S 1462 I
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUH.])ING-ELECTRICAL I'TIT NO. 1469 4^I{•.�/ 9
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL V\
.RUILDING PRME"'C I'IDP.YTIFICA:r1ON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMIT)'AI.DATIe
I033o V-A PIE!rIAL, AVr . la,
f 1AV NA 1 "fl ow PI Zi-q4-1-7
q4» CONTIEAC'I OR'S NAME: LIC NO:
N/C CONTROL,
(RCHITnCc/GNGINP.I?R, LIC NO: ADDRESS:
< _ o e-��z3o
CONTACT: PHONE:f"�A� -- BUILDING PERMIT INFO
k.''.,0,b)4 ° Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION Q'ry ELECfRICPERMIT FEE
I nnrnnr nfrinn mill 1 am ue.ntad auto prmvLJ+,IIs of Chaplc,9(emmmancing + JOB DFSCRIPTION
WAlQat wiah$ection 7(NMquf Oivisiun3nfine Business unJ ProfmsionsCWe,anA my li<enu is R IID- TI
PERMIT ISSUANCE
oe, PERMIT in full fmcennt effect. )WI. ❑KI I'CHEN REMODEL
�UU License Class Lick APPLIANCES—RESIDENTIAL ADDITION C1 PLUMBING RE PIPE
rel 6 W Dv¢ Cmnmcmr
ARO filECT'S DECLARATION ❑MUIM-UNIT ❑STRUC'I URAL
p.,❑on PANELS MODIFICATION
Z O V,Z 1 understand er,,lolt,shall be used as public records
00Z4O UpT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
F.N,.F.W Licensed 11 list..nal 201.1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER"HUILDIiH DECLARATION OVER 1000 AMPS ❑BATH REMOOFL/RCPAIR El DEMOLITION
CL 6 I hereby nl'lirm Ihul 1 oro exempt from the G'maw
ramr's LiecnLaw fur the
L U fallowing mason.(Section 7131.5,Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
which reclaims a,snail a+mnmmcl,alter,improve,demolish,or repair any somemrc _
N� priormit,isumnce,nlsu reynlres me applic'anlE+rsneh,wrmit u+file asigneo.ummarna SPECIALCIHCUIUMISC.
that he is licensed Pursuant to the provisiomofine Contractor's License law(Chapter9
W p�'Q� (commencing with Seeion]nlg)of Divivion3ofaM1e Business lmJ Pndesslnns Cm+le)or THMI'.ME1ER OR POIX INST. COMMERCIAL:
-L y m y mm he is nn famfrum and the basis bort he alleged exemption.Any viafmien of ❑NEW BLDG/ADDITION [ID17MOLITION
at Section V031.5 by any applicam fella permit subject,the applicant'a civil penalty of POWER DIiVICCS000
❑TENANTIMPROV
El FOOD SERVICE Z p+ nm mum mon rive handmddallars(S5(N). IhfPROVEMI:NT
SSC ❑1.us owner of the property.or my employees with wager as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
yF. will do the work,and the tantrum is not intended or offered for sale(See7,14,nosiness
413 m and Pmmsxions Code.The Conuuclodx License Low does not apply a an owner of off'TLE'1'S—SW I'TCITPS—PI%"TURES
property who builds or improves nerved,and who does such work himself or through
his own engdoyces,provided that such improvements me not intended or o0crcd for N17W RESIDENTIAL ELIiLTR SQ Irf.
sane.IChowever,the building or improvement issolJ wimin one yearof vampldion•the ^ SQ.FT.FLOOR AREA, b/SQ.17.
