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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUn.DING - ELECT RICA].
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFicxrION
Pr:R`�• IT NO
{J 224,4
HUILDINGADDRES9:
SANITARY NO.
APPLICATION SUBMIBTAL FAA
OWNER'S HOE
M A �04' F99475i
(42)"'F99475,10
CONTRAMON:S AME: LCNO.
� AJF111 0A _0A -73 2.-7-3
N/C
❑
CONTROL#
90/6
ARCHI'I'EC'I'/IiNGINEER: I-CNO',
MS Els 3 71 g 3
ADDRESS
11 8 O&ACAVI dtvel fir
CONTACT: PHONE?: 4
M�HO�' I res /�i NII LA (N I
is,� 9
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDGLEC PLUMB MECH
21
LICENSED CONTRAC'IOICS DECLARATION
I hereby infirm Inas 1; lieenaW under provlsion, of chapter 9 nom ucned,
QTY. ELECTRIC PERMIT hI?11
JOB DESCRIPTION
PERMIT ISSUANCEr^S'�
J
wish Sectinn]I%%B of Divi,innlnfrhe Business unJ Profe„ionsQde, and mylicensels
in full forcani e elfecl.
RBJ TIA'
❑SPOWL ❑ KITCHEN REMODEL
APPLIANCES - RESIDENTIALDDITION
I ANI].S
U 1'1021X1 AMPS
License Class Lich
Date Contractor
ARCH] ECTS DBCLARADON
I mulnsnnd my plans Shull be used ns Infl a records
❑PLUMBING RE -PIPE
I1LTI.UN I'I ❑SFR UCTU RAI.
MODIFICATION
❑INTERIOR CCHIM NEY REPAIR
IMPROVEMENT (]SWIMMING POOLS
Licensed Professional
201-1000AMPS
OWNER BUILDI?R DECLARATION
1 hereby affirm Ihm I am exempt from Inc Comoran,s License Law far the
following reason. (Section 7031 5, Business and Prol'osxions Codc: Any city or county
❑ BATE I REMODEIIREPA IR C1 DEMOLITION
❑ ulfirR
/JT�/x,•f
OVER IIX()AMPS
SIGNS HLECI'RICA],
which ,sprues u permit to Construct, ober, ou,no-, Je mink, cr I'c,s... any mmcuac
prior to its Issuance, also requires the opphemil far such Permit ill filensignedontenenl
Las,(Chaptern
thmin is licensed wiit paection mase provisions 3 Of t❑teamster add Profession,
of roOho Asioro'Cwle)or
exempt
SPEC IA L CIRCU ITEM I SC.
'1'EMI'. MITER OR NII.I? INS "L
COMMERCIAL,
on.
, that he is exempt therefrom unit me basis for the alleged exemption. Any viohtion of
that he is exempt therefrom and basis aged
❑ NEW tlLDG/ADUI'1'1(lN ❑DEMOLITION
Scd!mn7031.5 by any applicant for a permit subjects the applicant aa civil peouhy of
Onto .... than live hundul dullum ($51111).
r y employee,wi th wages a,(feir solcwmpennmion,
E] 1, the mpeny,nla
win eco mework. andthe evucturc isnnI imendeJ ter nrccred fm sale ISec. ](W, Basins
and Professions Code CnmmdnR License Law aces nm apply In am owner n
POWI>R [)[:VICES
❑TENANT El 17001) SERVICE
IMPROVEMENT
COMER
SWIMMING POOL EI.1?C'I'RIC
OU'r1.1:1S-SWITCIIGS-FIXTURES gs
property who builds or improves thereon, and whn does such wnrR himself or Ihrou r
his own employees, provided that C,h impmvemmo �are oat intended or mmertJ )v
sale. If, however, the building ur improvement issold within one yc:u Of completion. me
N17W RESIDENTIAL. ELE(7rR SQ Fr
SQ. Fr FLOOR AREA
Ss/SQ. PT.
inn -hander will hove the hnnlcn of proving dna hm did nmI mild or Idr mve for par,
"cr,tn"ale.),
I] 1, as Owner of the property, am exclusively contracting with licensed contractors est
TOTAL. s
consumer the project (Sec. VIW. Business and Professions Com,:) Me Commcmis Li-
-
nxLawdoesnotapplytounownerofpmPenywbobuildsorimprove%thereon, and
QTY. LU ING PERMIT [;Fr.
forjeetx with a cnmrnclnr(s) focused pnrsoutlands, nCou nremr'x
PENMI'1'ISS A
c ,EHI PCfor this awn
ACIER-DRAINdb V1?'1'- Bl-)
Dee
p/lbereby
VALUATION
N/ p
/`
7 Ooh
or
I?R'S CO PEN$ATION DECLARATION
penalty of Perjury one of the following declaration,:
BACK ROW PROIT:C . li
I] I huveund will mninminn Ccnincote of Conscnnn self-inmm lin Worker's COmpery
onion, trc provided for by Senium 9703 of the Lobo Cade, I the a rlm'nunce of the
work lir, which this permit is ismW,
DRAINS -FLOOR. It )PA C D.
