S 1497APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
PCITV,OF CUPERTINO 11011.DING-ELECTRICAL
BUILDING UIVISIGN APPLICATION/PFRMIT PLUMBING - MECHANIC L
RUIIAING PR(1JEICT IDENTIPICA'U0N
PE IT NO.
V 1497
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
N
:ZOSSfs-s%EVtKS If/RE'EK Li LVD• , Or; L /Ind I?A
1 i
tWNEk'S NAME: PHONE:
LWNoR rp .0 It 9V -/Roo
CONTRAC'TOR'S NAME?. LIC
-
J l D (�
NIC
❑
CONTROI,p
ARCHITECWHNGINEF.R: LIC NO:
(lu NEk
ADDNESS:
3/B q LPhVi 120 L4 f/ouaA P
CON'T'ACT: PHONE: �Al
y b
O y0 >e:,
ED Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
----------
FILINGIi1.liC1' PLUMB MECE
V U .r Nr NBEL 81Z0V, 6 yV-106 y2-
f�
E=2with5ection](NNbamivl,lnn2ofthe
300
err
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LICENSED CONTRACTOR DECIARATION
, of chapter 9 mmne..g
Rcced der provi orQd
1 hereby affirm Thal 1 .m rian
nuaineasund l'm[essiane GNe, and my limas, is
in Ball form and clgwt
— ? 3e0 3 S
IJcenu Class Lick
Dae--S/��nCnmmctor ?eaa CyP.�u ural
ARCHITECTS DECLARATION
underatwW my daas,Ibe l he uual as public awards
QTY ELFCFRIC PERMIT PEE
JOB DESCRIPTION
RESIDENTIAL:
❑ShDWh El KITCHEN RF -PIH
❑ADDTrION -1 PLUMBING RE -PIPIT
❑MUI71-UNIT El STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL.
P.\NIi15
aOWNER
4WJ
C U
WO y
3rthat
7330
C
UP 1020N)AMI'S
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑NA'I'li REMODIiUREPAIR (]DF.MOI.II'ION
❑ OI'I{ITR
Licensed Professional
- BUILDER DECIARA'I'[ON
1 hereby affirm that I am exempt from the Contractor's License Law for the
Inllowing rerrnm. (Sectlnn 70315, Rumors, and P ... O,Acru, Code: An y ciymanrn(Y
which requires a permit lin nmswder, , ulcimprove, demolish, or repair any slmdurc
prior to it, issuance, alsorequires the apdi,anm forsuch pmaino Bleosigned staemenl
he Is licensed pursuant to the provisions of tyre Contractor's Livens Law (Chapter 9
(eommencing with Section 70W)or Divisina 3"fine lmviocss and Professions Code) or
Thal he is exempt month nrn and the basis for the alleged exonrption. Any vinlmion of
201-1000AMPS
OVER 1000 AMPS
SIGNS!?hF.CTItICAI,
SPECIAL CHICLE'1'IMISC.
TEMP. METER OR POLE INST
COMMERCIAL.:
❑ NEW BLDG/ADDITION EMOL1'TLON
POWER DEVICES
1 e Tz-
; Z j
p^6
o
Section 7011.5 by any ordered for a pc,.I, subjects the applies.( III a civil peamty of
not mom than rive hundred dollars ($500).
[I1, as owner al(he pntpeny, nr my ernpleyees with wages as their ante ttnnpunsation,
vcture is ot intend,dornueredforxale(Sco 70O.Brrsiness
will do the work, and the structure n
❑ IMPROVTENANT ] F OD SI?RVICE
IMPROVEMENT
❑0'fliliR
SWIMMING POOL ELECTRIC
DO 11.17 TS - SWI [CUTS - FIX TURES
_R
NEW RESIDENTIAL EL j k SQ FT
I
13 _o
and Professio.s Code: The Cnmramm's License Law doe, not apply to an owner of
property who builds or Entrances Thereon, and who docs such work himself or through
his own employees, provided that such impmvemenu are not intended or offered for
xnleaf,however, Ihchuilding nr imprnvemem is nnld within mm year of contplaian.the
SQ. FI'. FLOOR AREA
$ISQ. 14.
owner -Molder will have Ibe burden of paving thin he did not build or:approve on pur-
pnscafsalo.).
I, as owner of the proper, am exclusively contracting with licensed contractors to
P A 1 D
TOTAL'
maruet Thu pmjwl (Sea 70M4, Business and Professions Cndc'J The Cnntmcmrx Li-
ceaseLowdoesnot apply to an owoerolprnpeny who builds (it utpavex Icrent. and
QTY. PLUMBING PFRMIT FEE
e
APR
who contracts for such projects with a nmlmclouO liecnsedpummnl mdm Commcwrs
PERMIT ISSUANCE:
License Law.
I am exempt under See. ,IT& P C for reasoncity
17
49 /�
NS,8
Al:fl?R- DRAIN & VFNT- WATER (EAI
net Date
/-[_fY/�4lJAI ION
1
HACK FLOW PROI'NCT. DEVICE
WORKERS COMPENSATION DECLARATION
1 hereby affmn under penalty of p, jury one of The following declemtinne
DRAINS- FLOOR. KOOP, AREA. COND.
