00010172 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY 0/10 1-7 Z
CITY OF CUI'ERTINO BUILDING-ELKC'I'RICA L PERM["1NO.
BUILDING DIVISION APPWCA'1'ION/PERMIT
PLUMBING-M ICA I' p j
NUILIHNC.I'N(XJF:C'Iamm
'IIXBNI'IF'ICATION �69��
HIIILDINGADIIRESS: SANITARY NO. APPLICATIONSUHMI'YI'ALDAI
WNERS NAME: PITONS: CONTR ORIS AME: LIC NO:
NIC CONTROL#
nRCfll'1'EC MN NEER: LIC NO: ADDRESS: ❑
CONTACT: PnoNE: HU ILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) III DO I],rCl PLU�M(x� ntp.C11�
I.ICIENSEDCOYI'RACTOR'SUECLARAII(LN QTY FI.IEC'TRICPERMIT FEE JOB
rL-J•DE�$CIZIPP TION
t....hy enj nt that 1 atm licensed rode,pmvixians Of Ch,ner 4(commcnci ng
Oat,
win
SoNnn]ago Of Da.i:inns mnhe Baame%%ane rrofbax;nm codo,antl my ut<nsr is RESIDENTIAL:
W p p PERMIT ISSUANCH
Foy full farce; it effef ❑SIZDWI. KITCHIEN RIEMODHL
aUU Li(cnsc Class Lac# APPLIANCES-RESIDIN IIAL ❑ADDl'I'ION �PI.UMBING HEPHIR
NZW Date Contractor
On Q Q. ARCHITECTS DECLARATION O MUI,ThUNI'1, [1 STRUCTURAL.
ZOZ
F,AZ I understand my plans%hall he used a%public records PANELS MODIFICATION N- UPTO200AMPS
❑INTIERIOR ❑CI{IhIN1EY REPAIR
I-H1=tlx1 Licensed Professional 201-10OCAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER 0000 HIS ❑BATH RIEMUDELIREPAIR El DEMOLITION
C C
36< I hcrchy affirm that 1 am exempt from the Contmnnr'%License Law for Ne
XV follOwingrcesou.(Section 7031.5.Business and Professions Cdr.Any city or county SIGNS ELECTRICAL ❑(rr111ER
W LL h which requires a permit m construct.alter.improve.demolish.or repair any structure
^u•OQ Incur La its issuance,also requires the applicant for such permano file a signed smmment SPECIAL CIRCUITIMISC.
y2 that he is IIcensed pursuant the provisions of the Cnntractia's License Law(Chapter9
COMMERCIAL:
61 x 00 mat he
rptM1 SCnloo7and the basis or th the alleged
exsmd Prulb%mons C�dc)or TEMP.METER OR 1411,E INBI'.
t1 p,o C IM1m he is uscn�pl IhercGom and the basis for the alleged exmnption.Any Iviolation
Pena I nr ❑NEW BLDGIADDITION ❑FOOD SERVE
n Scniun]1OISby any applicant fnrupcmnil subjccu IM1c xpplicanuOa civil pcnd1of POWER IJIiVIC1EN ❑IHNAN'I' ❑FOOD SERVICE
i- lonam him live mandrel dollar,($500).~Z6 I,a,Owner of Ne norm loeex with warns as their%ale rens lion. SWIMMING PI RB,I!LEGI'RIO IMI'N(IVIEMIEN'1'
In
pmpc y YcmV Y b .louq IHR
F, will Anthework,nnJ Nc%lmcwrc is nonntcndcd urnRereJ lm..(e(se,.9014.owner of /
W and I'®f"csxa no Core:Th.Calif.,,,),,Liecase Law does
nrn apply to an owner Of X OU'TLF,TS-SWI'TCHI!,S-ISX'TUHES
A.3-. prolerty who builds or improves thereon,and who doer such work himself nr through
his own employees,provided that such improvement,arc net intended or offered for NEW RESIDIEN'I'IAL EI.ECI'R SQ FT.
sale.If,frostier.me building or improvement ixxald within one rearnfrnmpiniea the
QSQ.I•I'.FLOOR AREA SISQ.Irl'.
