S 2839 -APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . . BUILDING-ELECTRICAL - PERMI'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING—MECHANICAL
BUILDING PRO.IE0 IDENTIFICATION
HUILDINGADDRESS: Nl ,i L-�� SANITARY NO. A PLICATLO M 'I' ."ATFL
235 4 p�r� v.�-Lt �p �-/9 g
OWNF:Il:S NAME: _._ ./f T p 1)10 ^ ON'I' CI'OR'S NAM,?: LIC NO:
NIC COMI'ItoLN l/I
ARC, '1 T . GINGER: LIC NO: ADDRESS: ❑ O✓
co rncT: PHorvI?: -; BI ILDING PE MIT INFO
❑6 Consultant Fees Paid by Applicant(Initial) BLDG IiLECT PLUMB MEc 1 0- � o �
mz winos«renbylo)annh Slly a,hn,rdml, ow�cne, fChpte,9J enicen�y . ISsuAN RIC PERMIT ', FEE _ JOB DESCRIPTION
LARATION QTY.
il
my
E�,OO PERMIT E S - O R )F I
aUUII lull l4 nreu IcReut. J SFDWI. ❑KITCHEN REMODEL.
Licen�l.icn AI'I'L.IANCES-NF_SIDIiNT1Al. ❑ADDITION CPLUMBUTRAL IPE
:UUu Dnm Contractor
PR•Moo RCHD'1?CT'S"ECL ❑MULTI-UNIT ❑S9'RI1CfUkAL
Z C)nz lundersr dney plane xhallMusW as public records PANELS MODIFICAOON
OZ—O UPT020b AMPS El INTERIOR ❑CHIMNEY REPAIR
I:•4FW Licensed Professional 201-1II(k9AMPS IMPkOVEMEN'IC]SWIMMING POOLS
OWNER-BUILDER UECLARA'I',ON OVIiR IIlt10AM1'S -1BAl'If REMODF.URF.PAIR ❑DEMOLITION
C a 1 hereby affirm Thal 1 am exempt from the Con occlors License Law fr a [lieX OW V following reason.(Seeiaa 7(131.5,Business and I'mfeuione Cole:Any city or county SIGNS ELECTRICAL El 01 HER
W 3 W,Fj which requires a pernal to cnnsuucb alter,Impervo,demolish,or repair any nroclem
F-�06 prionuim issuance.also rtynires the apprcant for such perms to file a.isneJ statement SPECIAL CIRCUIUMISC.
9999�p�.-4 that he is licensed pnrmant to the provisions ofthe Contractors License Law(Chapter 9
aG�q leommm�cing wilt,Scene.7(XX))cI Division 3nf be Hasincesand Plot ..inm Cede)nr 'I'i?MI.ME I'ER OR POLE INS'F. COMMERCIAL:
a c LL that he is exempt therefrom and the hmis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
to .tSl'e1 tion9031.5 byco,applicant lin a pent,,,auhjcdx theapplianl Inacivil penalty of POWER DEVICES,� ❑IMPROV' El FOOD SERVICE
than live hundred enLbrs 155 W). IMI'ROVIiMFNT
❑ Ltls owner k,md throme,or my cmplendeswithwred bristle
(Sere 044, bane,, SWIMMING POOL ELECTRIC
F: will dutnowon
ns Coe-The ntre,
is oat intended Law
of oaec.toan, wnirof ❑CfHCR
3 m and Prly,,,ions Code-The Cotntuerta License law saes not apply m an owner a( OI1TLEl:S-SWITCIICS-PI%TUNIS
properly who builds nr Improves Ihcreon,and who docs.such work himself or through
his own employees,provided that such innpmvenuents are not intended or offered far NEW RESIDENTIAL ELECI R $
sale.IL however,the holding or improvement is sold within one ycaoftrnnpleion,the SQ.17.FLOOR AREA LSQ.IT.
0 mer-builder will have the burden of pow'ms that he did not huild or.ilnpmve for pur-
1 afaowne
❑coronet an owner Ice, pee.704 am exolaslvnld eonlmetlns went Ii The Carmroca" i- TOTA
