S 1378APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDIN(L ELECTRICAL
BUILDING DIVISION APPLICATION/PRRMITPLUMIR NG -MECHANICAL
BUILDING PROJECTIIIENTFIF'ICA'ITON
PE 1T.NO.
1378
IIUILDINGADORESS:��I/� �.#��(/r-)
S IS`�11uXN�
SANITARYNO.
APPLICATION SUHMIVIALDATE.
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OWN .R'S NAM'. /V��C PI IO P.� D
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CON'I'INC'I'OI2lS NAME LIC N(l:
NIC
❑
CON'I'ROLp
RCHI'I'ECIENGINEER: LIC NO.
ADDRESS:
'
CONTACT : PHONE
ate.-y/[nV ry/,OZp-�
El Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INI'D
BLDG ELECT PLUMB MIiCH
Q9z
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LICENSED CONTRACTOR S IIECLARAI'[ON
I hereby affirm mat l am licensed ander provisions ofehapser 9 (comm ncias
with Section 70X101 of Division 3 ofthe Business and Pmlessions Cwe. and my license is
email tome and effect.
License Class Lic.X
Dme Contractor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDIVL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING R17.11111E
El MULTI -UNIT El STRUCTURAL
MODIFICATION
❑IbilPRIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
❑BATHREMODELIRITAIR El DEMOLITION
❑ OTHER �•v
PERM IT ISSUANCE
APPLIANCES -RESIDIiN'I'IAh
1., O m
z 0'^ K
OZ-qRJ
ARCHITECTS Uf:CLANA'fION
1 uaeasumn i my phas,hall bo ascd us puhllcrccord,
PANHIR
UI"I0200 AMPS
F%,,FC,J
4gw; N d
C Q
°XX' a U
3
Licensed Pmfcssinnw
OWNER -BUILDER DF,CIARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason Emit 9031.5. Business and Pref¢sions Code: Any city or county
201-100AMP5
OVER I(XXIAMPS
SIGNS ELECTRICAL,
W LL tia
fl!vi�j
5atap'
O
d
�W
^`n
H Z Y
F-
F
3 m
which requires a froom( to construct. alter. improve, demolish, or repair any structure
Ari, t t'.. L I th 'pPli ntf Ip It 11 g J:(lement
that her, licensedp n thep .' t: fm Contractor's I I' (Chapter9
(comnamiligwth Sort nt7m)EafD'v',in i 9 Of lha B"Ohne"atd lrtRss txChile) in
that he is exempt thercfrnin and the basis lin me alleged exemption. Any variation of
Salon 911315 by any applicant for a permit al jrel, thcapplinmt to ne'ivil penalty of
(m ore man Ove handled dollars ($501y.
❑ Lo the work. the theoney,or myemployees with wages offeyed fostnei(See 0,14,Bsiion.ess
will do the won, Cosand the Is not intended Law do snot apply 9044, weer of
and Professions Calc: The Conlm,:mrs License Law ecea not apply m an owner of
property who huilAs m improves thereon, and who does such work himself lir through
hisown emoyax, phprovided that such initiative car, am not intended or offered for
naleILhnwevar, lite huildingoe itninowetneu iexold within nncymanl'cumpielion,tile—
SVECIALCIRCUITIMISC.
( ! l
U)I"Ki 62 T
117 MEI ER 0141101.17 INST.
COMMERCIAL:
COMMERCIAL
OMSG(i AL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
a
[I TENANT ❑FOOD SENVICI.
IMPROVEMENT
y.
POWER DEVICES
SWIMMING POOL C:LIiCENIC
(1UT1.6f5- SWITCHES - FIX '1'ORES
NEW RESIDENTIAL. 1?LI?C'1'R SQ 1T.
AR .�.P QRAREA
$/SQ,17,
wner-nuilder wlame ve the bunloan f pmving shat he did not bund or iinpnnc for Aur-
JJUUB
Alof sale.).
, as owner of the progeny, am exclusively contracting with licensed contractors to
1'OTAh:
wet me part (Sec. 9044, Businessland Professions Cwe:) The Crntrwtors Li-
soneLtwduesnntapplyaan ownerofpropeny who builds or improves thereon,and
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmmar(s) licensed pursuant ill the Contractor's
PERMIT ISSUANCE
L(aonse Law.
I sat exempt de,Sm. ._, B By 11 C tar this m as
ACI'131t-DRAIN.@VIiN'I'-WA
Ownc 11 ,_Dam
VO H.SCOMr SA'1'ION DECLARA'I'I(ll
/// VALUATION
/
BACK FLOW'foUIB'I'. DIW Esip
I hereby nmnn under penalty Ofperjoryone Orme following dealmloom:
O)1
/ (/v
"
❑ Ihave and will haimain v Certificate of Comento self -insure for Worker', Compact-
cation, as provided file by Section 39W Of the Later Cade, for the performance of the
DRAINS- FLOOR. ROOR AREA. COND.
