29103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY aI�
CITY OF CUPER'TINO BUILDIN'el-ELECTRICAL � � PBRMITNO. /�
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL n O
BUII.DINGPROJECT IIHNTIF'ICAI'ION G 3
OUILDING ADUR45:ESANITARY NO. APPLICATION SUBMI ITA.UA'1
21 O INSOW Cr ewr-KriNo �z.ZO�S
OWNER'S NA E • PHONE: CONTRACIGR'SNMB: LIC NO:
8 NIC COM'ROLLN///��
\RCHI'1'E 'IIPNGINE. It t/o L I,IC NO. ADORE S: 71lam(// _
✓T z S T9-1 \/tel
CONTACT: PHONE: BUILDING PERMIT INFO
TONY W ON
/ qV—O' n I ❑ Consultant Fees Paid by Applicant(initial) quQ ELECT' PLUMB f'MEECCCH
LICENSED CONTRACTOR'S DECLARATION V A_ -
ya Ho,kionso QTY ELECTRIC PERMIT FEF,
I nemn trmt net 1 not ban„eJ ander renapmr 9(enntuaeneing JOB DESCRIPTION
"Z with Section of Division J ofthe Business and Professions Cale.and my license is
00 wt PERMIT ISSUANCE IAL
n full force and effect. )WL ❑KITCHEN REMODEL
U F l. iClLic.p
Q U mnm ass APPLIANCES-RESIDENTIAL ❑ADDITION [D PLUMBING RE-PIPE.
NQ6 ),It- actor
Contr
F7m ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Zb,N I undsoomadotyplansshall 6e uvdirs public record, MODIFICATION
UP TO 200 AMPS
O ZOO ❑INTERIOR ❑CHIMNEY REPAIR
Fwyt Licensed Pndcssionai 301-IINOAMI'S IMPROVEMENT
SY04; OWNER-BUILDER DECLARATION OVER 1000AMES E3 BATH REMODEUREPAIR ❑DEMOLITION
WtY Q 1 hereby affirm he,I am esempl from the Cmumcme,License Law for the
igqiS5O .0 following venom Seer lan]031.5.Bosincss and Podes.inns Calc:Any ci..or county SIGNSELECI'RICAL ❑OTHER
which rectums a Permit to commucl,alter,improve,Jenwlisn,or repair any structure
oct Homo it iomnce,lm recmueslhe applicant for such Pernirto file a signed miamort $PECIALCIRCUIT/b .'
1 } that he is licensed pursuant to the Provisions of the Contractor's License law lChapmr9
..00 0,niamenciag with Section](NH))uf Division 3 of the Business and Profession,CoJOcr TGM P.METER(IR POLI- NST. COMMERCIAL:
d c.e Y that he is amain therefrom it the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑OF OLf HUN
ern Station]031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�Z6not more than five hundred dollars($500). IMPROVEMENT
OI,as owncrofthe nopeny onuyemployees with wages aubeir.mle evorNmmion. SWIMM ING POOL EL1iMRIC
will do rhe work.and the structure is not marnded or offered for sale(See.J044,Business ❑OTIILR
S 3 m
and Professions Calc:The Consonant License law dues an
apply m an owner of OUTLETS-SwITCHB.S-n%TURIi.S
property who builds m improves thenen,and wno does such wad himself or through
his own employees,provided that such imprtvmnmas are not intendul or offewd for NEW RESIDENTIAL ELEC$R SQ PT.
sale.If,however.the building orimprovement is mid within one yearofeempldion,theSQ.FII FLOOR ARBA $/SQ.PT.
