S 0889 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELEL7PRICAL PEiRMI FIND.
BUILDING DIVISION AI'PLICKf10N/PF.RMIT PLUMBING-NIECHANICAL
BUILDING PROJECT IDRNFIFICATION ngpq
BUILDING ADDRESS. ../_ SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
f"IR,
O 3, �G P, �i\�.�
STAME: 2 PII CO .WS NAP: IC NO:
9A14 + rL e—� U �J� NIC CONIROLp
, ECTIENGINEER: LIC NO: ADDRESS: ❑ W_
CONTACT. PHONE BUILDING PERMITINFO -
�/�� � /I �J T_A/ /_��'� Consultant Fees Paid by Applienn[(Initiol) L ,L BLD ELIiCT PLUM MECH
c LCENSED C(ONNTRRJACTOGR''S DECIARA'I'[ONG QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
„MWZ with Section700(drd Division 3 ofthe Busineas and Professions Inde.andnryllenuse is PERMIT ISSUANCE
�FOC) in full hone. ndefiect. 'FUWh ❑KITCHEN RIiMODF.I.
aVV License Class Lim.# APPLIANCES-RESIDENTIAL ❑AD 'ION ❑PLUMBING RE- IPH
L {{++11 Date Cuntnctnr
b M ❑MHLT'1-UNIT ❑5'I'RU(F[CAIIL
AkCHITECT'S UCCLARATION
z Omz I understand my plans shall he used as public records
PANELS MODIFICATION
02=-0 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
J41W Licensed Pndcso,ad 2111-1088 AMPS IMPROVEMENT (]SWIMMING POOLS
9�d ..s1 OWNER-BUILDER DECLARATION OVIiR IWIIAMPS ❑BATH REMODELIREPAIR ❑DEMDLIT'IGN
Q I hereby affirm that 1 am exempt from dm Coorranor's License Law for the
�4 L V following reason.(Section 7031.5.Boniness and ProRssinm Ctdo Any city or county SIGNS ELECTRICAL ❑OTHIiR
YI m+14 f" which requires o permit m comment,n1m,improve,demolish,or repair any suucmrc
prior to its issuance,alorc,do dia. Pliant lorsuch)sorsa file alignedomemant SPECIAL CIRCUITNISC 0 g I
, y that he is licemedpuouanunthe provisions ofthe Contractor'.sLlcen,Law(Chapmr9 w\-'n�
m00 (commencing with Section 7")of Division Sof the Business and Professions Code)o, '1 R I I I MIiT eR E, s COMMERCIAL
6 6 y
'hat he is exempt therefrom and the basis for the allege)exemption.Any violation of ❑TEN�IngDDITION� �OD SEMOI RION
VICE
CE
X�N Semon 7031.56 an licant fora wit snh'cca thea lien...a civil 11 f I'OWCR DEV ff 22
fi r and rv� 1 pp puna fi n
n more(hum live humped dollars($5111).
IMPROVE .NL
�=Qr]1,as owner of the property.onnyemployeeswithwagcs asthcirsolc campensminn. SWIMMINGPOOLELCCfRIC
f- will do the work,and the structure is not intended onsfcard for sale(See 71Wf.Business
Lai] m
and Professions Coda The Contractor's License law dues not apply to an(wns'of OUTLETS-SWITCHES-FIXTURES s UJ'at r''1 IIY(1
property who builds or improves thercan,and who docs.such work hinwelt or through
his own employees,provided that such improvements arc not intended lir offered far NEW RESIUENTIAI.HLECT'R SQ Irl'.
vale,If,however,the building or improvement is sold within one yearofcumpletion,the '►k SQ.17.FLOOR AREA SISQ.Cf.
owner-builder will have the burden of proving that he did not build or improve for parO V /�
'aw.fsale.). 3 i/ �� s
❑1,as owner of the pmpmy,am exclusively contracting with hearmal eon8anuls to
armuan the project(Sec Business and Pnd'csslons Code:,The Comment,s I.,-
acuse law does not apply in an ow her of property who builds or improves thereon,and QTY, PLUNIBING PERMIT FEE I
whonontmmts forsucb projeclswith morrocmr(s)licensed pursuant otho Cnmmnor's /�� {i.11p/f
License I.aw.
