S 1871Ll
0
•
&PPI ICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL.
r BUILDING DIVISION APPLICATION/PERMIT PLUMBING.. MECHANICAL.
BUILDING PB(LIL+C'T IDENTIFICATION
PE ITNO.
1871
BUH.DINGADDRESS.
SANITARY NO.
APPLICATION SUBMI'II'AI. DA'I'S
y /ZOSE13LOSSt+ b/eSuf� GuPECTSnIU CA • 9501 L/
OWNER'B NAMG: T Iu'110GNE: of `
MZ�HA L- MUfU/ 400 �5y` 4
C(1NI'RWll'SNAME: LIC NO:
NIC
❑
CON 'I'ROLp
ARCH I'I'FCT/ENGIN HER: LIC NO:
ADDRESS:
CONTACT: W r/40,00-5,143
/40,00-56 /3
Mieyy�� aNt if jog Asaits3t
❑ ConsultnnlPecsPRIdbyApplicant(Iniliap
BUII.DINGPER O
BLDG RLEOT ILUMB UMI3 MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm mal I nm licensed made, moat. nnx of chapter 9 (.,in,oanamg
QTY (ELECTRIC PERMIT FEE
JOB DESCRIPTION
fERMI'I'ISSIIANCIi
walm Saminn 7000)of Uivision3ottheHmines5lmd Rafcacions Code, and mylicenseis
i'fall fon"annielfcn.
RES[ ENT1AL
SFDWL KHCHHN REMODEL
APPLIANCES - RESIDENT Al.
Dan Class Com
Dole
❑ADDITION ❑PLUMBING R17PIPE
❑Ml1LTI-UNIT ❑MOSTRUCTURAL
ATIO
MODIFICATION
AHCHHkme DECLARATION
TS DELL
I undemand my plans shall be useA m public rccnrJs
PANELS
UPT021x1AMPS
QINTIeRIOk C1 CHIMNEY I2IH'AIR
IMPROVEMENT E] SWIMMING POOLS
❑ BX1 H REMODEUREPAIR [D DEMOLITION
❑OTHER
NOW
Licensed Pole"i'aml
OWNER-BUILDERexempDECLARntractoI ION
follow1 hereby a(Sect on 1 am exempt goat the Contractor's n License T.mw for the
reason. (Section ]031.5, Itusites. and Amfe.ninm CMe: Any city or county
201-I000AMPS
OVER EXX)AMPS
SIGNS IiLIiCfRICAL
which mryircs a permit m crinmm�, etre,, improve, dmnnlish, ar rtpair any nweure
which re
SPECIAL CIRCUIT/MISC.
C J A c 1
,n I if,i I. :th applicantf h ,1 File a 11,11cal.1mmor
matt d inu,na II h p I he C o t' [Chapeau
(amnmmimgwlh Sfu(171110),dDvi'all 3 ofma 8mits,iod Pn lc'n sCode)n,
TEM P. M ITER OR POLE I NST.
L;
COMMERCIAL
that he is exempt berctiom and the basis lin life alleged exemption. Any violation or
❑ N17W BLDWADDITION ❑ DEMOLITION
Section 71315 by any applicant for a permit subjects the applicant o a civil penahyof
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
nm more man five hunJral dollars ($51x)'
❑ La ownand the boomily,or my enpluyces with wnye,a, Ifirode coopen nutiom,
will dome wok, and Iha%mclum ix n f in malod mollcrM lou,flc(Scc. 974, Hu'mcss
IMPROVEMENT
OTHER
SWIMMING POOL LhIiCI'ItIC
and Proassions Cale: The Contractors License Law docs not apply um an owner of
O GLEES - SWITCHES - MXTURES
NEW RESIDENTIAL CLEiCTR SQ FT.
property who builds of improves daemon, and who does such work himself or though
his own employees, provided that such improvements am not imendW nr offered for
sole.IL haweveq the M1uilding urimprovanem in Mold within ane year of,f idttiumthe
SQ. FF. FLOOR AREA
$/SQ. FE
own cr-I ildcr will have the huNem of proving daut he did ern build a, improve lin pur-
VpmopXcafxoloJ.
1, as owner of the ery, am exdtlsW<Iy contracting whh licensed contractors to
'('OTA
tlnstmet the project (Sec. 7014, Business and Professions Cale:) The Contraries Li-
-
censeLaw deasaotapply,,, an ownerofpropeny vsh.builds omimproves thereon, and
QTY.LUMBING PERMIT FEE
whin contracts for such Projeciswim a omlmnoovilicerwl pnrsuantlo the Contmdars
PERMrf WZITA CE
License Law.
FI I um exempt under Sec. . B & PC Om This reason
Owner Dam
ALTER - DRAIN & VI?NT- WATER (EA)
VALUXI [ON
WORKER'S COMPENSAIDECLARATION
BACK FLOW PROT[CT. DIiVICF,
parjui r(m
I herehy affirm tinder Penalty of perjury one of the following declarations:
❑Ihuvcand will lnuinluinn Cenillcamof Comment InrelGinwre far Wnrkurk Crinryen-
salion, as provided for by Section 3900 of the Labor Code, lin the perfornnmce of the
DRAINS- FLOOR. ROOF. AREA, CONI),
9'f01<IES
'I'YPB CONS'IRt1CTION
work for which this psmnir is issued.
