S 1260 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO l BUILIIING-ELF,CTRICAL TE�`Nd•IT NO.
IIUILDING DIVISION L' APPI,ICATION/PERMIT' PLIINIIIING-MECHANL'At V 1260
BUILDING PROJECT IDENI'61CATIOry
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'.
?7&3 S vc��LyCi Lt, ,?--/B— 9 g
OWNER'S NAME I PHONE: CON'IRACI'OR'S NAME: LIC RO:
�i&fre3 �w`c 273^4` �+ o r 45 5 NIC CONTROL
�.ARCHI'1'ECI'/F,NGINEER: LIC NO AUUIH S ❑
0a97 S•. QAz.. /glint
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGL'Lti'r PLUMB
LICENSED CONTRACTOR'S DECLARATION QTy, ELECTRIC PERMIT FEE ❑
O Z th Sv1 hcrchy on nn that I not licensed Buda,pn,v.,iom tel Chapter 9 OmmmencNg JOB DESCRIPTION
mmn]IXp)of Division 3 of the llminms and l'nsfemods Code,and my license is RESIDENTIAL:
Fob in fall lirzce and elect. PERMIT ISSUANCE
W- — ❑SFDWL ❑KITCHEN REMODEL
a_u Littnsc Class hicN APPLIANCES-RESIDENTIAL ❑ADDITION LUMRING RE-PIPH
fZZ W<lai Dam t Cond c
FDw ARCIU1 ECTS DECIARA'rION PANELS ❑MUCH-UNIT ❑S'TRU(SUkAI.
z py Z^ lundcrsuutdnty ptoo,s had be nIld as public records MODIFICATION
OZ-G, UP TO 201 AMPS GINTERIOR ❑CHIMNEY REPAIR
(-.t"W Licensed Pracssionol 20110MAMPS IMPROVEMENT []SWIMMING POOLS
<��-1, OW NIVE-RUILDER DECLARATION
W,,y, OVER I(NI(IAMPS BATH REMODHIJRITAIR ❑DEMOLITION
6 I hereby united Thal I am exempt Gnm the Cmuaemh Gcenm Law for do,
K;1 U Iidlnwing remon.(Section 7031.5.Hminao and Prof e..lons Cede:Am'city of county SIGNS ELECTRICAL ❑O11'HFR
u]offW h which requires a Fannie to cootmcl,titer,inydvve,demolish,or repair any sanction
C,1, Pbum it,i...imm,alk.ot the applicant hdsach permit m file aligned statement SPECIAL CIRCUI'17MISC.
} Nat he is licensed pursuant to the Lro,ki,a ofthe Court mctnr's License Law(Chapter9
�L`1 Ironndmming with Sent 7000)0 Division 3ofthe Fu.sin...and Professions Cdeptr 9'EMR MI-TSR OR POLE,INST. COMMERCIAL:
a a e C Nm he i..exempt Ncmfmm and Ibe M1mis for me ullcgal exemption.Any violation of ❑NEW RLDGL\DDITION ❑UEMOLI'LION
wm
vi Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of MWI7R DEVICES ❑TIiNANI ❑FOOD SERVICEn more than five hundred dollar.(85(0). IMPROVEMENT
[-Za C11.as owner of the Property,ter myemployees with wagesas their sale compenwtion, SWIM MI NO POOL ELEM RIC
will de Nework.and lhestructure is not intendedormoredforsale(Sm.1011,Emidms IMPROVEMENT
1.
F
L 3 w and progeny
Cd e:The oyes thereon,
Li,.,,,dwhoLaw dons
os does nut apply to if owner of OVCLE'TS-SWITCHIS-PIX'rUREs
property who builds or improves Ceram,vnd vee docsm m work dad ,,or Kronor
his awn cwever.the p ilding n h such improvement,am nm intended of,ldioJ Tse NEW RESIDENTIAL ELECTS 5
-Wal[hower willhavetlborint ofprovcntitatlhe did nrbuildur imprvehopd, ! SQ.IT.Iq.OfIRAREA $ISQ.FE.
