S 0189 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL rERMrr N°.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-bTBCUANICAL �+ p
BUILDING PROJECT'IDEM'IF'IC'ATION J O
1 [LDING DDRE ♦ SANITARY NO. APPLICATION SUBMIT-I'AI.DNI I'.
Ald
NAME: P 1, # ./d'hCONTRACTOH'S NAME LIC NO'.
WC COMHOL#
( ARCHITECT/liNGINFF.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
`rn n ,/-� �^_/ �/� ❑ Consultant Fees Paid by Applicant(Initial) If[DGLb I.1 PLUMB SUCH
VT I L �JLICENSED CONI'RACC TORS DECLARATION QTY HLECTRIC PERMIT PEE
I hereby.ff Nnt l am licensedunder pr^.'i.ionxor chapter 9(cammeariag JOB DESCRIPTION
O pLZ with Section 7a#n of Division 3 ofine Business and Professions Code.and my license's RESIDENTIAL;
a100 in PERMIT ISSUANCli
F�.. Lifer Class dcBcn. ❑SIUWL ICHEY RIiMOUEI.
C U F' Liccna Class Li<.#
6 V APPLIANCES-RESIDEMIAL ❑ADDITION UPLUMBING RIiPIPE
GL Da¢ Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUC'TURAI.
PANlil.l
Z understand my plans.still Ma used as public.cords MODIFICATION
UY T0200AMPS
OZ^L, ❑IMERVE ❑CHIMNEYRPOOL
Ir�.E'.W LiceneJ Pmfensinnnl 2111-I(MOAMPS IMPROVEMENT SWIMMING POOLS
�,=; OWNER-exemp ER m Ce RAIContractors
OVER I(WAMPS ATH REMODEIJREPAIR 0DEMOLITION
0 Q 1 hereby affirm tote 1 um cxctnpl from the Commnor's Licenm Law fnr the
1 V following reason.(Settle.7031.5.Business and Proc ie.s Cei Any city m county SIGNS ELECTRICAL OTHER
al'3 W E' which..quires it peril 10 a+mlruel,alar,improve,demolish or repair any deco, c
FSO prem to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIUMISC.
fly } that he is licemW around to the provisions ofthe Comenesss License Law(Chapter 9
f+1�00 (nom uo,ingwilh Section 700(Bn ...ion 3ofNe Businceeand Prmfnsdnns Ctele)or TEMP.ME'I 17 OR POLE INS'll COMMERCIAL:
a a c p: that he is exempt therefrom and the oasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xma
Section?031.5 by any applicantfor a Permit bjmtr the to a civil penalty of POWER DEVICES
m^rte w ❑TT?NANT ❑FOOD SERVICH
not more Than Five hundred dnllacs($5fq).
IMPROVIiMENT
fSQO ❑ Lothe work.the pmpmy.re is
wagecmale(Sm.compuiween. SWIMMING POOL ELECTRIC
F will do the work and the he Comm intended or Law
dosed not apply to an owner
os OOT'HF.R
6 3 m and Profession Code:The Centre.co License Law Nres not apply u+an owner of OUTLETS-SWITCIiT:S-FIX'fUHF,S
properly won buil%,nr impedes t such improvements mvem ta veno work deed ol'nr Ibnmgh
his own empbyem,builds g Nat sash ensiold are not intended or offered for NEW RESIDEMIAI.ELECTS I',
sale.ILhtwerxellthe base
bor urden
is he diinone ycaofcompletfor the SO,17.FLOOR AREA $ISQ.FT
owner-builder will have the ourdcn of Proving that he did not buil)or improve far pnr- PAI
FoeoLw]arW). I D
1.as owner of the proper,am exclusively contracting with licensed enntmaom to
construct the project(Sec.7044,Business and professions C dc:)The Contractor s].1-
neLaw does not apply it)un owner of propcoy who builds or improves thereon.and QTY. PLUMBING PERMIT F < -JUN 23 D[A
who contracts for such pmjccm with a contcrctini licensed pursuant w the Contractor's 1�/�D HG1J
License Law. PERMIT ISSUANCE
lir. Ali non See. l /__/_L.1 SPC for this reds' f.-
a - �l•��Ap�ai" I ALTER-DRAIN&VENT-WATER(I'A) A 'I
WORKIiR'S COM VIENNA)[ON DECLARA I'ION BACK FLOW PROTECT'.DEVICE O
crelev idar under penalty of pe jury,one of the folhwing declarations: OQ
I have and will maintain a Compete of Con.ae^uo elf-insole for Waders Compo^- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TVI'li CONSIRULTIOb
sotto.,as provided fnr by Section 37(s of 16e labor Cole,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker'..Compcmatio^Insumnce,m res,meJ by Section
37M of the Labor Code.for the performance of the work for which this penal is lois.%. GAS-EA.SYSTEM-I INCA OUTLETS OCG GROUP ANN
My Worker's Corr,mal it Intense currier and Pal icy number are:
Cartier: Policy No.: GAS-EA.SYSTEM OVER J IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI!ASFANDUSTRL WASTE IN'I ERCLPIOR
(['his section need not he completed ifthe permit is for one hundred dollars($100) BUILDING DIVISION PEPS
art leezd GRLASE TRAP PLANCHECK FHE
Ioys,lha in lbs perfnrnmcw.d...the ars,forhichobject
N.the mit Wixisv ed, shallSEWER-SANITARY-STORM FAIWFI'.
