99100015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE MTN .
xUn•DINC,DIVISION APPIJCATION/1'ERMIT PLUMB IG-MECHANICAL.
f1U11.DIN(:PROJECT'IDENTIFICATION
BUILDINGADDRLSS: SANITARY NO. APPLICAT11 NSUBMIr=AT1
lo5po A rit>cgavtqA;J CT GAJPSIZtWO y� 10�/ �� 5 rj
OW ERS
IENI'1 \f'4) 9_49-PHONE CQNI'I4Olt'SNAhIL: u3 MvCnlJkk1 ?r161O
Y 1nNL�J elf-/ NIC CUNTHOL��'p
CIII'� �1O EBR: C 'O 1 cI A1210 C40L(- -A r T � a �4-I� 1:1 9 y /
C, t-+ T UGa`�') N!M .l/ 11-DING PERMIT INFO
" Ax 272—776 3 Y es G �( for Sec O
C ,^L JA "`LL1�� J�6 5V ❑ Consultant Fees Paid by App(cant Iniliaq BLDG F.LeCI: PLUMY. MECH
WKL LICHNS1i)CONI RAM OR:S DECLARATION QTY ELECTRICPERMI'F FEE tL-17a' L1rO/ IrYJ/
I hereby mlma that I am licensed under provisions of chapter 9(emnmmndag JOB DESCRIPTION
D0Z with Section]000)of Division J of the Ru,inessanJ l' Code.aadmylicenmis RESIDENTIAL:
F�� in lull force amt e0ea rr}y11ff '''}}} if PERMIT ISSUANCE
CCCJ11 •CIO ❑A DWL ❑KITCHEN REMODEL
¢UV
LicenseLic.x—y- ApphIANCCS-RESIDEDITIAL [I ADDITION [I PLUMBING RE-PIPE:
NQ6 Date TS DECLAR
ARCHITECTS DECLAR TION ❑MULT6UNIT []STRUCTURAL
F-y Z I understand my plans shall be used as public records PANELS P MODIFICATION
0Z=- UP TO200AMpS FINA Ealy"® C]INTERIOR 12 CHIMNEY REPAIR
�oe�Z Licensed Vr,dce,lomd 201-I010AMPS IMPROVEMENT (]SWIMMING POOLS
�,1 ; OWNER-BUILDER DECI.ARATION OVER IINNIAMPS C1 BATH RFMODE:IIREPAIR (]DIiMO1.IT10N
C Q 1 hereby affirm that I am exempt from the Cnmranor's License law fur the
X a U fallowing reason.(Section]0315.Business and Professions Cure:Any city or county SIGNS HLEM RICAL ❑OTHER
u:3 LL y which requites a permi,it,cnusrmcl.altar,improve,demolish or repair any stmnurt
� poor its issuance,also requires the applicant for such Barratt file a signed statement SPECIAL CIRCUIT/MISC.
LLce that he is licensed pursuant to the provisions of the Commences License law(Chapter 9
uzia QpC (commencing with Section TH10)of Division3 ofthe Businessand Prefessioro Code)or TEMP.METER OR POLE INST. -GMM R IA :
d Xe C then he is exempt therefrom and the lasts far the alleged exemption.Any viclunno of ❑ W BLDG/ADDITION ❑DEMOLITION
WIoe Section 7031,5 by any npplicam tarn Perron subject,the upplicaau+.civil paralty of 1'OWIiH UBVICGS TENANT ❑FOOU SERVICE
-~+^6not inure than five hundred dollars($500). IMPROV EMEN'p
Dl.as owner of the pmpeny..treysmployeevwi[h wvgcs astheir soleeompenmtion, SWIMMING POOL ELECI'R
�P=..� will do the work,and the sbucmtc is not intended or offered for sale(Sec.704,E Business DOTTER
L 3 vad Pref tome,Cade:The Comma of,Li...a Law Jens not apply .nn owner OVTLLTS-SWITCHPS-FI%gLRE.S
pommy who builds or improves thereon,and who does such work himself or,hroug
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL R SQ FT.
vale.If however.the Buildingor improvement kind wi,hinone year ofmmplction.0e SQ.FT.FLOOR AREA $/SQ.Fr.
hander will have the burden of prov ing that he did not build or improve for pur-
p nc o
owner-l,olc.).
to CII
C!�/f Clnsuns owner N',bc prulxrly,um exclusively enntrucdng with licenlicenseecontractorsocontractorsnm TOTAL: II" '\ (9 .,(X 0
muct the pupae[(Sec.701W-Brone,s and Professions Cade.))The Cn norauur's L',.
cruise Law dues not apply mm an owner of property who builds or improves thereon.and QTY PLUMBING PER FEE
who contracts for such projects with a cantrmup(z)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C fur this..on
ACI'CR-DRAIN&VENT-
[R 7 A
wncr
Date
If 0 Ki
WORKER'SCOMPE,aUtuy DECLARATION BACK FLOW PROTECT.DEVICI:
Ihand waffirmunderpenulnic of perjuryent to elffallow lug Juamminnu.