SI'ORIP
TYPE C(INSI'R11C'flllN
work for which this permit i, i...ee.
FIXTURES -PER TRAP
❑ 1 have and will haintain Workers Contpcnsutloo Insurance, as required by Section
3900afthe Laher Code, forihe pall.oulnchol'tire walk fmwhichmi,punull is issued.
'
OAS-EA.SYS'I'EM-I INC.40UTLETS
OCC, GROUT'
AIN
My Wrnkees Cmnpmtsatian Insurancewniernnd Policy number ntiv
Carrier: Palley Nna
GAS - HA. SYS I'EM-OV IiIt 4 fill/)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRFASIVINDUSTRL WASTE 1NTF.RCEPPOIt
BUILDING DIVISI IVES
(This section nein not be completed ifthe permit is for one hundred dollars ($ItX1)
lir less)
pHIiASF.TRAP
NANCHECK FEF.
Loy any per in the ficiformanymournnce erof as Inword,lshwl
subjectch to the Wornat rkers
not employ any person in any manna so m um Menmo ennjem m the Workcrd Cnmpen-
SIiN'ER-SANITARY-S'IXINM F.A. 2flfl Ff.
IiNI1RCY IIIP.
WAI'HR HEATER WIVI NIJIIiLECI'R
Oz
z O
f,fNOTICE
a ,
y0
V Q
u' H
W
A,rn Lawsill California. Dae
Applicant
GRADING FEE
IY) APPLICAN'C It; after, making this Ccn'dwte of Exengmm�n, you should
become subject to me Workers Compensation provisions mitre Lubar Chile, You mus(
forthwith comply with such previsions or this permit shall be deemed revoked.
CONSTRUCTION uctNDING AGENCY
euhere isaco (See. 30 binding agency for Performance of
the work for which this permit is issued (See. ]1199, Civ. C.)
work which this
Lander, Name
WATER SYS'I'ENIGTHA'1'INC,
WAIGRSL'RVICE
SODS PL7L7
PAID
Dam Hcceipt#
NEW HESIDEMI'IA1. PLMB. SQ. 17.
'I
TOTAL:
hander'Address,
OIAI,
BUILDING P E
I:
unify that I have reed this uppl'mution unJ slum that the above inlitrnunion is
Vii
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correct. l agree to comply with all city and county ordinances and store law, refining to
building convtmction, and hereby arthoriremlar,e•n(ativerifthis city to emeropen the
QTY. MECIIANICALPERMIT PEE
SEISMIC FEE ,
FERMI '1' ISSUANCE
IJ.[CfRIC FE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdess the City of Cupcnino .,.last
AEI' ER OR ADD TO MSCI I.
PLUMBING FEE
liabilities, judgments, costs and expenses which may in any way accreenguinst said City
in consequence nfhe ,chain, of thisp cit
Alit HANDLING UNI'I'('if) 10000CFM)
M17CIIANICAL FEE
APPLICAMC FIJI?I45TA A 4D 411 f T.V WITH ALL. NON P INT'
SOUNCE I` d11.' I'.
AL It I IANDLING UNI'f(OVER 10,000 CFM)
CONSTRUCTION TAX
/O
Sig./Ur ;Appfft ideal etc
HA%ARDOUS MATERIALS DISCLOSURE.
EXHAUST HOOD(W/DGCC)
HOUSING MITIGATION ITE
HEATING UNIT (TO I00dM1 BTU)
Wtllmcapplieumorfu.rebuilding,ecupant,mmorhmwlehveardousnatcriw
as defiled by the Cupertino Municipal Cade, Chapter 9.12, and he Health and Safety
Code, Section 25532(x1t � �•
Ely,
/'
1117/0INC, UNIT (OVER 101,X10 BTU)
PAID
Date Recall,#
VIiN'TILA'I'ION FAN(SINGI.HRESID)
B(111.F,N -CGAJp (3HP ON 100,00(f) BTU)
whim
on ants as building by them use equipment or Management
Will the air contaminants
emit hacveoas air commninants as defined by me Bay Ann Air Quality Munagcmem
District?
El Yes f,No
'fOTA
ROLLER-COMP(OVOR I(XLfXXh BTU)
AIR CONDITIONER
yuircmna p
aW Re hmaNnus matenalsrc is area CM1n car 6.95 nftho evl6
(have had'
ISSUANCE DATE
NEW RESIDEN'HAL MECIL SQ. FII
fornix Ilenhh &. ty Co Ie,. Sedioryry 55(15, j51 ad 25534. I undemund the f the
nulldingeues etc ) yafyp (' t rcxposihllitymnnf' thea enpltnt
r O
3—�
ofthee of ! .( r lice of ocenifieat•
ISSUED BY: ,e "
TOTAL:
O r riesmrenodagent ole
OFFICE