S 0234APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
............ ........eT..... HIT LDING - ELRCI'R
BUILDING DIVISION APPLICATION/PERMIT
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0234
JOB DESCRIPTION
Cl FDWL ❑ KITCHEN REMODEL
AUDITION [I PLUMBING RE -PIPE
MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL: lI'ION
❑ NEW BI.UG/ I IN ❑ II jkk
❑'TENANT Vt — j3FUGESfRVICV.
IMPRO�F NT l
❑/p�a�` D
OTHHk l '
SQ. FF FLOOR ARIA
FEE
in / VAIAAIION
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Consultant Fees Paid by Applicant (IEilial) _
LICENSED CONTRACTOR:SUECLARAI'ION
I hereby affirm that I am licensed undo, provisions ol'Chapter 9la.mora ng
with Scanlon AXO)of Division 3 ofthe Bmines,ard Pndessions CWc, and my hear -is
in full force and cRca.
Licen Class Lics
Date Contractor
QTY. ELECTRIC PERMIT
Ed Z
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PH RMI'FISSUANCE
APPLIANCP_S- RESIDENTIAL
OZ y Z
ARCHITECTS DECLARATION
I understand my plans shall M used a% public records
PANELS
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Licensed Pmfcsxlln..
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OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contract License Law for the
following rcaam. (Section 70315. Business and Profmsinas CWa: Any city or county
which requires a permit m contract, acct• intpn,ve, demolish, of repair any someone
prior it) its issuance, also requires lheapplicant lormch permit,co Me v signed statement
that he is licensed pursuant to the ptnvisinns of the Contractor's License Law(Chapecrif
(commencing with tiaaian]1X0)nf Divisien3ol the 1lusinesuund l'm(cssinnxCude)rn
mini W Is exempt flaro form and the basis for the alleged uxcmpJnn. Any violdion of
Sealnn70315 by any applicant fore permit subjects the applicant his civil penalty of
not more than live hundred dull... ($5011)
mowner of the Ferry, or loess wird wa their sole compensation,
pnape Y YemP y areas as pBsi
Business
will dothcwirk, and dha eContishou'% kens nr owdored li,nalelply to
unit Pmfcs%ions Cook: Me Cnmmaors License Law does not apply to an owner of
pmpeny, who wild.. or improves thereon, and who Joos such work himself or through
his own employees• provided that such improvements me not intended or oRcred far
sale. If, however, the wilding or improvement is sold within Inc year of completion. the
or wild or improve for pur-
enwikler will have the burden of proving that he did a,,;,
OVER I(XOAMPS
SIGNS ELECT[CAL
SPECIAL CIRCUIVMISC.
TEM('. MEDiR ON POLL INS.
POWER DIiVICI_S
SWIMMING POOL ELECT RIC
(IUTLIffS-SWITCH&S-FIXTURES
NEW RESIDENTIAL. ELECfR SQ
If sale.).
L as owner OF the property am exclusively contracting with licensed contractor no to
QTY. PLUMBING PERMIT
msuuct the project (See ](HJ. Business and Professions Cada:)The Cant ... In, Li-
nseLawdoesnotapplyR, an owner of pivotally who builds or improves themon,and
who contracts fin ouch projects with a umtmmor(O licensed p useanno the Commaor'x
Licca law.
Ej I ant exemptunA See .11& P C For this re:oon
PERMIT ISSUANCE
AITI7R-DRAIN&V17N'r-WATE . )
Owner Ilam
iR'S COMPENSATION DECLARATION
BACK FLOW PRUI'IiCr. OR ICE
I hereby affirm under Penalty of perjury, ane of the Billowing declarations:
(] I have and will maintain aCertificate of Comernloselfawarcltrf Worker's COmpcn-
mJnn, ax pn,vidcd far by Sation 37011 of the Lehr CWu, I'or the performance of dM1e
wurk lin which this Permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
mod. which this Permit is iscd.
3]{0 of the Labor Class. for the perfomtance ofthe vnrk iso
DRAINS- FLOOR. BOOR. AREA, GOND.