I Ihaa,and provided
for
eCco 377 of the Labor
sol for the Worker's Comp the DRAINS-FLOOR.ROOI;AREA.CONI. SIX)RIES TVPE CONSTRUCTION
un ,as pmviJW for M1y Salton 3](p of[M1e LaMrt Gde,for the perfomance of the
for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Inatome,as required by Soadiml
3700.fthe lLair,Coda.into,pcdotmantt f,ha work for which this panni,is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP
M Wo,yors Com Ina ace carrier and Pol icymho ko �D
Canice)TiLT mpcos,µ -- - TV, Paley Na.9Af :19Q 4 I GAS-EA.SYSTEM- VF I
CFR HFIICCATTEE OF EXEMPHON FROM WORKERS'
COMI'F.NSATION INSURANCE GH R E Itm BUILDINGDIVISION ITES
(This section need no,be completed it permit i,fanme hundred dollar%($100) GRI: P
nr lesvlCHECK ITB
I cenify that in the Performance ofthe work horwhich lhispennit is issued,Ishall SEWER-: ITAR
IJ
not employ any person in any mnn
aer a as p+beamme subject to the Workers'Coinpen- GY FEE
'Z sat ion Lars of California.Dale WATER TIE -RW
2 Applicant
.E
NOTICE TO APPLICANT:If,afar making this Celli lica,e of Exemption,you shn.IJ WN :MffR
'ER SY. EATI W
1" 'N•' beanme suh cet in the Walker,Canalnsnlnn IF vision,of the Land,Cede.you mart I IiF
fumtwim comply w,,Itsuch IF ioraor thin pertni n shall be deemed mvnked. IVAN
CON S'I'RUCTION LENDI NG AGENCY NEW SIU• 1 B. SQ.FL PAID
V O thereby affirm that there is a consounion lending agency for the perlomtance of at,
ec nN
Ne week foe which,hi,permit is issued(Secs 3qJ],Civ.C.)
u' F- Landers game tIVTOTAL:
L:
Landers Address TOTAL:
BUILDING
6. 1 cattily that I have read this application and scat.that the above information is
En correct.I agree to Comply with all city and connect,ordinances and nam laws relating to QTY. - MECHANICAL PERMIT FEE
U ,Z tmild'mgan,trucrion,and herby unit, -mprcleaativcs of this m,ym en[cnipnn "1iEAHNG1JNIT(TOI00dXX)B1U)
SEISMIC PE
above-mentioned Pmp.ey lar In,pation Trip a,. UANCE
(We)agive m ave,hdmnnify and keep harmless the City of Comoro ugELECTRIC ITIE
Iiahilito,.judgmenb,co.atold eapen,es,hicham,in any way occme ogalna said CiDDTOMECII. Q
PLUMBING FE
in amsequence of the granting of this permit.
APPLICANT UNDER! N A PLY WITH ALL NONPOINING UNIT(TO IO.BW CFMI MECHANICA 'EE
SOURC- LLAT
,T A/ysING UNIT(OVER I0.000CFM) CONSTRUCTION X
u otA I' VC'at .t V ([edamOOD(WMUMT) HOUSINGMITIGATI NFP,
IIA%NtDOUS MA'I'ERIAI S DISCLOSURE
Will, upplicumortears M1uilJingoccupwn Sanestbundle h...nitaturfrnJNIT(TOI00dXX)BTUIas defined by the Cimemoo Municipal Code,Chapter 9.12,and the Health and Safe
Code.Section 25532(0'! HEATING UNIT(OVER Igktl(IB BTU)
❑Yeas C]No VENTILATION FAN(SINGLE RISID) PAID -
Date I N
Will the air urn or fusers building occupant y A ex An,Qu or devices which
Oil hmallous air cunmminams an Jef neJ by,ha Bay Area An Quality Management BOILER-GGh1P(3HP OR Igl,gxl B'TU)
q TAE:
saict9 11011.ER-COMP(OVER 100,051[1 TO)
�Vc, Fl No
I have mal the bvunlons materials requirements under Chapter 6,95 of be Cali- AIR CONDIT IONER ///ISSUANCE DATE
bonds llcallh&Safety Ctdc.Sections 255)5.25573 and 25534.1 understand the if th. NEW RESIDENTIAL MECH. SQ.FL /l W ._ 20 9
be liing docs ma currently base a ratan neworiboitymmodythemcupanl - L�
Ther ems ¢h mc.fa Ccnific skc nc.
r ouch 'r gem ate TOTAL: ISSUED BY.
OFFICE