S 0656 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PENH No
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL k 0656
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: :SANITARY NO. APPLICADONSUBMITTAL DNU
ao USD Ro s Pare_ C;-LAA
OWNF.R'SNAME: 1' NE: NTRACI OR'S NAME: LIC NG:
NIC CON I Rol,or
_10
HITECT/ENGINEER: UC NO: ADDRESS: r� ❑
CONTACT. PHONE: BUILDING PERMI'I'INPO
_�^�\ -kOa-,-LI --n\0
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB(♦^\r`/ �LECx
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FLE
1 hereby offrm tam I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,D,rxZO with Section 7")of Division l of the Business and Professions Cade.and my license is RESIDENTIAL:
�F PERMIT ISSUANCE.
n full force and eti a. ❑SFDW1. El KITCHEN REMODEL
�v� Licensecla:s �'� seen 55"a >?
QF.<G Dam Cammctnr U APPLIANCES-RESIDENTIAL [-]ADDITION ❑PLUMBING RE-PIPE
N - ❑MULTLUNIT ❑SfRUCILRAL
OARCHITECTS DECLARATION PANELS
FN2 y G 1 understand my pmlushall he used ax public records MODIFICATION
Z.O N ill'TG 21h1 AMPS
❑IN'I'Iik ION [_1 Cl REPAIR
E•�1p-a1 Licensed Professional 201-10100AMPS IMPROVEMENT 0SWIMMING POOLS
j.4 OWNER-BUILDER DECLARATION OVER IIN)0 AMPS ❑RA'TII RIiMOOIiIIREPAIR ❑DIiA101.IT10
C Q I hereby nation that 1 oro exempt from the Commnor's License Law for the
KOLLU ❑Orriln1.1
ul 6 following reason.(Section]031.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL
3 LL 0.4
which requires a permit to conswet alter,improve,demolish,or repair any swcwre
L.�mO pdono its issuance,also requiresthe applicant(orxuch permit m file a signed statement S PECIAL CIRCUITIMISC.
that he is licensed pursuant o the provisions of the Contractors License Laws(Chapter 9
p:p0 (aammencing with Seeien]Wt)of Division 3 of 0e Business and Professions Cadc)or TEM P.M 13'I'17R OR POLE I NS r. COMMP.RCIAL:
G y c that he is exempt thcrcfmni and the basis for the alleged exemption.Any violmlan of ❑NEW BLDG/ADDITION [D DEMOLITION
YXl 4,
Section 7031.5 by any applicant for a permit snb]mld thanppliwnno a civllpemdly of POWER DEVICES ❑IIINAN'f El TOLD SERVICE
m of me Nan five hundred dollars($501
=zC E]I,as orowner of the property,or my employees with wages as their sole annpensaion, SWIMMINGPDC1 OTtfl
IlikOLELECTRIC I :R IiMIiNf
will do the work,and the xtmmure is not intended or offered for sale(Sec.7044,Business
ad 3unit Pmfessmas Calc:The Centimeters License Inw daces not apply m as owner of DO GACFS-SWITCHES-FlYfURFS
0. propeny who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.however,the building or improvement issold within one year of coo.pletlan,the -1 .IT.FLOOR AREA $ISQ.Ff.