O I am exempt under Ss. ,li&P C for this'cmon 1'I?I1M1T ISSUANCE, a
ALTER-DRAIN&VENT-WATER(CA) VALUATION
wner Date
WORKEII'S CUM PEN SATION DECLA RXI'ION BACK FLOW PROTECT'.DEVICE
I 1 hereby affirm under penalty d perjury one of the fol lowing decimations \
Cn I lewtnd will maintain.CmiBcmeofConaulm,alf-inmre for White,',Comber- DRAINS-FLOOR,ROOF,AREA,COND. to STORIES TYPE CONSTRUCI]ON
sation,as provided for by Section 3703 of the Labor Code,for the performance of the
work for which this permit is issued. It]XI'URES-E'ER TRAP
❑1 have and will maintain Worker's Cm.,ho inn Insurance,as required by Section
37M of the labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-11 .ET OCC.GROUP APN
My Worker' Cmen Ins rose a,No:nutr(IKra GAS-EA.SYST 4(
Carrier:-�.�--�P9licy Nn:
f yL
CERTIIBCCOMPENXP, PTIINN PROM WORK QRS' (;pdgSIIINUUSTRI.! P
'F.1 , CCPION
COMPENSATIONINSURANCCU IMONFEES
(Ibis section nttAndthcnmplacd iDhe permit is(unmc hundrcJ dollars(ElfN)) GREASE'I'RAP /
or leas) PLANCHECK E
Ia'rtify that in the Ferfonnunsx of thework fnrwhich this permit is lnsneJ.l shall SI7WCR-SANITARY-STURMI7A.2IN)FI',
not employ any person in any manner so as to become subject .,he Workers'Comped- ENERGY I'liliIWO
Z sation Laws of Cpace
WATER HEATER WIVEM7ELECIR
7�
Applicant t rcia}^�— L GRADING FEE
F7 NOTICE'TO APPLICANT-],,otter making this CeAficam of Exemption,you should WATER SYS'I EM/IRUNI ING SOILS ITHE
a ; become subjen to the Worker's Compensation provisions of the Labor Code,you must
W forthwith comply with such poi inuns or this .it shall be deemed revoked. WATER SERVICE
Z CONS]HOC]ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,1.7. PAID
L) OI hereby affmuhat there is a construction lending agency for the performance III Data cci itp
the work for which this permit Is issued(Sec.300.Civ.CJ
0 U Lender's Name
T)'fAh:
6endn's Addrcna
AWi
ramify that I have read this application aad atom Our theabnva information Is. BUILDING SIDE
h counsel.l nine to comply withal]city and county ordinances and state laws relming a QTY. • MECHANIC, PERMIT FEE
V building construction,and hereby authorize representatives ofthis city m enter upon the SEISMIC PEIi
abovo-mcmioned property for inspection purpnsus PERMIT ISSUANCR
(We)agree to save,indemnify and keep landless the City of Cupertino against E ECIRIC FF.
AA
Iiabilitiesjudgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MIiCH.
in consequence of the granting of this pewit. PLUMBING 'E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'('1010.001 CFM) MECHANICAL FET:
SOURCE REGILL6T1014S. /1�
StgnaT"' / 6 � �) �,fy' AIR HANDLING ON]'I'(OVF.R 10,M)CFM) CONSTRUCTION AX
ureof Ap�pmanV ntranor — - UaIL O EXHAUST HOOD(WIDUC) HOUSING MITI ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WI1Lhart,licam or future building occupant mentor handle Indianians dradonal DEALING UNIT(TO 10(UIW BTU)
as defined by the Cuptiono Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(vl' HEATING UNIT(OVER 10),"11'1'U)
❑Yes 7 N PAID
VBNTILA'1'ION PAN(SINGLE RBtiIU) puns kra rpt N
10 1 Will the applicant o,future Wilding vacation use equipment lir devices which BOILER-COMP(3111'OR 100,000 BTU)
Isar hazardous air contaminants as defined by the Bay Area Air Quality Management 'OTAL:
' �istnaR BOILER-COMP(OVER 100,000 11 UID
❑Yes ❑Nn
I have read the Whoudous material. AIR CONDITIONER ISSUANCE D
reyuimmems umbo'Chapter 6.95 of the Cali-
Run.Heahh At Safety Code,Semlons 25505.25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.pr.
building Ams not cuwmly have tenant.]bat it is my responsibility to nobly the occupant
of the"mo mems which as,rbe met Form m i...of u Camb,m of Occupancy.
Owner lir umhnugent O
Data • ISSUED UN,
OFFICE