not employ any pmmn in any monose sn as m become subject m the Wadm'Co.,.-CuPcn- ENF,HGY FEE
O Z ,aline Laws ofCalifomia.Data WATER HEATCR WNCNT/F.I.ECfR
Z A,dvam GRADING FEE
NOT ICE 1'0 APPLICANT:If,after nmking this Cmi ificme of Exemption,you should WATER SYSTCMITREATING
C , become subject to the Warkci Compcmmion provision of the Lather Code,you must SOILS FEE
kl fonhwithc^mply with such provisions o.his permilshall he Jecmed resided WATER SERVICE
Q
7 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMBL SQ,Ff. PAID
V Q I for which
thanbere iso.mnamai3097.lending agency For the peRorancc of Rec.iplN
Q. t-+ the work lin which this permit tr IsxnW(Sec.309].Civ.CJ
F'' loan%a'r Name
I TOTAL:
Leri Address TOTAL:
y II
I era ify that I have need this appliedion and sImc that the above infnrntio i is [full H
fq correct,l agree to comply with all city and county ordinances and stale mwsrelamg to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby authorize represe^mtive.afthir city menier upon the SEISMIC -E
above-mcntiened p o,I for inspection p.,sci PERMIT ISSUANCE
(We)agree to save,indemnity and keep hamdns the City of C.,mro against ELECT C FEE
liabi[iliex.judgent costs and cxpc a ay in anyway acme against said City pLTF;R OR ADD TO M[CH.
in con he gmming is permii PLU PING IFI'
A' K ANT ON ERSTA S AND WE COMP WITH ALL NON-POINT AIR HANDLING UNIT(TO 1T001 CFM)
OU .CRF ATIONS. MIECHAN AL PEE
_at y AIR HANDLING UNIT(OVER 10.111 CFM) CONS'I'RUC TON TAX
wee afApp]icoMCommcwr Date EXHAUST HOOD(W/DUCT) HOUSING MI CATION FEE
MATERIALS DISCLOSURE
Will the applicant or I'm n,building Occupant sones nr handle hazanln I,mnrerial HEATING UNIT TO Ikt0C0 B'IU)
as defined by the CuKdino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532m)^ HEATING UNIT Di 100,000 BTU)
❑Yc, No
VENT]LATION I AN(B INGLE R ESI D) PAID _
Will the applicant or fusee building occupant zee equipment or devices which ADate �Y.�IPL a
.,mit baardous art contaminants as%.fined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR IOtl,gp BTU)
1)inMa7 T(yI'A L:
Yes ON. BOILER-COMP(OVER I00,IX10 BTU)
I
I hew reed the huwrdonx mmviul.retryiremems ends.ClmPlcr 6.95 of the Cnli- AIR CONDITIONER
ISSUANCE DATE
build Hath&Snlrre Cy have rise 25505.25533 and 25534.I understand that if the NEW HESIDCNI'IAL M11 F,CH. SQ.Ff.
- building Jow,na currently haveamnant.Nat it is my responsibility mnotify the occupant
of the requirements which nun he met primus i....rec al a Cenificuta of0u^cy,
Owner mr o rlim oaed agent Dalc ccupTOTAL: I
ISSUI. 13Y:
OFFICE