S 2158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I11111.pIN0-P:1.1?CTRICAL PEl D1 NO. w a
BUILDING DIVISION APPLICATIONQ'ERMIT i'hUhIRINO-MECHANICAL `V •2.",L
BUILDING PROJEC'I'IDEN'i'IFICAT'ION
58
HUIL��I�S� ��� � �]a� SANITARY NO. APPLICATION ti1JRM1'1'1'AI.DATE
Qb
OWNS ' NA lis �PHONIi: /U\ CO CTOR'S NAME: // �. LIC NQ' Z . �� _�
dJ 'F(Y!'O�KI�I v'l NIC CONTROLN
AR.HITECI'/IiNGINEHR: LIC NO, ADDRESS /O N w ❑
CONTACT. PHONE: BUILDING P RMI'IINFO
31 /0`7 5/ 3 ElConsultantFees Paid by Applicant(Initial) BLDG ELECT U MECH
❑ ❑ ❑
LICENSED COMMACi'OR'S DECLARATION QTY ELECTRIC PI7RMIT FEE
1 herehy affirm that 1 me licensed under pmvisinns of Chapter 9(commencing JOB DESCRIPTION
p08 with See6on7000).fD'o,,in i h the lin.inew and Pmfesdon,Code.andlny license is RESIDENTIAL'
�+IOp 1'I?ItMI'f ISSUANCIi
ka— m full force and effect. ❑SFDWL ❑KI'ICHIiN RIiMOUEI.
aVV 1.iccnsc Cl s Cone APPLIANCES-RESIDFNIIAL El ADDITION El PLUMBING RE-PIPE
P 4 d Oatc Cnmmnor
Fly AI HI"I'EC'I"SDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z0m',z I understand my plans shall he aunt as public records MODIFICATION
py=Q IJP TO200AMPS ❑INTERIOR El CHIMNEY REPAIR
F4lt:41 Licensed Profeaipnd 201400IIAMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION
6 I hereby off Bmf I ata exempt from the Conuvcmr'u License Low for aloe OVIiR 000AMPS [I BATH REMODF,IIREPAIR DEMOLITION
x2 p d U following reavm.(Section 7031.5,Business and PmfevAm s Gine Any city c,county SIGNS ELECTRICAL ❑OTHER/,/p/!_L._.� �
1+1 LL O
F" which requires o permit m construct,alter,improve,demolish,or repair nny se.mre ETT//�
.a primuttasiamnce.also requimsthe applicant fomeh ploont it flea signedxtutement SPECIAL CIRCUIT/MISC.
y that he is l iecisei pursuant m the provisions of the ContrLl
mna'u erne Law(Clopter9
000 (enmmencingwith Sectinn71x10)of Dlvlsion3oflhciiusinessamd Prnfesslnlss Code)or TI?MI1MEfL'R(IR POLE INS'I( COMMERCIAL:
6 q o y 'hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLXl LL Section7031.5'by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES [I TENANT FOOD SERVICE
1-. y not more than live himemidollars(4500). IMPROVEMENT
❑5p [] I,as owner of the pntpcny,nrmyempinyms with wagesas Thcirsnlennntpensminn, SWIMMING POO,ELECT RIC ❑0'1'HER
y 1-seewill dolhe work,and the structure is not mended proffered for sale ser,7044.Business
Q 3 and Profess tav,Code:The Contractor's License law does not apply to an mvner of OUTLETS-SWITCHES-ITXTIJRES
property who builds or improves thereon,and who does such work himself or through
his own enrployces,provided that such improvcancnt.s ore nm imm�dcd or offered Isar NI7W RESIDIiN I IAL ELECIR s4TT.
sale.ILhowever.The building or improvement ix sold nn
old .PI'Jq,00R AREA g/SQ.IT.
oweepbuilder will have the burden of proving that he did not build or improve for Far-
pooe of sale.l
[-11,as owner of the propcny,nm easel unively mnlrucdng with Lee..ed ennlrucmers TOTAL:
mmmna the pmjmt(Sec.VM L Business amd Prde isions Code)The Comranors Li.