STORIFS
/
1
'I'VPI: CONSTRUCH(IN
5�/.a,- f
FIX I IJBIRS - 1))66pp
❑ 1 have and will maintain Workers Compensation Insurance, as required by Sects olt
3700ofrhe labor Cale. tonne pcAmmuceofthe work forwhichrnispennir is issued
OOZC. GROUT'
•'"Y/
APN
GAS -1;A.. STEM. .i OUTLETS
My Worker's Compensation Insurance carrier and Policy number are
Ceder; Policy No.:
12
CAS - LA.. STEM.OVI!R .A)
GIFAS Nl LW :'Itil CI?I'IY)It
CP,RTIPICAI'17 OF EXEMI11'ION PROM WORKERS'
CfIMI'IiNSAI'ION INSIINANCF,
BUILDING DIVISION 117 IS
(B'hk,etlion need not M: eompleed if lhcpcumil is fmrone hundredd.11los $IM)
or los.)
CREASE TRAP
PLANCIIIiCK PER ,9J'45L
I certify that in the performance of the work for which this pemrit is issued le hall
not employ any person in any manner so as In become suhjecuo the Workers'Comper-
SEWER-SANITARY-S'IU E S)FL'.
ENERGY FEE 35'l io
WATHIt HEATER WIVIIN'I'/1?L R
GRADING PF,.•
sation Lawsnr California. Date
Applicant
NOTICE, APPLICAN91 It: after making this Condemn, of Iixetnption, you should
become suhjecl est the Workers Compensation provisions of the Latour Code. you must
WR'I'ER SYSTEMOKIiATING
SOILS
WWI IR SERVICE
forthwith cnmPly with such provisions or this lwmrir shall be deented revoked.
CONS IRUCrION 1.17NDI NO AGENCY
nrnchydfi ithat mere isae,nstraodmr Dndingagency lour the pertmrnamcell
IIr^l
P VZ�e1'
Dute aenipt#
NEW RIiSIDENTIAL PI.MB. S
me work tet which Ibia permit ix issued (See. 3397. Civ. C)
Lenders Nunn
TOTAL:
1<nder,Addre„
1 ccnify Thar 1 have rcaA this apPlicmion anJ state Thar the aMwc infnmmrinn is
erred. I agree to comply with all city and county ord'eancros and state laws relating to
mildirli, u,ion, and toorehy Oil maive repm4culdlive, of this city In enter also l he
TorAL:
.
UI 71TE -
(r�
Q'EY. MECHANICAL, PE OvFEE
SCISWC 'E 7
abovo-mcntioned property liar In,feenc n pOrto,cs
(We) agree m save. indemnify and keep Formless rhe City Of Cupertinn against
1'Ii1tMl'I' ISSUANCE v s�
F.LEC' T?E y3.. 6
ALI HR OR ADD TO M ECI I.
PLUMBING FEE
Iiahililiea, judiall costs or espen,e, whichum, in any way accrue against said Cit'
or C asequence raffle gmming of do, permit.
AIR HANDLING UNI'1 (101 Od"cl
MECHANICAL FEE "41, Co
APPLICANT UNDE STANDS AND WILL COMPLY WI'1'If ALL NON -POINT
SOURC"REGULA ONS t
AIR HANDLING UNI' I(OV14R QB0f1 C17M)
CONS' I' RUCTION TAX
Sigalumof Applicam/Commemr Dem
HAZARDOUS MATERIALS DISCLOSURE
EXHAIISTHOOD(W/DIICT)
HOUSING MITIGATION PER
HAAT INC, UNIT (TO I IXk(k10 BTU)
Willrne np,licato, krone buildingOccupammorCm handle hamrdo., material
as dertnell by rho Crandon Municipal Code, Cbnpmr 9. 12, unit Tho Ilwl th and Safety
Code,Scnimn 25532opy
E] yea [:1 No
11117AI'INC, UNIT (OVER 100,1100 BTU)
PAID �6- ��
Date Receipt#
' VENfl CATION PAN IS INGLE IUMD) ./
Will the applicant Or future building occupant use equipntom or devices which
emir hot dous air connminoms as defined by ncc Bay Area Air Quality Management
Diad,^
❑Yes No
BOILER - COMP (311P OR 100.OD3 RTI])
TOTAL: ' O.Z ,90
BOILI?R-COMP(OVEk (%1,000PTU)
AIR CONDITIONER
nquimmcn p G95d Call.
haode,Se mn%255 a
Iabli
ISSUANCP. DATE?
NEW RIi.SIDENTIALMliCii. SQ. FT.
Sac
1!553 .fund that
forms Heinen ASafetyd,hae. Canxdiani is day533 esp25531.I understand Ihmifrhe
huildin6 docs not currently have a mnanl.lhm it is my responsibility m noxi fy the cecupam
g
ofmc.luire a shicham met pdonoinsurance Or. comicme pf_ ?n
ISSUr.D Ii V: �S/�~�O �V�'•
TOTAL L / a tl
dDate
Potato, mi, egral
A OFFICE