owner Wilder will have(be burden of proving that he did not build Or improve for pur-
��C rpr�r'a, .). TO'
jj r of the property.em exclusively contracting with IicenuJ comnmmrs to
construes the propet(Sec.7044.Business and Pru&,mons C, 1:)(fie Conlrnclors
c se Law does not apply m an owner of propeaY who builds m improv h FEE
who contracts for such projects with a contracmr(s)licensed punuam m I t
License Law. T N
1 am exempt under Sec. H&E'C as
'RI' VALUATION
ser RUatc ( -
WOR 5 COMPENSATION DECLARATION t HA Ri An O JX O
hereby nlRrnt under penally of perjury ane Of the fidluwing Auaamlun Cl
Ibave....twill innamain a ClomcnmafCmsem msdl'-In%um lin Wnrkcr'sG IIRAINS-FLOOR.8001 .0 S'IORIp TVI'Ii CUNs'IXt1C'rl0
axion,ax Pnwided he by Seaton 37(X1 of IM1c Labor Cade,fin the perlurnt ince 0 1 r
work tin which(hiders(.(is issued io E PE
F- I?roc roil will main rin Workers Comrynsmion Insurance,as rcyai li nwIrm 647
3700of Nc lyhuC:de,fnhelwrfurner,cuflhc work for wM1ichltixpn tis O OCC GROUP 6 /sk PN� �
My Waders Compensulion Insurance carrier and Policy number are -E
GAS A.SYSTIEM-OV ER 4IRA)
Carrier Policy Na,
CERTIFICATE OF EXEMPTION FROM WORKIERS' OREASIYINDUS,RL WAS TE INTERCBPIOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisscefitai admalwor mplend ifthcpcnnit i.sforanchundmildollam(SIOB GREASE TRAP
nr less.) I'LANCIIIECK LYE
I certify that in the Performance oflbe work for which this permit is issued.(shall SEWER-SANITARY-S'FORM EA.201 FT.
not employ any person in any manner so a%m become subject to the Wnrkcn*Compen- ENERGY FEE
sation laws of Caldoo ire.Date WATER I TENTER WNHN'VEiLECB
GRADING I
Z Applicant IFEE
NOTICE*I0 APPLICANT:IL after making this Certificate Of Exemption,you.should WATER SYSTIEMffREAI'ING
SOILS lath - r
a > tanb,o.mhjccl y the W.In par,Cmmpcnl'his provaslons of the oned Code.you mull
fill lonhwilh nmtPly with such provisions Onhis peon.(Shull he decnaJ revoked. WA'1'EH SERVICE - -- _ _ - ---- __—
n' � CONSTRUCTION LENDING AG17NCY NEWRES1,17 I'IALPLMIL SQ.FT. 10\IU 't
U p n
I hcrch tlinnaml Ncrc&acunsauafi I lading agency fin the perNnt rof Dale, R upl#
(~ the work for whlem Nis panni(Ix..sued(See.31191,Cas.C.1 ,l J 1�
O lendr.,
e' Na me f [1
TOITI" 1
V Lendcb AJJreex 'TOTAL:
I cenily?but I have read Nas application and smie that the anew,information is BUILDING P`E`[I
.FsN comet.(agree b)comply with all city and county ordinances and rime lows relating toqE
HANICAL PERMIT FLEE ti-ISMICIIEIi II
V Z building construction,and hereby authodu rcprescnmlives of this city to cater upon the
aMwe-mentioned propcny fur inspection par tswel. PERMITNCE ELIECI'RIC PEE
(We)
agree m aavc.indemnify and keep harmless Ibc City of Cupertino against
Eiabilitics.pagmcox.casts and expenses which may in any way accrue against said City TO MECH. PLUMBING
in eonxquence of the gmming of this permit. ---
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT UNI'T(TO 10.000 CFM) MECHANICAL FEE
SOURCE:RIE(iU1.AT10 �
iAl�G��yL UNI'1'(OVER IgIXNI CFM) CONSTRUCTION 9'AS
ti re Of AppllcanVCn actor Date HAUST HOOD I WNUCII HOUSING MI I'IGAI'[ON FEE
TIN RIIOUS MATERIALS UISCLOSUndl
Will the xpplluum or future building Occupant sone car mond(,huxanlnu%material HEATING UNIT('IO IIXI,0X1IfI'U)
us der,.,by the Caption,Municipal Cn I,Chapter 9.12,soul the Health and Safety HEATING UNIT'(OVER I0K),011113'1'U)
Cwle,Sntlon 2554200'1
[]Yes F-1 NO VB N'IILA II ON FAN ISI NGI.H ICES ID) PAID
Dam IO'e"t#
Will the applicant or fetor,building xcupam use equipment or devices which BOILER-COMP(31{1'OR 100,000 BTU) �'J
mal hamrdous air mmaminalls.%defined by the Bary Arca Air Quality Management TOI'AI 2
27
District? BOILER-COMP(OVER I00.0f0 BI U)
C]Yet ❑No
I have lead the harardous materials requirements under Chapter 6.95 of the Cali" AIR CONDITIONER ISSUANCE DATE
fomaa Health k Safety Code.Sections 25505,25533 not 25534.1 undersl-it Nm if Nc NEW RESIDEENTIAI.MECIL ML FT. 2,?
huildingd«s mit cummly have a moist.Nat i1 is my resrym%ihihty m notify the xc rearm
of the«y 'm ms which mutt he me 'Ort is of o Cenme.ee of Ove.gancy.
or authorial reg Umc TOTAL: ISSUED BY:
OFFICE