cense Law does not apply to on owner of property who builds or improves liberation,and QTY. PLUMBING PERMIT FEF
who contracts for such projects with a enneactods)licensed pursuant o the Cnmmcmr's
License Law. PERMIT ISSUANCE
❑ I nm e.etupl ander Sea. .H&P C rm dris na.o
AM ER-DRAIN&VENT-WATER IEA) VALUATION
Owner Mata
WORKE R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby union under penally of perjury one of the following dechmninns:
I haveand will maim.m.Cenific.w Of Cnmentloseif-in.aue l'mr Worker's Cmite . DRAINS-FLOOR,ROOEAREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3701 of the Labor Code,for the performance of the
we fpr whichumspermanniissued. 19XNRES-PER TRAP
1 have mad will morecin Workers Compensation Insurance,as rcquirel by Sectinu
aO J 00 of the labor Code.for the lowdomance of the work for which this pernnit is issued. GAS-17A.SYS'I'F.M-I INC.4 OU9'LEI S OCCGROUP / 6 111
M Worker Cpmpensaenn ins ncc di'olicy nu fp �jJf,' V Jam/
Cartier:, (gJ('Pdicy No.:� l� �0'w GAS-EA.SYSTfsM.OVER 4 IFA) a
CERTIFIC�MPTION FROM WORKERS G111iASE/1ND(IS'1'11l.WAS 11;INTERCIiI'I'OR
COMPENSATION INSURANCE; BUILDING DIVISION IBES
(This#tionneedn(A ecpmpletediflhef miitinforonchundt dnllam(SI(XB GREASE TRAP
nr Icss.7 PLANCHF.CK PEE
I certify thm ihartatiformaterof the work far which this permit is issued.I shall SEWER-SANITARY-S TORM EA,21X1 lel'.
not employ any person many manner se as m Femme subject In the Workeri Comical- ENERGY FEE
0z nein Laws of Culifomia.Date WA'T'ER HEATER WNW]MLECI'R10
z 0 Applicant GRADING PER,
ion r7 NOTICE To 1 APPLICANT:If,after tasking this Certificate of Exemption,you should WATER SYSI HMIFREA'I'[NO soil's EEE
a became suhjr,,m the Worker's Coanlosmoomm pmvixions cI the Luber Coer.you mal
LSI for th comply with such provisions or this Worth shall he deemed revoked. WAI ER SERVICE
Q
Uz CONSTRUCTIONLItNDINGAGENCY NEW RESIDENTIALPLMII. SQ IT. PAID Date Barone,#
t.) 0 k fit,
Thi end(here isnpmNee.30leading agency for the perlonnvneenl
E~-I the work for which This permit is IxsucJ(See.3097,Civ.C.)
Lenders Nmnc TOTAL:
0 V I<nders Address 'fOTAI.:
�-a nJa - - ECONSTRUCI
f:E
[�. 1 cenily 1hm I have read this application and smethut the above ininrmotion is
A .
f�/J utrtect.l agree mcomply with au city and camnty oNlnaneeo mad state laws rebning n` QTY. MIiCIIANICAL PERM I FEE
C..) ,z building connection,and hereby amhorixe representatives of This city to enter upon the .
uMve-mentioned progeny,for inspection purposes. PERMIT ISSUANCE
(We)agree at save,indemnify and keep harmless the City of Cupertino against iE
Iinhi111iea.judgmema,rose and e.peosef which nuay in say way accrve v,it not slid City AUI'IiROR TOMECII xx
in mmoodurt.of the grunting of this permit. PLUMBING9?li
APPLICANT `NDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HAND I I NITL EMI
SOURCF.R VS I.FEE
AIR IIANDII J INIT(OVER L,ONICFM) UON TAX
Signature ofApplican a enter Date EXHAUST IJED( HOUSING MITIGATION FEE
HAJARDOUS MATERIALS DISCLOSURE UU
Willbe.pplieltm or future building occupant storemimmilcho,noo1,am', l HEATING T(TO 10.0001CU)
as dafned by the C.Penino Municipal Gude,Chapter 9.12,and the Health and Safety HEATING N®vv..VBR IIq 0X1 BTG)Sown..25532m)? Y'
E]Y., VENTI LATION FA N IS INGLE RESIDI PAID
• Date Receipt# ((//
Will the air reenactments
or future building by the I y A ea Air
or devices which
emit haaardnus air comnminants us dcfinW by the Bey Area Air Quality Management 1301LER-COM P CHP OR 1(1(1.0X1 p'1'Ip
Dion't?
❑Yes BOILER—COMP(OVER 101.00 RTU1
I have tend the hmadoa mumrials nequirenmms under Chep¢r 695 of the Calm AIR CONIN I'IONER ISSUANCE DATE
forma Health&Safety Cale.Sections 25505,25533 and 25524.1 understood that if the NEW RESIDENTIAL MECII. SQ.PI.
building dross not currently have a mount,that it is my responsibility to notify the ocmiant
of the 'c cn most be met prim 10 isooame of o CenOlca�a or Occup. .y.
Offer or uulhnn t l�amTQTAL: ISSUED BY: —
OFFICE