28991 APPLICANTTO FILL INJNEORMATION WITHIN RED LINES-USE BALL POINT PEN.ONLY' " -
CITY OF CUPERTINOBUILDING-ELECTRICAL . PERMIT NO.
•BUILDING DIVISION APPLICATION/1PERMIT - PLUMB NG-MECHANICAL - 2 8 9 91
PR
BUILDING O,IHCF IDENTIFICATION v
BUILDINGADDRTHSS: SANITARY NO. APPLICATION SUBMITTALLD✓DATI
'11111111116WjWk'S NAME: PHONE.� CO2ACI'ON'S NA 1G:6/Y'� #3 3 LI1 io,
U rN/C �x CONTROL a
ARCHITECT/ENGINF:F LIC NO: )DRT•,5:, h, �� n ,a� SdRa� ❑ /'y�
CONTACT, PHONE: LL 1. J BUILDING PERMIT INFO
❑ CangDltant Fees Paid by Applicant(Initial) 'BLDG ELECT PLUMB . MECH
❑ •' ❑ ❑
.LICENSEDCONTRACtnR'SDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION,
nCZO with Section 7(Xm)ofOivinim 3ofthe Business and Professions Cocoanut my license is PERMIT ISSUANCE NFSIDENTIAL:.
m full mrea and arccn�nj �x n
".'au License Clms I] - 'Lie.A _ •t�'� �� ❑$FOWL C1 KITCHEN REMODEL
,I. M Data C ntrucmr -"APPLIANCIS-RESIDENTIAL ❑ADDIPION El PLUMBING RE-PIPE
ARCHH'FCTSDFCLARATION '•,y ❑MUI7I+UNIT . ❑STRUCTURAL
FnH PPANELS -
OOz!/1� hl der I y01 sshull banned public recoNs MODIFICATION"
."41 UV10200AMP5
ZI - ❑INTERIOR ❑CHIMNEY REPAIR
aJ �
LicensedProlussiawl 201.10110 AMPS IMPROVEMP.NT A
OWNER-BUILDER DECLARATION
a I hereby.infirm that I em cnempt'f oat the Counrew,a license Law for the OVER 1000 AMPS ❑BATH REMODEDREPAIR El DEMOLITION
i65, 6 U following reumn.(Section 7031.5,Business and erefecsions Code:Any city or county 'SIGNS ELECTRICAL ❑OTHER
'which requires a Fend,m summust,eller,improve,demolish,or rapid,any structure 02 in
prior to its issuance.also requires the applicant for such purmino file a signed statement SPECIAL Cl RCUIT/MISC
} that he is licensed pursuant to the previsions of Ne Contractors License Law(Chapter 9
ty� 00 (commencing with Section 7000)of Division 3 ofthe Business anJPrefwssions Cole)or TF-b1P.SimiN OR POLE.INST. COMMERCIAL:
6 a c C Nm he is exempt thercfmm and the basis for she alleged exemption.Any violation of - ❑NEW BLDG/ADDITION (]DEMOLITION
m Section 70316 by any applicant for a permit subjects the applicant o a civil pcnolry of POWER DEVICES
not more than five hundred dollars($5081. - ❑TENANT El FOOD SERVICE
Sec Lasownerofthe rt,orm laaeawith woes as thcirecle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
D ❑ Prepe ct Yetnp, Y 6 .Bsi
p. d dothework,and the he structure is not s License aw dosed not apply to an owner of ❑OTHER
and Preleasinna Code:The Contractor's License Law does not apply to an owner of OVILFTS-SWITCHES-FIXTURES _ it-)�;» �R n.
6 3 property who builds or improves thereon,and who does such work himself or through .•d
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL FLECTR SQ PE
sale.If,however.the building or improvement is sold within one years(completion.the R�aREA NSQ.FL,
ownerbuilder will have the hunkers of proving that he did nos build or improve for pur- V 9Qats
pouofwle^I. C /any
'❑1,us nw er arrhe property, in exduaivelY contracting with licensed contractors h, - TOTAL
: CII�'
e a erect the pmjeet(See 7044,13minesa and Promedoas Code:)The Counsel.,s Li- Ur L(lr
cense Law does not apply of an owner of property who builds or improves mcnen,and Q•PY. PLUMBING PERMIT FEE tI�III��
who contracts forsuch projects with o contructons)licensed pursumi to the Contractors
License LawHMIT ISSUANCE
. - 4
Iran exempt undo Secs 1 ,B&P C for thls,canon
4 ❑Lha Iendwill firm uniroCertlfcatenfConson atter(following Wmkcre Com ALTER- / r
Owner Date DRAIN&VENT -WATER CA)' � VALUATIONN..
