTROL#
,k ;IFECI'/EN NEER: LIC ,: ADDRESS ❑ e eye
fAli
CONTACT. iA'`ONE: BUILDING PERMIT INFO
�e ®�///r (�/�j /l/���frM ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�uJ SET
LICENSED lien iDCONTRd ander
SDIiConsof CON QTY. ELECTRIC PERMIT [TEE
1 hereby union mal 1 am licensed under odPo fiess as Copmr o(aa'nmencing JOB DESCRIPTION
��Z with Scaion]IXXpafDivision3O(Ihe Business and Rnfeasians Crxle.and my license is RESIDENTIAL
F in folIforec and tfca. PI?RMI'I'ISSl1ANCH
Frew 4 El ❑KITE({INREMODEL
aUU Lorena la Lia. �h9 � „ gl'I'LIANCIS-kHSIUliNT1A1. �ON ❑PLUMBING RE PIPE
H�L Dale TS DE '
Dm ARCHITECTS DECLARATION ❑MULThUNIT El STRUCTURAL
F- 1 undcnumd my plans shall be rased as public re.os, PANELS NIODII71CATION
O Z UPTO HIa AMPS
❑INTERIOR ❑S IMMING POREPAIR
�y {a] License)l'mfexsinnul 201.1040AMPS IMPROVEMENT SWIMMING POOLS
a Qill ton I.. UILDIiR DECLARATION OVER 1000AMPS ❑BATH REMODEVREPAIR El DEMOLITION
1 hereby afOmt that am axempt frmn he Comracoc's Liamae Law for me
3 a v billowing croon.(Section 7131.5,Business and Note..am,Cade:Any airy or county SIGNS ELECTRICAL ❑OTHER
W which requires a permit to connmo,aper,rmprovo,dmanlish,or repair any ntmamre
0 prior m its issuance,also requires lire applicant for such Permit o rile a signed statement SPECIAL CIRCUIT/MISC.
� } that he is licensed pursuant to lire pmvisionx of the Canlmcrnr'a License Law(Chapter 9
Mao$ (commencing with Section 71101 Division 3 of the Business and Pruression,Code)or TEMP.METER OR POLE INST. COMMERCIAL-
L y o C 'hal he is exempt therefrom and the noir for the alleged excmplion.Any violation of E]NC•W HLDGIADDITION El DEMOLITION
W^4N, Sec'ion]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�0n mart than five hundred dollars($500).
❑ I,as owner of the property.(it my employees with wages as their sole compensation, SWIMMING POOL 12LEM RICIPROVMENT
will do The work,and the official not rc is nontended orolfened for sale(Sec.7T L Business _,64PR
63�° and Professions Coda: I'he Contractor's License law does not apply to an moner of 2 OUTLETS-SWITCHES-FIXTURES
property who builds Or irupmvaa thereon,and who does such work himself or through
his own employee,,pcavidad but such imp rovemems are not intended cr uffessi for NI?W R lDENTIA(.ELEC'i SQ 2_0
sale.If.however,the building or improvement is sold within one year of complcr inn.the Q�1FLOOk ANIiA $ISQ.FI'.