FIXTURES - PERI RAP
1 husband will maintain Workers Compensation Insurance, as rejoiced by Sorsa
370 of the LnEa Coca, fothe perfommnceof the x mk En which this permit is issued.
OCC GROUT'
N'N
GAS - HA. SYSTEM -I INCA OUTLETS
My Worker's Compennnio 0 Inmmnca conic, and Policy nwnIm, arc:
Carrier. • Policy No,
GAS - HA, SYSTEM-OVHId 4 ECO
CERI'IFICATH OF EXHMI'I'ION FROM WORKERS'
COMPENSATION INSURANCE
GREASE✓INDUSTRL WASTE INTERCEPTOR
It1111.DING DIVISION FEES
DRisseeionneed not becamplel+ifrhepermilisforonehundmd Jollan(SIMI
orlcss.)
GREASHTRAP
_
I'LANCHF.CK THE
--
I cetilythal in lheneffnrmancesd the work howhieh Ibis permit is issued. I shift
not employ any pennn In any Inunner m as In become nubjccl 1m the WnRmx' Gunm n-
SEWER -SANITARY-S'B)I2M EA. 200111.
Ii141iROY I E r
WATER HEATER W/VENT/HLECTR
GRADING Feil?
'noun (:owe of Califi,miu. Data
Applicant
NOTICETO APPLICANT: If. after making this Ccrtificne of Exemption. you should
become subject .,be Workers Compcnsalion pmvisiom of the Leber Code. yon must
WATER SYSTEMOFREATING
soil's FEE
WATER SERVICE
forthwith etmmply withmmh provisionoulthis permit shall be dmar,devoked.
CONST RUCTION LENDING AGENCY
I hefehyaffirmthanhere is a coastunion lenJingugency for the perliamanceof
PAID
NEW RESIDENTIAL PLMIL
IGS Receipts
the work for which an, permit is issued (Scc. 3097. Co, C.)
vifts
Lender's Norm
'IYITAL:
Lender-4Addroxs
fl'1' L:
HULLOING FE
1 certify that I have read this application and Male that the above information is
correct. las= to comply with all city and county ordinances andxlme laws mining to
building construction, and a hereby radiative repnewmatives of this city to enter upon the
QTY. MECHANICAL PERMITn'HE
SEISMIC
PERMIT' ISSUANCE V
ELIiGTRIG .R
abovo-mculioncd propuny for inspcolim,purposes.
denifynmdkcephannlcnx,hc Cllyof Cuperinnl,gaifnl
(We)mgreclo>avm,inm
linbllilics, jtWgmen¢,cu<Ls unJ expenses which miry in lnry way accrue npuinw euiJ Gly
incrinxeju are, of the mi this pc,mit
ALTER OI2ADDTOMECII.-
PLIIMgINGF i
AIR HANDLING UNIT ITO 10.000 CPM)
MECHANICAL
APPLICANT UNDHRS'I'ANDS AND WE LL COM PLY W I' I' IT ALL NON -POINT
SOU Ii RECR -ATI s._ /
AIR HANDLING UNIT (OVER 10,0!1!1 CPM)
CO NST ION
CONSfRUC'1'ION'IAX
T
17L, 9�
� / /
Signature of Applicant/Conmmmt Dole
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST t IOOD(WIDUCT)
HOUSING MITIGATION FHL
HEMINGUNIT(TO 100,000BTU)
Will daeapplicant or furore buildingocctmentslm,fulcndle hamilionsonnerial
as defined by the Cupeftion Municipal Code, Chapter 9.12, and the health and Safety
Code, Scellon 25532(m)I
Yet, �No
1 HEATING UNIT (OVER 1011,00 B'TU)
LAID
VEIN '111,A'I'I(1N FAN (SINGLE RES] To
Date Reoioar
BOILER -COMP (OHP OR IIx),ll(M) BTU)
infurore building by the B use ea Air Qu of devices which
Will the air contaminants
emit havarJous air conmminanu as defined h)' dao Bay Am'v Air Quality Management
'TOT1L
BOILER - COME P(OVER 100.009 BTU)
Dimnn7
❑ Yes )(No
AIR CON DI'I IONER
I have read the haamdors maternal, re ti immenls under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL. MECH. SQ. EE
fomia Health & Safety Cala. Sections 255(M25533 and 25534. 1 understand that if the
building dues net curremy bas rcnam,mm if is my owto-inlay m notify he«cnpam
have.
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ofineraj q�wn' Ira ramp ,nm torede "in Candi cele flue Ire
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[itSSIII?U
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BY: b � t
'fO'FALI
O rt uamiki w—Igcnln sec
OFFICE