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT DEVICE Iw/w coO
I hcmh f0nn under yrs pe j ry a of the following decimations: AYYCCJJ<�CJ
Cooper- 'DRAINS-FLOOR.HOUR ,COND. STORIES TYPE CONSTRUCTION
tonin,as provided for by Seen,,.3700 of the Labor Cade,for the performance of the
work for which this for,is ismcd. FIXTURES-1'FR TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W f,he LahrCade,for perfanatime of the x mk far which an,permit is issued. GAS-IEA,SYSTIi -I INC.46 EfS OCC.GROUP APN
My Work ''aico�yp(ieryl s ee cars, Policy familiar arc:
rti
Caer.LL -`` /B Policy Na: GAS-HA.SYSTI' VP 4 )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRP FUND ASTE INTERCEPTOR -
(This sectionnttJ notMcompineJi(the pemrisisfor ocehundrtd dollar(511X)) B LDIV 'DIVISION PEES
or less.) OREM P PLANCHAK-64
..
Icmify thvtinthe perfo,manceoOhe work for which thispe,mit isissucd.lahall SEWS - 'ANI'LARY-STORM EA.2W FT.
not employ any perssm in any menace so as to become subject to the Workers'Compeo- - FNERG h
O Z soundApplicant
ant of Ca1iGypice.DY(e� WATI7H HEAVIER WNENTMLEC1R
O Applicant r �fS kt GRAD( FP.E
,'Zy y NOTICE 7U gPl'hICANT, after making this Cenificoa of Exemption,You should WATER SYS'1'IiM/TREATINC
f^ became subject to the Workers Compensation provisions of the Labor Code,you must 501 :L
WQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDEN1 IAL PLMB.s. SQ.FT PAID
UO (hereby m 1irnnhat there iso construction kiningegency for the pare coca of Date Receipt#
{1i the work for which thispermll is issued(Set.3097,Civ.C.)
Land Name - _ TOTAL:
' O L) bender:Ad bets ,a TOTAL:
I certify that I have read this application and state that the above Information is BUILDING PL' Gf
.�.
ry f/7 cnrrem.l agrtetncumply wish all city and county influencesend state lewsrelating to QT'Y MECHANICAL PERMIT ' FEL?
617 building construction;and hereby aathoriu representatives of this city to enter upon the SEISMIC FEE
above-mentioned property far inspection pmpows. PERMIT ISSUANCE
(We)agree to cove,indemnify and keep hamtlesS Ne City of Cupertino against ELECTRICE
Iiabildies.judgmenu.cosh and expenses which may,in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the grand ng of this permit. PLUMBING hE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-PO p1µHANDLING UNIT(T010,000 CFMp 1
SOURCB NE 'g / _
/ MECHANICAL.FEB
/�j AIR HANDLING UNIT(OVER 10,000 CFM)
l��d1 9. CONSTRUCTIONTAX
Signatureof ApplicantlContmctddor Dam IDUTAUST FOOD OODUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or future building occupant store orhandle Windows antitrust HEATING UNIT CTO 100.000 BTU)
as defined by the Criterion Municipal Cale,Chapter 912,and Ne Health and Safety
Code.Section 25532(x)'! BEATING ON[T(OVER 100,000 BTID
❑Yes ❑No PAID
VENTILATION PAN(SINGLE RESID) Date ' Receipt#
Wndousl the air contaminants
icant or ntaminanture building by the use Bay
Air nt or Quality
Manages ement
est BOIIFR-COMP(3HPOR Off"BTU)
emit District?
ur our contaminants nr ok0nnl by she Boy Area Air Qu5lity Management ',roT
DlmriclP MOILER-COMP(OVER 1W,000 BTU)
❑Y's ❑N.. . . - -
I
1 hoe read the Inowdnus m le,ick re u inments under Coffee 695 n1'L Cali- AIR CONDITION(?R
9 p ISSUANCE DA
romia FetBh&Safety Code.Sections 25505,25533 and 25534.1 understand that indite NEW RESIDENTIAL.MECH .SQ:Ff
building disk and po
currently have a tenant,Thin it is my resnsibility m oaity the occupmn' . . -
orterequir enB which most bo ism pndnolssuunw oln CertificnteofOreurymcy.' _ -' - s "
r Owmn,muothminad agenl Data t TOTAL: I ISSUEDB
OFFICE