owner-builder will have the burden of proving that he did not build or improve for pur. ' /I IN67 v,k,k. A
pose elf.owns L Y /•���'
1,as owner of the prnpeny,am exclusively commcdng with IicrnuA rnmmmnrs to 1i
a+mhuct the Emicet(Sec.7014,Rosiness,and Prnfcssii Gvlc:)The Commelar's LI. - + -
cause Law Joos not upply to an ownerof property who builds or improves thereon,and QTY. PLUMBING PEREEE �
who contracts for such projects with a conuaclortst licensed purauant to the Contractor's _ [YKLW`
Lici,,mc Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for his u eras T
Al:T1iR—DRAIN&VENT'—WAI'HR(HA) VALUATION
Owner K`
O d,r p COMPGNlAll N D LLARATI RACK FLOW PROTIiCf.DEVICE y
lnemny nnirm annarprnally or�:rm rp+.mnnwing a«Iamdmnx: -
❑lhave vnA will mainmin vCeniricue of Conscut to off-instar.far Worker's Cnmpem DRAINS—FLOOR.ROOT.AREA.CONI). STORIES TYPE CONSTRUCTION
ration,as provided fm by Section 3703 of the labor Code,ranl+e performvnce of Inc
work for which this permit Ix issued. FIXTURES E •2 V-N
❑1 have and will maintain Worker's Compemadan Insurance.as required by Section
970Iol'm.Labor Code.for the p,rfnnnanm nfthc work for which rola permit it issued. GAS—H&IS 4f'M-I IN 4'.Ol 'LETS OCC.GROUP MIN
My Worker's Compensation Insurance carrier and Policy wmbe are: ,1
Como. Policy No.: GAS—EA.S "OVER 4(EA). R3/u
'CEKI'11'ICATE 017 EXEMPTTION IiROM WORKERS' GRIiAS[/IN 'RI. Q" I iR®+I
COMPENSATION INSURANCE 13111 NG DIVISIONEE
1need nm'En,wetter be w+m,lemd ifthepc,,air is forma,hmideeddolla,IS I W) GREASETIt
nr Ices) - FLANGE /a
lcenifythal lithe psrfonnameaflhe and,forwhich mis,armii is issued,l shall SHWER—S N RV-51URM Iib 21X117.
re,in"lmy any,anon in mlymannersmit,to hccomesubjecuo m,WurAu'e'Cunapen- EN FE'
0 Z sation laws of California.Date WATER HE
17 Applicant G +19iE
NOTICE,TO APPLICANT:If,alio,making This Cenilicme of Exemption,you should WATER SYSTCM/IREA1'ING
become subject to be Worker's Compensmion provisions of the Labor Code,you must SOLI FF.E
!7i forthwith cvml.1,aid,such pmvisi,nsonhis yanel,ball he deemed mvaked. WA'll?R SERVICE
WW
7z
CONS e RUCTION[.ENDINGleading
tical NEW RESIDENTIAL PLMa. SQ FL PAID Due RteciplN
V Iheleby nfYirin lhnuher,isncmnxranian lending agency lirz the perfmm+ancc ml'
F the work for which this permit is issued(Ser.3119].Civ.C.)
O U _mak,',Ni e TOTAL:
Lenders Address
W0 BUILDING FF:
1 certify thel 1 have read this npplicuainn and slam al+m thv vhovc infonnmion is
fn earnest.I agree totmtpty wim all oily and coumy nNinuneos aodemcku,,mintin,le QTY. MF:CIIANICAI,PERMIT �PF.I?
U Z building contraction,and hereby vuhncre sepresematives almis city as enter upon the SEISMIC Fli:
uMrvcaaenlinnW,mfeny for intpcctinn Purpnacs' PERMIT ISSUANCIi
(We)agree In save,indemnify and keep handless[tic City of Cupertino against IiLFCI RI PEF
Iiabililiet,juJgraces,emir, ad expenses which may in any way ocemeagainn sato City ALTER OR ADD 11)MSCI I,
in teuyumme mime gmmingof mit pcnnit. PLI]MRI G iE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CENT)
MECIIANI Al.FEE
SOURCE
s AIR HANDLING UNIT(OVER IUhat CEM) CONSTRU ION'I'AN
r
Signa of ApplicmaCnnrrnclmr
Data EXHAUST HOOD(W/DUC'1) HOUSING MINIGAI'ION PER
HAZARDOUS MATTRIL DISCLOSURE
Will the applicant or future building Irenpam sure or boodle hamNnus mmeaal HEATING U NIT TTY)100,000 BTU)
us d,fined by the Cupeninm Mmuci,al Gds,Chapmr 9.12,and the Health and Safety
Code,Section 2553200! UNIT'IINI'1'(OVER 110,(Np RTU)
[I yes El No VENIf LATION FAN(SINGLERF_SIU) PAID
Date Receipt 9
Will the applicaln or future huilding occupant use equipment or devices which IIOILI3R—COMP(3111'UH 11NI,INIa B'TU)
emit haeumars air emomminnnts as d.fincd by the 16,Area Air Quality Management O AL e D
Disawt?
FI yes E]No BOILER—COME(OVER IINLINNI RTU
AIR CONDITIONER
1 have read the h ode,Se ma¢dah r5,2553 an under Chapter a,95 of the Cali- ISSUANCE; E/�
Inmlugdoes&Safety CoJe,e a muss,Thaii2s53J snns5)4. undersumJIlial If me NEW RESIUP.NTIAI.MECIL SQ.Ff. 7
building Jus bol currently have a tenant,Nm itis my responsibility m notify Ihcsecalam
J.m uiremenw whh R+musl he met roar tel'tutus nfu Ceylienu oroccnpnluy.
O vvulhnrized agent Dotc ISSUIiD BY:
OFFICE .