PIX'1'URES - PER TRAP
CAS-IiA. SYSTIiM-I INC. J OIITLFTS
GAS - EA. SYSIEkl-OVER J(EA)
My Workers Compensanin Insurance carrier and Policy number arc:
Cartier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRFASMNDUSTRI, WASTE INTERCEPTOR
GREASETRAP
(This,%action need not be completed if the pentonkfon,nchundreddollam($100)
or less.(
Lrelay that podpormance thewerk which his rdlswll
SlWlk- SANITARY - STORM EA. 2!X114.
oat entpoy any person in anymnnnersn as it))become mocclm theWorkers'Cnmpcn-
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%in on Laws of Calltorron. Date
Appllceal )
NUI ICH TO APPLICANT: If. after making this Ccnilicatc If lixanpual. you should
W,omc subject to the Works'. Compensation foreman, ol'the Labor CWc, you must
forthwith comply with such provisions or this permit Shull be devoted revokW.
CONSTRUCTION LENDING AGENCY
(hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued IS.. 3(07. Civ. C.)
Landers Name
L.cnJcrs AJoltcss
I certdY that 1 have read this application and %tate that no aMnc admanntfon is
concet. l egret of comply with all city and county ordinances and state laws relating to
building construction. and hereby authonae reprnenmrives of this city to error often the
• WA'I'IiR I IIIA I[ IN W/VENT/ELECTR
WATER SYS 'ITMTI'REAfING
WA[ US SERVICE
NIiW RIBIDIiNT1A1, PLMH. SQ IT.
QTY. MIICHANICAL PERMIT
aMwe-mentioned proKny for inspection purpmn.
(We) agree m save, indemnify and loop wools the City of Cupertino against
Inbdinles, lodgments, costs and expenses which may many way acme against said City
in nmqucnce el the rami,of this pcm,it.
A PPLI CA N UNITERS'1ANDS AND WILL COMPLY WI'III ALL NON -POINT
PERMIT ISSUANCE
AUPER OR ADD TO MECH.
AIR IIANDI.I NO UNIT ('1011.1110 CFM)
SOURCE REGULA'I'I NS.
AIR IIANULING UNIT (OVER 14(tH) CPM 1
EXHAUS'p H,fU(W/DUCT)
T 0"-
Signamreof Appl' in 'minor O e
1 A , A ERIAI S DISC[ USURH
Will the applicant orf art buil nogiwa.mm store or handle haenNous material
m defined by the Cupertino uni<ipal CWc, Cheaper 9.12, eml the Health and Safety
Code. Section 25532(x)?
❑Yes}/y�V'ta
Will the applicant or of wmwilding accepted use equipment or devices which
emit hmardms air contaminants as defined by the Bay Arca Air Quality Management
HEATING UNIT (TO 100,000 BTU)
BEAT UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESLD)
BOILER -COMP (3HPOR U0.000BTU)
R(IILER -COMP (OVER 10.000 HTU)
District?
❑Yes❑No
dr
Ih Jth rd hw�tdl, raintiman,re, under Chapter 615 of he Cal'
lemin Hould, & Safety C nl SootSootiars 25505 25533 12553) J t 1 ohm d rhe
AIR CONIII'HONIiH
NI:W RCSIIIIiNI LAI. MECH. SQ. FI'.
h'IJ b l t Oyk d m tit t t y 'P 'h'llyt toy the axa.upant
at the c.arensms witch mesa bona pror in issuance of a Comillon, itCocepancy
Owner or anthmimd agent Date _
M 0
a
0234
JOB DESCRIPTION
Cl FDWL ❑ KITCHEN REMODEL
AUDITION [I PLUMBING RE -PIPE
MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL: lI'ION
❑ NEW BI.UG/ I IN ❑ II jkk
❑'TENANT Vt — j3FUGESfRVICV.
IMPRO�F NT l
❑/p�a�` D
OTHHk l '
SQ. FF FLOOR ARIA
FEE
in / VAIAAIION
«IC A CIE' 0 -