00020044 APPLICANTiYO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY OIrJ Z
CITIIUY IVISION OF CUPERTINO BUILDING.FLRCTRI(:AL PERMIT N
ILIJING DAPPLICATIONIPERMIT PLUMBING-MECHANICAL.
IIUII.DING PROJECT IDENI'IFIC"Vl lDN
NUILDINGADDRMS: SANITARY N0. APPLICATION SUBMI]TAT.DATE
y7 ,
OWylj$'.S NAM a �PH E: O CO RB(1I'OW55 NAME: Q� J.1 NO: D NIC ^ CON I'HOLp
%RRCHG ECT/ENGINEER: LICNO: ADDRESS l/'� / ❑ �,�,•//11 ^�O�
CONTACT. PHONE: BUILDING PERMI.1'INFO
6 y ?V/ ❑ Cunsullant Fccs Paid by Applicant(Initial) BLDG iF.LEC _ PLUMBz MLCII
LICENSED CONTRACTOR'S DECLARATION/VI (7 l/ QTY ELECTRIC PERMIT FEE Ir—�t/ Lr� 4^1/
I hereby affirm that I am licensed under provisioes of Chapter 9(commencing JOB DESCRIPTION
wd'Z Willi Section 7")of Division 3 of the mein%and Professions Code,and my license is RESIDENTIAL:
tU W r I'F.HMI'1'ISSUANCE
Fa� full force and effect. ❑SPDWh ❑KITCHIiN RIiMODEL
�yyyuyyyu Lic...c Close LIC.# APPLIANCES-RESIDENTIAL. ❑ADD[T[ON ❑PLUMBING RF.-PIPE
ya1 Ualc Cnruador
GGA' ARCIlUG!CC:SDECLARATION ❑MImi-LINIT ❑STRUCTURAI.
'Dat PANELS MODIFICATION
ZOv2,44 (understand toyplonseholl bcuacdmTotilnuccod, UP'IO 2IXIAMPS
OZ- , El INTERIOR ❑CHIMNEY REPAIR
FQ4t:E Licensed Professional 201-10( AMT'S IMPROVEMENT E]SWIMMING POOLS
CY�; OWNFR-BUILDER DECLARATION pyI!µ❑Xp AMI•S [I BATH ItEMODEUREPAIR ❑DEMOLITION
C < 1 hereby affirm that I am exempt from the Contractors License law for the
aOiV which
(Section]ID L&B,alter. and improve.
demolish,
Cade:Any[il rcnunt AGI HI'R� /�C`I
x g reason. y n y SIGNS ELECTRICAL
x13 C)ha which requires a permit m consumer,ulmr,improve.demolish,or repair any xwaurc
.F.-OJ priorto its issuance,also requires the applicant forsuch Permit 1.file vsilpaplamemem SPECIAL CIRCUIDMISC.
that he is licensed pursuant o the provisions of the Contractors License Law(Chaprer9
W�pO (commencing with Section IlXXp at Division 9 of the Business and Professions Code)or TEM It MITER OR POLL INST. COMMP.RCIAL'
dk�M yy rho he is exempt therefrom and ilia basis far the elleged exemption.Any vinictinn of ❑NEW BLDG/ADDITION ❑DEMO[.]'I'ION
WIN Section 7031.5 by any applicant tor°permit suhjeas the applicant a civil penalty or POWIEt D13VICES ❑'TIINAN'I' ❑FOOD SERVICE
= y of more(ban five hundred dollars(&51X). IMPROVEMENT
j6 01,as owner of the propene or my employees with wages as their snle compen.saioi, SWIMMING IM)OL ELECTRIC
C will dothework,and the.vucmrcisnot inesndcdoroffez,11.1 ale(Sri.]IN4,Business ❑OIIII:Lt
a 3°. emit Professions Codc:The Cnmmmnr's I.icense Law dors nut apply o int owner of OUTLETS-SWITCHES-FIXTURES
prnpeny who builds or improves Ihercon,and who does such work himself or through -
Edown employees,provided that such improvements are not intended or a fered far NEW RESIDENTIAL oil TIM S [!?
sale.If.huw'ever.the building or improvement is sold within one yearof completion,the SQ.IT.FLOORARIEA 5/SQ.FT.
owner-milder will have the burden of proving that he did not build or improve for pur-
pnx ).
