S 0689 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO.
PINO-M1
BUILDING DIVISION APPLICATION/PERMIT BUILDING PRfIJI:CT EICUIehNN1IGFCdl-ATIOry J 0689 6vQ
SANITARY NO. AYI'hICA'IION Sl11tMl'I'I'A I.DRI'li
BUILDING AUDRESS.
Ig990 Pse.Ta—SE— L. HF- L b
OWNER'S NAME: PHONE: CO RACTO NAME: LIC NO'.
KNENIC CONTROL
L� 1 ❑
LICNO'. ADDRESS:
M CONST• k loon AenRN W. SRK s
CONTACT: PRUNE 13UII,UING PERMITINFO
❑ Consultant Fees Paid by Applicant(initial) BLD Iil.li T PLUMB SUCH
211' ❑ ❑
LICENSED CONTRACTT OR'S DECLARATION QTY ELECTRIC PERMIT FEE J DESCRIPTION
I homby affirm that I am licensed under provisions of Charter 9(commencing
�=0ZO with Section Dlvisio.3ofthe Businessland Profiovaims Code.and my license is PERMIT ISSUANCE RESIDENTIAL•
aWF, in full l,around effect. ❑.'rDWL ❑KITCHIiN k1iMGDE1.
U License Claw Licp
< U APPLIANCIi$-BESIDES'1'IAI, )ITIUN I'LUh1BING RIi-PIPE
F a a Date—Qmtmnor
fV/I ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑ti'TkULTURAL
MODIFICATIOND on
O �Z I understand my plans shall W used as public temN<
UP T02fX1AMPS ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
�t3(:. Licensed Professional 2111-I(N111nM1'S ❑
NIX: OWNER-BUIhU13N UECLARpfIGN OVER IOOOAMP5 El PATH REMODI?IIRF.PAIk ❑DEMOLITION
NIX:6 1 hereby affirm Thal I am exempt firm Ne Comma....License Law for the DOTTER
X 3 6 U following mason.(Section 7031.5,Business and Pmfessime,Cade:Any city m county SIGNS ELECTRICAL
W ncOy witch 4 permit construct. Pte improve.demolish. P y.mcmrc
N.al pre t t H y 're tis PPI nt1 hR 'n fl b J't Cement SPECIAL CIRCUIT/MISC.
�yy 'bar lie Iw. dp u u the a o. III C t L 1' (Chapter MFR -I I'
W�GO (commencing with Section 7000)ofDivision 3 ofthe Busness and Pmvcsiin:Code)or T1dAPMEI"Ek ORPOLEINS'f. WBLDG/ADUII'ION ❑DIiMO1.I IlON
0.a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of
WaySection 711JL5 by any applicant turn pcmtit suhleats the all civil penalty of POWER DEVICES ❑ ANT ❑1'COD SERVICE
not mom than Fila hundred dollars($500) IMP 11iNT
F,Z^YQ ❑La%owner of the property.or my employees with wage,us far compensation, SWIMMINGPOOLIiLECTRIC �yYl'HER
$y+M will do(lie work,and the structure is not intended oroffered for sale Sec.7094.Business
ty"m and Professions Coda:The Contmetolr License Law docs not apply to an owner of OIIfLIi'I'S-SWITCIIILS-I IXTUkE$
a 3 property who builds or improves thereon,and who does such work himself or through
his own employees,pmvided that well improvement are not intended or offered for NEN'RISI DENTIAL ELECT R SQ FT.
sale.If.however the building or improvement is sold within one year ofmmpletion,the SQ.FT.Il(X)R AREA S/SQ.IT.