6 I
msLome project,sec.91H4,Business and property
whoi but Code)The Contracmr's Li-an cevino, Q PLUMBING PERMIT FEF
who contracts liarsuch projucb wi0nnconeueor(al IirsnwJ pununN to the Cmvraceds
Licenx law. rA
1 UANCF.
C]Ta exmnpt miler Sec. ,B&PCfill this reason _
Owner Dam Al: - RAIN&VENT-WATER(EA) VALUATIO`N
WORKERS COMPENSATION OECLARA'IlON BA 1.0 'ItOTECT.DEVICE 313 f1 �-,
1 hereby alarm under penalty of perjury one of the following Jedarabiom:
❑ I haveand will retinal n a Ceni lleateol'Consent to sel l-insure for Worker's ComNu- DRAINS-FLOOR,ROOF,AREA,COND. S'I ORIES TYPE CONST KION
sation,as provided for by Section 370()of the Latin CWe,for the permanence of We
work for which this permit In issued. FI%TURES-PER TRAP ez/_ v
❑ 1 have and will amintain Worker's Compensation Insurance,as required by Section
37W after Lalwr Cude.forbhe Emburomnce.(,he work forwhlch this permit isk,ued. GAS-HA.SYSTEM-)INC.4OFF'F.LTS OCC.GROUP AIN
My Wader's Cnmpensatmn le-o ace condition!Tolley mother ire: �fa
Cartier: Policy N., GAS-HA.SYSTP.M-OVER 4(EA) 7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - NtEASIJINDUS FRI,WAST,?INTERCEPTOR a
IIAING DIVISION FEES
Misseadon neednotbecompleted ifthe permit is foroachumbaddollam 011018
,It b".l GREASHTRAP PLA FEE
Lamely that;,the anyperfommnce oOhe becomefar w lloic,ch i,,permit isiusued,rEionall SEWER-SANITARY-STORM F.A.2W FT ill
3q 4-
not on play any fervnn in mry munnuuve ua to become subject to the Wnrkors'Cnmpen- EN ,Y PGE `7 Z-'+
,$ subject Laws of California.Dam WATER 141ITER W/VENT/ELEC IR
Applicant - GRA, NG FEE
NOTICE TO APPLICANT:Il;alter making this Cenifieme of Exemption,you should WATER SYSTP.M/TRENr1N(I
aheemrs,subject to the Worked Compensmian Provisions of the lnba Code,you.net SOILS PER.
[i7 bmhwith emt,ply with:..1,It Work or this punnit,hall he dcomede—ked. WATER S17RVICE
0
UO Cat hem k6TIONLENDINGAGENCY NEW RP_SIDENTIAL,'LMB. SQ,FF. PAID
l hereby affirm thmincreissued(Sec.30s lending agency for one perfinmmrcuof Dam keceipt»
0 F Leader',for whim this permit is issued(Sec.1W],civ,C.)
QU Lcdder'n Nater TOTAL:
I<nJei s cc
edif TMAL cnify bh:n I have read this I.
application and state that the above information is RUILDIN PE' /
oH.l y 'covert,1 agree ec comply all Ill city and camdy mblemaee and mala laws,eluting to Q'T'Y, MECHANICAL.PERMIT FTE
U building conewmion.and herebymbhorize representatives ofthis city to enerupon the SHISMI I :B 3/a
abovemenooncd pmpuly but inspection putpoI PERMIT ISSUANCE
(We)agree to save,indemnify and keep homeless the City or Culprit againstagesi CLE( 1'IT -1
liabilities,judgments,costs and expenses which nlay in anyway accrue against aid City AFTER OR ADD TO MECH,
in sonnet Ice of the gra legal mialeconl. PLUMBING IEE
APPhIC N UNOERSTANIS AN WILL COMPLY WITH IL ON OINT ALR HANDLING UNIT(TO Flood CFM)
SOUL It GULA'1'IONS. xl MECHANIC L Flili
AIR HANDLING UNIT(OVER II00h CFM) CONSTRUCT, 'fA%
Si m r an a ate HXIIAUSTHOODOV/DUC'q
HAZARDOUS MATERIALS DISCLOSUR HOI151NG MITIGATION I>EE
WIII I heappiicant al'fawre buildingocculmnt Ionic.'huddle 1aLlerdoas material HFiATING UNIT(TO 100,000 BTU)
n dt ined by bhe Cupenino Munici al Gds,Chapter 9.12,and the Health and Safety
Code,Seenor 2553$a)7HEATING UNIT(OVER 100.0 10 HIM)
❑Ye, n PAID
VI!NT,I.ATIONFAN(SINCI.ERCSIDI Dem Receipbp
. eaus Will the opplicare or lama huilding occupant axe equipntcm or devises which
mit haMuan council defined by the Bay Area Air Quality Management BOILER=COMP(3111'OR I W,g10 BTU) TOTAL:
.District 0Ya an HOLLER-COME(OVER I i10,000 B1 U)
I have teal the hunrdunsloserials comicmmae ander Chapter 6,95 of l he Cul, AIR CONDITIONER ISSUANCE DATE
fomes Heat, Safay Cede,Sectinns 25505,25533 and 25514.1 Jcrsmnd t if the NEW RESIDENTIAL.NIECE. SQ.FI'.
huildingdnc tcu rcndy havoamwmt . 'tis my meear=v///'''///;;;''' nl l upon,
of there I t rissuancc nfafcn ��� ( 1�
min
eo r he
L n TOTAi ISSUED BY
OFFICE