S 0210 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELECTRICAL PERMIT NO, 0210
BUILDINGnIVIS10N APPLICATIONIPF,RMIT PLUMBING-MECHANICAL S
BUILDING PROJECT IDENTIF'IC'ATION
BUILDINGADDRISS: SANITARY NO, APPLICATION SUBMITTAL DAT[
103 2_
\ IOWNE 'S NAMH 4 9 ONE: CONTRACTORS NAME: LIC NO,
7r � N/C � C�O/NT�ROLp
ORCHITECOENGIN EER: 7 LIC NO: ADDRESS: ❑ la X{A *
7
CONTACT: PHONE: BUILDING PERMITINFO
E � �1 - p ,y�/ ` ,� ❑ Consultant Fees Paid by Applicant(Initial) BLL ELf:Cy PLUN1H Mf:Ct
LICENSED CONTRACTOR'S DECLARATION I 'J �a QTY CI.ECTRICPERMIT FEE
1 hereby am mro
affirm 1 am licensed under provisions(if chapter 9(commencing
-. 1013 DNSCRIPTION
O�Z Th Setion JIXlllla(Divisiun3nfthe Businesxand Pndeasinm Cede andmyliecassia T
WO wa I'f.1041 r ISSUANCE
JOUF in full force and effect. l/,�� SFDWL ❑KITCH17N REMODEL
GUU Limma rs-s�Lie.4 ?O APPLIANCES-RESIOENI'I Al, ❑ADDI'T'ION ❑PLUMBING RHTIPH
�naa Date - Y A TSDECL�%P�
F-Om A CHITECTS U[CLARA'T1440NII PANELS C1 MULTI-UNIT []STRUCTURAL
IFICA'IION
Z O nes z 1 understand my plans shall M used as public records lll'TO 200 AMT'S
oz- INTERIOR ❑CHIMNEY REPAIR
r4tW Licensed Profesxinnvl 4111-ImOAMPS IMPR'OVEMEN'T' SWIMMING POOLS
OWNEH-BUILOIiR DECLARATION
Q I hereby affirm that I am exempt from me Contractors License law for the OVER 1(kgJAMI'S C1 LOVE REMODEL/RIiPAIR DEMOLITION
xtl O0.U following reason.(Section 1831.5,Business and Professions Cadc:Any city or countySIGNS F.LF.CT A ❑OTHER
W 3 W y which requires a permit to construct,altar,improve,demolisha repair tiny"in' m T
„F,� rt706 prior to its issuance,also requires the applicant for such pennino, dleasignad stv¢ment SFl!CIAI IRCI /M �—
�y'� that he is licensedpursuannotNepro.mmsoftheContmctolsLicenseLaw(CM1apterY
X00 (commencing with Seelonl(00)of Division 3 ofthe Business and Professions CrMdm TEMP.SUFFER LEIN / 1
6 p,m e' that he is exempt thendmm and he basis fur the alleged exemption.Any violminn of ❑NEW ILD i (STJ f��[�,7(/����r./�I"fION
iLLCl�lcoL Section 7031.5 by mry applicant has ,Iransubjects then,acant wndvl...... ty til' POWER DEVICES 01 EN IJ I'lIltn Sl!RVICE
F Z Y not more man five hundred dollars($500). IMPR1'
< ❑Lasnwnerofthepropcny,ormyemployeeswithwagesuxmattutl<compcnsminn, SWIMMING POOLEI.06 L`01'GiiIig
O will dutha wmrk.and theswatute isnot intended or offered fnrsale(See 7044.Business ❑OTHER
m and Professions Code:The Contractor's License taw does not apply to an owner of OUTLETS-SWITCHES-FIX
pmparty who mJt N or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered bar NEW RESIDFNFUAL ELf.C'IR qso FT.
sale.IL hawevee the building or improvement issold within one year ofeempletion,theO� 00-1SQ.FT.FLOOR AREA s1SQ.ref.
owner-builder will have Ne burden of proving that he did urn build or improve for put.
pase of aaleJ. 41%%IkiW IC
1,as owner of the property,am exclusively contracting with IicenseJ cnntramnrs to
on.swct the project(Sec.70FI,Business and Professions Lad e:)'fine Co......