er-bmlJer will have the burden ofproving that he did not build or improve for put- CIMAAN. tocc,
�
pose oLsula)' aVF
i,.,,,.act of the pngteny, at exclusively utmmet Ing with licensed contractors to Ol
om ante.the pmjea(Sec.7044,Business and Professions CWe:)'Me Contractor s Li-
se Law does not apply to m owner of propcny who builds or improves thereon,and QTY, PLUMBING P RMT FEE
who contracts for such projects with a contractors s)liccmed pursuant to the Contmcmrs _
License Law. PERMIT ISSUANCE
1 nm esampt under Sec. .B&P C for this reason
Owner
ALTER-DRAIN E TE VALUATION
Dalc ��
WORKER'S COMPENSATION DIi he following I1ACK PLOW PHO ”'. )1' C' qac�
I hereby chum ander pertly of Pe Jury one of the fallowing de iker's nn: l
In,as and will for byneCion37M of the Laor Code,
for Workers C..... DRAINS-FLOOR.ROOP,A R 'I'YYIi CONSTRUCI'IOF
as provided far by Section 1]W of iM Labor CnJc,for the performance mf the
work for which this permit is issuedFIX'1'URF.S-I'IiR TNAP
I have unit will maintain Worker's Compensation Insurance,as neyuirW by Section
37M of the Labor Cale,for the performance of the work for whith,his .it is issued. GAS-EA.SYSTEM-1 INC.4OTTLETS G AM
My Worker's Grmpennt0on Insurance carrier and Policy number arc:
Cartier: Policy Na, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGRGSFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE ON FEES
(This-section nudnolnccwn.vord iDliv,e+mh is faronehtmdreddalln,($100) CREASE'1'RAP
nr less. PLANCHECK 117121 L
Icenify
nm cmPlny any lPehr,u.inpneyrfamamtnnecresofa1 sewM1orckrmocrwsubject m Pehe Wardens'Counter- SEWER-SANITARY-STORM EA.200 F1'
ENERGY FEF. L.+
Z taboo laws of California.Dam WATER HCATIiH WNENT/ELECI'N
zQ ApplicantGRADIN F :
y NOTICE TO APPLICAND.If,after making this Certificate of Exemption,you should WA'1'F.R SYSI'EM/TIIFA'1ING SOILS FE'
necome subject to the Worker's Compensation provisions of the Labor Crde.you must L4 fal�
Qt'onhwith comply with such awkinna or this pemtit shop be devoted revoked. WATER SERVICE
4' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIAI]L SQ.PT. PAID
LI p Ihemny orf nn lhauherc iza cnnstrunian lending agency for the Perfntmance of Dam Rece a
IL f^ the work for which this permit Is laucd(Sue.3(97,Civ.C.)
Q U Lender's Name
BUILDING{7.1 lender,,Address
0. I cimify lost 1 have read this application and xu ne thou the above infnmmtion i,, IEE
W) ronst.Ingmsmcomply.,In all city..,,,aarmy mdioomar,and rune laws relating to QTY. MECIIANICAL PERMIT FEE
U building cmmouctma,and hembyau@ave represetnifte,of this city m enlc,.,n the SEISMIC ME
above-mentioned property for inspection purposes. PERMIT ISSUANCEden
(Wcm
)agree Rt save.indenmify and keep hatlres the City of Cupertino against ELECTRIC FEE
Iiubiliuics,judgments,costs and expeaseswhell may in any wayacemcagain.a said City AIA ER OR AUUTO MECH.
PLUMBING PI?li
in consequence of thegaming ofthis Permit.
APPLICANT UNDERSTANDS AND WIL1.COMPLY WITH ALL NON-POINT Alli HANDLING UNIT(TO 10,(NN)CFM) MECHANICAL ItiE
SOUK i REGI' TIO
• .� AIIt HANDLING UNI'I'(OVEH 10.0m)CFM) CONSfRUC'I'ION'1'AX
Signamreof plicm/ ommcmr Da EXHAUST HOOD OODUCH HOUSING MITIGATION FEE
f ZAND(org A'1'ERIALS DISCLOSURE
Will the applicant or Iinure building occupant store m handle naeurdom ma edul I MATING UNIT U O 110.100 H'I U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
fide.Section 25532(x)'! HEATING UNIT(`
VER I W.000 BTU)
E]Yes ❑No VENTILATION 1.(SINGLH RISID) PAID
Date Rccciptp
Wllthe applicant or future building«cupant use equipment or devices which BOILER-COMP(JHYON I W,UW BTU)
it hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
is ict'! MOILER-COMP(OVER 100.1110 BTU)
❑Yes ❑No
L1wId ,',',,d-
read the haeordous materials requimmcnu under Chapter 6.95 of arc Cali- AIR CONDITIONER ISSUANCE DATE
&Solely Cale,Sections 25505,25539 and 25534.1 anderswnd that if the NEW RESIDENTIAL MECH, SQ.PT.
nut cumendy have u tenant,Ihut it is my resptroibiliuy In notify Ne occupant
mentswhimmustbetrotpdmrtoissuanceofaCenifict of(Xcup y.hon, agent Dam ISSUED BY.
OFFICE