,),nor huildur will have the burden tuf proving that ha did not build or improve far per- w
paseal,ule.l. TOTAL (AY
❑1,a,owner of the pOpeny,am exclusively cnntmning with licensed canno tors to
onstma the projca(Sec.7t3L1,Rosiness and Ymfessionz CsdeU The Cornowna s Lb
sal.uwd'c,n.tapplytaanownefofptnpeny whobuildsofimprovcs thereon.and QTY. PLUMBING PERMIT FGF
who mouses fte mch project with a cantrvgngs)licensed pursuant the Contractor's
Licatec Law. PERMI"IISSUANCE
❑ I am exempt under See .B&TIC or Elis reason
ALTER-DRAIN&VENT-WATER(IA) VALUATION
Owner Dat
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTBCI'.DEVICE
1 hereby affirm under Penalty of Perjury one of the following declarations
❑ I tromand will mommdn aCer30wmol Consent tomli.in-re far Worker's ConTrn- DRAINS_ITOOR,ROOK AREA.COND. S'TOI(IES 'IYP[CONSIRUCI'ION
soup,as provided for by Sen inn Gold of the Labor Cut lin the performance of the
work for which this permit is issued. FIX TORUS-PER TRAP
❑I have and will maintain Worker's Compemmtion Insurance.as required by Section GTS-F.A.SYSTEM-I INCA OUTLETS
37Wnf the Coal,Code.forthe performance nfthe work for whichthis Permit is issued. OCG GROUP APN
MWrnA�('eC suti� Inver a rand Pa iey�ry�gIcr are'77�.7 GAS-13A.SYSTEM-OVENa(EA)
Carrierl]Cwl GA14 f3. rrtic Policy N(,.: 1 . —
CERI'119CATE OF EXEMPTION FROM WORKERS' GRBASI%INDUSTRL WASi'IiINTRRCRPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thls.sell neeJnm be completed Blue Permit is fortune hundred dollars(SIM) OR PSH TRAP
PLANCHECKRE
or less.)
Toy any that in the any nterior of the work for which this held ixis'C Lvhnd SEWIik-SANITARY-STORM F.A.21X1 Irl'.
nil employ any person in any manner nn m'In hecnmesubject ei the Wnderv'Compen- ICN13W'I!
O Z satin.Ivw's of Culifnrnia.Dutra WATER HENTER W/VENT/IH.ECTR tPAlD
E
ZApplicant
N NMIC17 TO APPLICANT:IL after making Nis Ceaificme of Exemption,you should WATER SYSTENUTFULATING n
become subject to the Worker's Compensation provisions of the Labor Code,you must '
{1a fnahwith comply with w¢M1 pmvi.vinns or Phi,le.it shall be Jecmed oo,oked. WATER SVRVICE
a o !//V0
CONSTRUCTION LENDING AGENCY NEW RI7SIDFNT1AL PIAB. SQ.FT
Z) z Iherehy off nn that there is a Ctumwnion lending agency for the performance of Uma RcaiPta
U0 the work far which this per mit is issued(See 3097,Civ.C.) TOTAL:
O U t<ndcr's Name
T<H'AL:
Lender's Address
r d P cenify that I have read this application and state that the above nominalist i, ItUSLI WG 19113 raA
h cturen.I igmememmply with all city and county ordinances and state laws mixing to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building construction.and hereby authorize representatives of this city or enter upon the
aMn'e-manlituncd pmpeny for inspection purpnxes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep heatless the City of Cannons,against
liabilities,judgmenta,en.ws and expenses which mayln any way acerae aguin.a said City ALTER OR ADD TO M YCIL PLUMBING FEE
in asequence of the granting of this count.
APPLICANT UNDERSTANJND WILL COMPLY WITH AEI.NON-POINT AIR HANDLING UNIT(TO IO.Oq)CFAO MIiCHANICAI.FEE
SOURCI RF,GUL 'g10N5/
bsl AIR HANDLING UNIT(OVER IQfKK)CFM) CONSTRUCTION TAX
Signature afnpplicanUContmclor
Data F:XHAUS'1'I{OOD(W/OUC'ry Ira moil MITIGATION FIiIi
HA4AR000S MATERIALS DISCLOSURE
Will the applicant or funcre Wildingoecupant vote or handle ha..Won,material HEATING UNIT(TO 100.000 U)
a def ted M1y the Cupertino Municipal Cde,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.003 BTU)
Coda.Scan...25532m)?
C:1 Yes El No VI3MHLn1'PON FAN IS I NGLE RBSI DI MPD Date Ba,,,(4
Will the applicant is,future building ceoupam use equipment or devices which BOILER-COMP(3HPOR 100.000 BTU)
i .nit hmatduus air enntnmi...I,a defined by the Bay A.Air Quality Management 'I OT'AL:
'District? BOILER-COMP(OVER 110.000BTUI
❑Yes ❑Na
I have madthe ha.dnus materials mr immwm under Chapter rl the Cali- AIR CONDEI ONER ISSUANCE LATE
for
e
Health&Safety Code.Sections 25505,25533 and 255.1 1 undersutM that if the NEW RESIDENTIAL MECIL SQ.FT. /
Wilding does not currently have a tenant.that it is my m%Poaihillty to notify the eccupard
of the mluiremems which must be met prior to issuance of a Ceniecam of Occupancy.
Owner(it authodmil agent Data11
TOTAL: ISSUED ICY',
OFFICE