❑ Ihavot (will maintain. Ceniricancol ConsenOoulf-inome l' or Wmkdx Compen-
satin., w pmvidW Our by Section 3700.0 the LaborCale, for Thu p,rtormnncc of the
STORIES
TYPE CONSTRUCTION
work for which this Iremil is issued,
FIXTURES - PER 'I'RAP
C e and will maintain Workers Compensation insurance, as required by Section
3(Nl aflhel.abm Cotte. far the Dcohnnmowofth, work for which Thispermit i,issued.
GAS - EA. SYSTEM-) INC. 4 OUTLET'S
OCC GROUP
APN
MyWorkcr, Cnmpcnsntinn Invuranw candy and Vole, number ne
Carrier.�r lQ Policy No.;�.$
GAS -I:A. SYS' I'T o OVER J H'A)
CERTIPIC TE OP EXIEMPTION lzROM WORKERS'
COMPENSA'T'ION INSURANCE
GREASFIINDUS'IRL WASTE: IN'rERCEPI OR
pt111.01NC DIVISION
(This section need not h,wntplm,J if the permit is for one hundred dollars 1$ 100)
nr les,)
GRI?ASB TRAP
_17_iILS
PLANCIIECK PIE!!
D Z
O
I certify That in the performance of the work l' or which this permit is issued, l,holl
not employ any peon in any manner so us to beconn abject m tM Worken' Gmmpen.
sudnn Laws of Cofifomiu. Date
Appllcam I
SIEWER- SANITARY_ S)Y)RM EA. 200 FT.
ENERGY ITE
WATER HEATER WNENTIELECI'R
GRADING FET?
NOTICE.10 APPLICANT. IL afinmaking this Curnicateof I:xemptinn, you should
tnxonw subject to The Workers Compcnonion provisions of the I,zher Coda you most
fonhwithcantply wilt such provisions "obis pemtit shall h+Jcemnl revnAed
CONSTRUC I(ON LENDING AGENCY
len ding agency lisr tM1e perli�mmnce of
I huhby aEirm Thauhere iso issued
the dark far which Thls p,mtiT is issue) (Sec. 309]. Civ. CJ
Lenders Nunte
WATIiI( SYS] EMITREAI'INC,
SOILS FEE:
Q
7z
J
C
^pp
.J Z
WATI7R SERVICE
PAID
Dom r' Ik
NEW KESIDF,N'I'Al. PLMH. SQ, FI'.
TOTAL:
Isnder'1 Address
TOTAL:
BUILDING F. -
1 ccnify that 1 have read this applicabnn unJ slam That the strove infnnn.mob is
correct. l agree to comply with all city and county ordinances andstate laws mlatingm
building construction, and hereby aatM1mU.e representatives ofthis city menterupon the
QTY. MF:CI IANICAL PERMIT FET?
SEISMIC FEE
PERM I'I' ISSUANCEELIiGTItIG
PD1? S
uhovsntandoned,raper It,, Ir,,cIn pnrpn,us,
(We) agree w save, indemnify and keep harndens the City of Cupenlno against
liahiliticz,judgmemn,ttnrs and expenus which may in any wey seem, against mid City
in comma,ance of the granting of this permit.
ALTER ORADD'In NOTCH,
PLUMEING F :E
A l TO I IANDLI NO UNIT (TO 10,000 CFM)
MECIIANI AL ITIi
A PPLICA NT UN DHRS TAN DS AN I) WILL COMPLY WITH ALL NON -POINT'
SOURCER``GULAI ONS.
AIR IIANDhINO UNIT IOVL'R 10.IX CPhp
CONSTRUE"TAX
AA /) y% 6
Sigrwwrt ofA und/Cmaacwr Ina
HAZARDOUS MATERIALS DISCLOSURE
EXIIAUSTHOOD(WNUCI')
HOUSING MITRiArN THE
BEATING UNI' I'(110100,000BTU)
Will the applicant orfuture buildingoccupunl smrn aromatic mzardnnx matenal
as defined by the Cupcnino Municip:d Cade, Chapter 9.12, and the Health and Safety
Coda Section 25532(0)!
HEATING UNIT (OVER Britoil BTU)
❑Yes ❑Nn
PAID
Dum RAIPI q
VEN'I'ILA '1'ION PAN (SINGLE ItESID)
HOILI:R- COMP UHP OR 100,0100 BTU)
Will The applicant or town, building occupant use equipment or devices which
emit humdous air contaminants as defined by the Bay Area Air Quality Management
Dotnct7
El Yes EINI,
T
NV C
BOILER-COMP(OVER 100,000 B'1'l1)
AIR CONDITIONER
I haverewl the hsvardous materiels rcquirtmems under Chapter l.95 of The Cali
ISSUANCE DATE.fomia
NEW RESIDEM LL MSCI I. SQ. PT.
Health & Safely Cale. Sections 25505, 25533 and 25534. 1 understand thin d The
building dna, nut currentlyhave u Ienou(. lbw it is ray respon. latity tonally the occupon(
f the
o"mmmenls which must lb,nal He, m ionernce of a Cenllic.e ol'Occupancy.
TOTAL:
ISSUED BY:
Owner or autherzed agent Date
OFFICE