ownerbuilder will have the burden of forcing that he did not build or improve for pur- C
pat of sown, - I Of f
1,if owner of the property,nm exclusively contracting with license)contractors to ,-S /� '/�T-/}—/7
construct the project(Sec.7044.Business and Professions Codi Tot Conwmors Li- .0
came Low does'lot apply to an owner of property who builds or improves thereon,and QTY. BI GPE 1IT FEE
who contraa.s for such project,with a contractor(.)licensed misuanno the Corti
License Law. PERMITI. AN
El Isom exempt under Sec. ,B& so
P C for this rean
Owner DataALTER-IIRAI VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARAHON BACK FLOW('ROT .DFVICH
l marry ntrcm under peraty of perjuryme of me fill..in,dedamtini
I husband will mstood naCeftn,alcot Consent,,od Natme for iaWorker's Compen- DRAINS-FlO(JR.ROD AkEA,CO' STORIES TYPE CONSTRUCTION
ation,as provided for by Sec' n 37M of the lahor Code,for the Performance of me
for which thin pamu'is issued. PIXI GRES-PER TRAP
I�f'1 have and will maintain Workers Compensation Insurance,as required by Section
3700ol the Lador C,,de,forme partnnnnal the wnrkf..which this permit is issued. GAS-EA.SYS"I EM.I INC.4 off FIT-[S OCC.GROUPMyWAYN
cann"+rk ,la pe �olq.prancc name Policy NuYn�I� SG?j -NH GAS-EA,Sys'PBM"OVER 4(BA)
]fICCEERRTIFIC•ATTE OF EXEMPTION FROM WORKERS' GRF:ASUINDI1fiTR1.WAS Up 1NT612CEPlUk ��
COMPENSATION INSURANCE BUILDING DIVISION FEF_S
(Trisector need not becompletedif'hepermil isforonehundmddollar,($110)
orlacs)l , nt nrOworkrhnlsmall GREASE TRAP -
PIANCHECK FEE _- - 9si
ser
Old.I
empoyanpcoan in any mo�r a usser beroure,objedthis
Wmoarc Con pSEWER-SANITARY-STORM FA.200 FT —
—
ENERGY FEE
salon Laws of California.Dam WATER HEATER WNENTELEC IO
z o Applicant GRADING FEE
NOT CE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMHREATING aSOILS PEE, become xcbjaa,,.The Wnrkar',Compensation Provisionsof the labor Code,you mus'
r forthwith comply with such provisions or permit shall W deemed revoked. WATER SERVICE
U0 CONrmisa']ON LF.NDINGAGENCY NEW RESIDENTIALI'LMR. SQ.FT. PAID
—L—y Z`I
U (hereby offmnhm lnerc isrnnswnirn lending agency for Ill."(,)...craccof Dam cerp'p
the work for which this perm'is issued(Sec.3097,Cil C.)
U Lenders Name TOTAL:
Lender's Addesa TOTAL:
/r
1 cenify teal I have read his application and slate(bar the durc information is BUILDING
Uz
rn correct.I agree to comply with all city and county ordinance..and state laws relating to QTY. MECHANICAL PERMIT pithpithOO
building construction,and Wordy authnrire reprem sentatives of'his city enter Upon the SEISMIC
.dxw1+naminnld property for inspection purposes.
(We)agree m save,indemnify and keep harmless the Cityof Cosmino against PERMIT ISSUANCE
Iiabill'icx,judgroems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. 2(7 PLU ChF.E
in consequence of the granting of this permil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00OCFM) O
SOl/'Y)CEREGULATIONS. MEC ANICAI,FEE. s
2'/,h nA / 1A I/L�w syn //y /IS AIR HANDLING ON[[(OVER III,(Np CFM) C STRUCITONTAX
SignaurreofApphcanoCmnom,,r ry VY 7DDate EXHAUST HOOD(W/DUCT) t )USING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form Wildingoccrpalooreor handle homrdausntredal HEATING UNIT IT 0100,001 BTU)
as deM<d by the Cupertino Municipal Calc.Chapter 9.12,and the Health and Safety
Cade,Scctinn 25532017 HEATING UNIT(OVER IIN),'gxh B"TO)
❑Yes ❑No V EN'I I LAI]ON FA N IS INGLE RFSID) PAI
•
Will the applicant or future building occupant use equipment ser Ila, Receipt X devices which I{OILER-EOMI'13Hi'OR I(N1,IMNI RTU)
ani'huranlous air cnmm�rrrwnd o dined by the Bay Area Air Quality Manogemen' 15T 21Y
District?
❑ye, C]No 1301I.-ER-COMpOVER IOB,N)OBTIft
I hove mord[lie harandro..materials regn Ucn+cn's under Chapter 6,95 of the Cali. AIR CONDI'lTONES ISSUANCE DATE
foods Hard,&Softy Code,Salinas 25505.25533 and 25534.1 understand that if me NEW RESIDENTIAL MRCI1. SQ.FT.
�
b ld gA+evmm.•
+scuI+nant
y1+:+veana ,matilixnVv pmTam
ibilitym+tiryd ,<
le, upant �eJG /�n.TJJ.-VCs
..ftIn (tYris/ gbelntiq mel an af
issuance a Certifcate,{(O ta+aaly.
Owner or author ted
dl ageolLL�1_�)/�e�l)/m/
Date TO ISSUED BY:
OFFICE