er-builder wi 11 have the hurtle.of provi ng that he did not build or i Illative for par- 1 UM UQC* C\fL\\* �^1
posy of saleJ, L_iC�A1
1,as owner of the property,am exclusively contacting with licensed canmsmrs to TOTAL:
consumer the project(Sec.7GUI,Business and Professions Code:)The Commram's Li- D
cense law does not apply m an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT F /I$/ n �a
who contracts for such projects with a cantvere(s)licensed pursuant ro the Contmmors x-11 2 1 1O(IO
License law. PERMIT ISSUANCE �7A57
IamexemptunderSm. ,B&PCfonhismman
ALTER-DRAIN&VENT-WATER(EA) B VAIAUA N
Owner Dale
WORKISR'S COMPENSATION DECl.ARATION ISACK PLOW PROTECT.DI3VIGI1
I hereby air mt under penalty of perjury mortar he following declamtin I,:
11 I have and will maintain a Certificate of Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOIIARIIA.COND. STORIES '1'YPECONSTRUC'GOP
,.a...as provided for by Section 3]W of the IyMn Cade,for the performance of the
xnrkjA which this permit is issued. FIYT/RIS-PER TRAP
^YAhave and will maintain Workers Compensates Insurance,as tardiest by Section
37W.fthcla1or Csdc.hn the pertormance ofthe work forwhich this permit kiNcied. GAS-HA.SYSTEM I INC.40MLES DEC.GROUP APN
My Wor Cn ape ason Imm ace carrier uad Policy rther� .Z"�O� GAS-13A.SYSTEM OVER 4(IiA)
Curticc:PONY No.: 'OR ll
CI3Rt'l1 ICAOMP EXEMI'1'IINN FROM WORKERS' GRHASEIINDUSTRL WASI'13 IN I'HRCF.PTOR
COMPENSATION INSURANCE BUILDING DIVISION PIi13S
(This section aced not be,amalloted ifthe permit is for ono hundred dallars($IW) GRI?AS13TRAP
nr less.) PLANCI I13CK PEC
I certify that in the perfo...see oflhe work for which this fcrtsit is issued,Ishall SEWER-SANITARY-STORM F.A.200 It.
not employ any person in any manner so as to become sahjem to the Waderi Compen- ENERGY FEE
OZ satian Laws ofC.I ismia.DoneI WATER HEATER WNENDELECTR
O Applicant GRADING TEF.
7
Ggei NOTICE TO APPLICANT:If,ate,making this Cenilicme of Exemption,you should WXTER SYSTEM TREATING SOILS FEE
a' beco n,subject to the Worker's Compensation pmvlalons of the Lio a Code,yon Troost
fonhwlth comply with such provisions tar this penult shall he deemed revoked. WA'1'I IR SIHtVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLA113, SQ.Ief. PAID
U 0 Thereby amrm thauhcm isacnnnmctinn lending agency four he performance of Dam Rcniptp
the wads for which this permit is issued(Sec.30HA Ci,C.)
ULender's Name 'IDEAL
Lender's Address TOTAL:
L�.II G I certify that I have read this application and stoic that the above information is BUILDING FEE
Fry correct.l agree to comply with all city and county ordinances and state haws mlanngh, ,QTY. MECHANICAL PERMIT PEC• - ((
U V auildmg comtuc0on,and hereby authorize rcprcum:nives of @is city tocnter upon the SEISMIC 1:1311 vim,
alxrve-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupcni.o against F;LP.CTRIC ITP
liabilities,judgmena,cops and expenses which may in any way accme against said City ALTER OR ADD 7O MliCll.
in consequence of the granting of this permit PLUMHING I :F.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T(s I(1,(kp CIM) Ism
S UR R ULA ON MECHANICAL EEE
�s, p S1 NJ-F, - �e.q 1 � � AIR HANDLING UNIT(OVER ILLWBCFM) CONSTRUCDON TAX
Sift, eh X�tunor [Xl )ole 17XIIAIJS'I'HOOD(W/DUC'lD HOUSMOMI'HGATIONBEI
I IALARDOUS MATERIALS DISCLOSURE.
Will the applicant m fatrommilding mmup.nl store arhandle hazardous material HEATING ON]'T(TO I IIB,tghl B'I'D)
as de Ined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a):' HHATING UNIT(OVER 100.000 BTU)
❑Yes El No VENILATION FAN(SINGLE RGSID) PAID -
Date Receipts
Will the applicant m future building aceupad use equipment nr devices which BOILER-COMP(3HPOR 1110,000 BTU)
mit Interactionsair commitments as defined by the Hay Area Air Quality Management pOpp),:
District? R,Ed3R-COMp(OVER tgl,(p(111'1'U)
El Yea F7 No
I have read the incautious materials requiarments under Chapter 695 of the Cali- Alit CONDITIONER ISSUANCE DATE
basis Health&Safety Calc Sennas 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building d«s nate fly haven sunt that it isnry six 'bilitymnsnify the occupant
of er m issuance Celli ¢r Ok
\`] ♦
Dw.cr r Durr TOTAL: ISSUED
OFFICE