pmter-builder will bme:the burden of proving he did nm buil)ter improve fur pus
c
Fl L m owner of the progeny,am exclusively contracting with licensed coundetors to 'f(l'ITL:
mama' he project(Sec.TBW,Besides,and Pm e-mr,Cede:)The Cmmemrs Li-
mow Low does out apply toadminimal).,Lady who build-1,nnproves thereon,and QTY. PI,UMBING PERMIT FEE PAID� B
who enam6 -a
u foreh pmlcdm with a,onlraalor(-)Iden-ed,tu dural ince Commelm', V
License Law. PERMIT ISSUANCE
teen
Owner Date
0 I am evempt under Sec. .B&P C for Nix¢
ALTER-DRAIN&VENT-WATER(&4 VA
WORKER'S COMPENSATION DECLARATION BACK FLOW PROIECI.DEVICE
1 hcrchy nfllrne ander pcndly of pefjory ane of the following decknaliu is �Jei(J
Ih:ve and will maintain a Cenificaic of Cementself-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.CONI. - S (IRI:S" -"' "TYPE CONSTHUCII(
.sled,m provided I'or by Section 37W of the Labor Cale,for Ne performance of the
wnrk for which this perddt is inen al. FIXTURES-PER l'RAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37101 of the Lulwr Code.for the pe'rf'ormance of the work for which this permit is issued. GAS-PA.SYSTEM-1 INC.4 OUTLETS (ICC.GROUP APN
My Wo s Co sntip IRB pncc o-n r and Policy
Cam sly ,R.. J ate Policy No.: / ��� GAS-EA.SYSTEM OVER 4 LA)
CERTIFI ATE OF EXEMPT ION FROM WORKERS'
COMPENSN'IONINSURANCE GRIASE/INDUSTRI,WAS HE IN'IERCEPIOR
O'hisscnion near Bat be cnmplemd if the Itcmeit is hdane M1nnJnel Aollan(51101) BUILDING DIVISION PERS
orlmJ GNL'ASE TRAP PIANCHECK FEE
(certify Nat in tlto pevmnnans'eoOhe work forwhieh Nis permit is-sued,lshall SEWER-SANI'T'ARY-STORM EA.200 Fr.
not employ any Lenon in any mvneecr sit as m become subject w Ne WurkecJ Compen- ENERGY FEE
O Z -anion laws of Calibormra Ilam WATER HEATER W/VENC/ELECTIt
Z Applicant I .
FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exempting you.shouldWATER SYS'l1iM?REAIING
a > become subject m life Worker-Compensation provision,of the tabor Cale,you mml SOILS IEE
forthwith comply with such provi.ani Yn,or this Lenoir shay L,decided revoked WAFER SERVICE
aQ
U Z CONSTRUC'T'ION LENDING AGENCY NEW RI[SIIlENT1AI,PLNI3. SQ.FT. PAID
U 0 I for
nnhm Neva is vard(See 30 Ending agency ltd the perl'mmande of Date He ipt N
LL F the work for which Nix)emelt is ixweJ(Sec 3pN],Civ.C.)
Q Lender's Name TOTAL
V U.&C-AAdrts, TOTAL:
F y I certify that I have read this application and state that the above infomueion is 4FE
E
(n correct.1 agree tet comply with all city and county ordinances and dam laws relating m QTY. MECHANICAL PERMIT FET:
U z. building donsutmtion,snit M1erehy nuNnrizc rcprescmmivas of Uri-city...cmerupm the
above-mentioned property for inspection perif .
We)agree tit save,Indemnify and keep handless the City of Cupertino against PERMIT ISSUANCE E
Iivbilitin,juJgntcnU.cussvndcx(wnees which may in any waymwnivii,idrlmid City AIMMORADDTOMECH.
to nsm,n nce of Ne gmming of(his)mitt'. EAPPLICANT INDERSTANI AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI- TO IOJgUCPM)SOURCE IIONS� AIR f1ANU1,INC UNIT(OVER IU.0I)CPM) ON TAX
Sig rc tel Applidan nmtncmr hole EXHAUST HOOD W/DUCp IIOUSING MII'ICAI'ION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcam or loran:building ecevpam snsrt ur handle hvaNnux material
]BEAT ING UNIT(TO 10,00X1 IFUH
s defined by the Cnpenino Monow,vl Cd,.Chapter 9.12,and the Health and Safety
Cane,Section 255321x)7 HEAIINC.UNIT(OVER Ik)LX 1 BTU)
❑Vcs ❑No
VENT HAd ION 1'AN(SINGLE RESIU) PAID 1 Ilam kccei tp
mil huWill the applicant or future building occupant use equipment or devices which F
Emmoa,air umtaminann us Jeirdd by the Bay Arm Air Quality Management BOILER-COMP QHP OR 101,000 RTU)
Ui.dricf, TOTAL:
❑Ycs [DNo BOILER-COMPO0VER I WIMM RTU)
I haw read the harardmo m;acrid,t is under Chapter(.95 of the Cali- AIR CONUU'IONER ISSUANCE(TATE
gaoemen p
fo lit Ilvahh R Safety Cede inns 15,25533 and 25531.I u nuffly d Nm if,h, NEW RESIDENT AL MECH_ SQ.IT.
baudingaecx no mmat a' navy re-pen immymrtadny Nenaanam
off n t i sal psi .fssounce or
'("tpy'e Jsfj prosy.
i j
Owne nxedagem Dave T(ITAI.: ISSUED BY:
OFFICE