,as ownpm
er of the mpauy,am exclusively contracting with licensed ibmmemrsT(YfAL:
compact the project(Sec 70,44,Business and Professions Camp ine Convector's Li-
Iso Law does not apply loan owner of prnl'cmy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who nomas forsuch Prj 7x with ucr:mmemr(s)licensed puma no No Cenvncmr'x
License Law. PRRMI'C ISSUANC[
lam exempt ande ,R&P C fort,".rex. n
J AI:I'Iik-DRAIN&VENT-WATER(EA) VALUATION
Owner )' O
WOR ER:S rmlyoflappiry n D t A '10 BACK(LOW I'µOl'EGT DEVICE 5 O
I Eunchyal mai vain a enallyof ofCoyoneofthefnsumor Work tions:
❑I have unit um.a,EmsidomorbyeCion 37mofComentmCodensure forWorkersComp the DRAINS-I'LOOR,ROOF.AREA.GOND. tiTO 5 TYPE CONSTRUCr10N
Weekf r provided for by Section J]IXI of the labor Cade,for the performance of the
work for which Nispemtai is"sued, FIXTURES-PER TRAP
I have and will acromio Workers Compensation Insurance,m rcquircd by Section
J]II)nl nhe lallor ,Code,for the perfnrmanccofthework for which Nis pcnnil 1."Waal, OAS-IIA.SYSTEM-1 INC.4OUTLETS (ICC.GROUP _ / r� AI'N/Q
My Workers Compensation Insurance carrier ant]Policy numberou' GAS-HA.SYS'I'PM-OVER4 EPA) G r
Carrier: Policy No.: b
CERTIFICATE Op EXEMP'I'[ON FROM WORKERS' GRI:ASI%INDUSTRL WAST[IM'GRCGI'ION
COMPENSATION INSURANCE. BUILDING DIVISION]TES
nr less.)Thiowevionneednrnlecnnlpined if Ne permit is prone hundred dollars R dao) GRl?AS13'I RAP
PLANCHIiCK PEE
I cmify that in the performance of the work fn-which this permin is issued,Ishan SEWER-SANITARY-STORM EA.20114.
net employ any Person in any manner so no it)became subject o the Worker"Co.,.- ENERGY IEE
O Z snion laws of Califomfa.Done ( WATER[WATER WNEN A LECTR
Applicant ' GRADIN01:1!17.
y NO(ICE TO APPLICANT:If,after making this Certificate of Exemption,yea should WATER SYS'IEMIT BEATING
aheemnc subject to the Worker's Compensation provisions of the Labor Code,you must SOLI ti FIA!
W Emhwith comply With such prn,wiia.or this permit shall be decmcd revoked. WATER SERVICE
Q
UZ CONSTRUCT a'IONLENDINGACENCY NEW HI!SIDIIN'TIAI.PCMB. SQ,FIE PAT]) [).to Servitor#
G� k bar by Which
his
Narnal i is..Id(See 30lending agency for performance of
Nc wad for whieM1 this permit is isxueA(Sat.3119],Civ.CJ
Lcnders Name TOTAL:
V Icndeh Address 'IOTA L:
} a BUILDING PGI!
1 coney that 1 ply read Nis application anJ sem Na Ne above information i.
F' tg rnmdingcomcmco,and hereby cityandcnuntyotali vnces anddato)entroperago QTY MECHANICAL PERMIT FEES
V z
building construction,and heathy authorize representatives of this city to)enter upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree o save,indemnify and keep harmless me City of CUPcrtino against ELECTRIC 1131!
linhili(ius,judgmenrs,emi,undexpenses whichnay in any way awruc nguinq said Cuy ALTER OR AUD'I'O MECH.
In n
Inoalacrec ZH�RDOUSMXCERIALSDISCLOSURE.
s pe...a PLUMBING IAiE
APPLICANT NO I:L COMPLY WI'1'll ACI,NONd'OINT AIR HANDLING UNIT(TO Ir1,OW CFM(
SO .REGMECHANICAL 1'liE
/ � ALR HANDLING UNIT(OVER Ek0X)CCM) CONSTRUCTION'TAX
aw of APem EXIIAUS'C HOOD(W/DUCT) I IOUSINGMI'1'IGATIONFEE
RIALS DISCLOSURE.
Will the applicant on furore huildin,werilamsmrennbamdle hmmdnusmatedal HEATING UNIT CIG 110,00(1 BTU)
as ddincd the Cupeninn Municipal Clslc.Chapmr 9.12,unJ Nc HcaIN and Safety
Calc.Scdi.ian 25532(e)? HEATING UNIT(OVER 100.001 BTU)
❑Yes 0N VE!N'TLLATION FAN(SINGLE RESIDE PAID
Dme Receipt#
Will the applicant ar f fl use building IMcupan(use equlpnmo(ar devices which BOILER ORP OR 1(X1,001 RTE) '
emit hazardous zlr coutnminunrs its defined by the Buy Area Air Qualhy Management pry
�.
District'
El yes 0N BOILER-COM P(OVER 100,000 BI'U)
61.1vz,7,1,.tlr e hmaNn r On Dementsundr Chapmr 6.95 of Nc Calm AIR C(INDITIONER ISSUANCE DATIicry tions 5.2551]and'' J4.1 undemanA thin if the NEW RESIDENTIAL MECH. SQ.FII a,doonism NilirymnmifyN Ir ment. i m t prior to i of a Certificate of to it
harizedagen( I e TOTAL: ISSUED BY:
OFFICE