cense law does not apply to an owner of property who builds or improves thereon.md QTY PLUMBING PERMIT I FEE
who contracts for such projects with a contraemr(0 licensed pursuant o the Commemr's
License Law. PERMIT ISSUANCE
❑I am exempl under Sec. ,11&PC for this reason
ATTER-DRAIN&VENT-WATER IEA) ��yALUA'{IO��
Owner Date /y�„�I 6 �•
WORKERS COMPENSATION DECLARATION BACK PLOW I'HOTECf.DEVICE
herebyaffirm under penalty oeperjury one ofthe fuxure for decWorker's
o
❑ Ihave and will maintains Certificate of Consent to self-Insure for WnrAer's Compen- DRAINS-FLOOR.ROOIy AREA,CONU. STORIES 'I'VPE CONS'fRI1CTION
cation, provided for by Section 37M of the labor Code,far the psfotmaare d the
war mwhichthispcmtitisissued. FIXTURES-PER TRAP'
1 hove and will maintain Workings Compensation Insurance,as required by Section
TRO ofthe Labor Cade.for(he performance of the work but which this permit is issued GAS-EA.SYSTIiM-I INC 40UTLU'B (ICC.GROUP AI'N
My Worker's C•mpe seOinn Insurance dPolicynumher are:
Cartier.��Policy No.: GAS-EA.SYSTEM OVER J(HA)
CERTI .0 :OF 'EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASFlINI3USTRL WASTE INTERCEPTOR
N f )'1140 DTVI (3N FHHS
(Thissection rtadnm be complete !o
d it permit is hundred radius 6100) GRPASETRAI'
or le".) PLANCHIiCK Jay
I modify that in me perfermanreufthe work forwhichmis permit is issue4lshall SEWER-SANITARY-STORM EA.200 FT,
not employ any person in any manner so as to become subject to the Warkers'Comfu n. ENERGY dal
OZ smlon laws ofCuburnia.Dam WAI'UR HEA'1'HE WNENT/ELECTR GRADING E
Z 2 Applicant
fn NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSIENITREATING
a ^ become subject to the Workers Compensation provisions of the IaMn Code,you must soli S PE.
fIJ G forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Ct La
U0 CONSTRUCTION uLENDING ng agent NEW RES IIII!N'I'IALPLMB. SQ,FT PAID Date Reccin,M
V � Thereby affirm manhem is acommmainn lending agency Taube performance of
the work for which this permit is issued(Sce.3097,Ci,C.1
0 F'' Lender's Name 1(TfA L:
U Lenders Address '
�-I aBUILDINGIrt
[r 1 rectify that 1 have mail thin application and stale that the above informationis
10
V) correct.l agree to comply with all city and county ordinances and state laws relating or QTY, MECHANICAL PERMIT PEE
U Z bu dagconstrumion,and hereby omthorim representatives ofthis city menterupon the SEISMIC FI a
above-ntendoned property for inxpecdon purposes. PERMIT ISSUANCI!
(We)agree m save,indeannify and keep harmless tire o a
e City of Cup,mrgainst F:LECfltlf Is13F.
Top
liabilities.judgmems,costs and expenses which may in any wayaccme against said City ALTER OR ADDT'O MECI I.
in consequence of the graining of this permit I'LUAIHIN6I'.-
APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALL NO -POI AIR HANDLING UNIT PTO 10,000 CFM)
S(3UNCP.REGULATIONS. ^ /y�� 1 MECHANICAL PE'
/S /�. _ice , / 1 Iy �l AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Srgnmureef�pbcandCmdmctarme ENHAUSTHOOD(W/DUCT) HOUSINGMITIGATIO TE
HAZARDOUS MATERIALS DISCLOSU
Will ate applicant income haddlag omrifunt mom fir handle haznnlnus material I TENTING UNIT('10 Hx),1100 It'1'U)
as defined by the Caperton Municipal Axle.Chapter 9.12,and the Health and Salley
CMR,Section 25532Rd? HEATING UNIT(OVER 100,000 BTU)
E]Yes ❑Na V17NTILATION VAN(SINGLE RESID) PAID
vat EVE d
Will the air xamn or furore building by he Be,use equipment or devices which
:mit hevaNmus air amuminants as defined by the BArea Air Quality Management R(111.ER-COME)LHP OR I10,BB0 BTU) TOTAL:
t Districtl]yes C]No BOILER-COMP(OVER 10k000 BTU)
I have rod the hmznlous mated,requimments under Chapter 6.95 mf the Cal. AIR CONDITIONER ISSUANCE DATE
media Health&Safety Cede,Seminars 25585.8533 sad 25534.1 amdemund that if the NEW RESIDENTIAL MECH, SQ.FT.
Wilding does not currently have a tenant,Nm it is my respmsihiliry to notify the occupent
of the requirements which must be and prior to issuance of a Certme te of Occupancy.
Owner or aumhnriwd a gent Date T ISSUED BY:
OFFICE