S 1572 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PBUILDING
OF CUPERTINO BUILDING-ELECTRICAL PEdg11'1'NO, 1572 5 7 2
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �\l 1BUILDING PRictiour�IDENTIFICATION
ADDRT SS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS NAME: I' ONE: CONTRACI ORS NAME: LIC NO:
7"NrN
St '(38,60-7
�� NIC CONTROL#
: LIC NO: ADDR ❑
') PHONE I ' aUILDINC PERMIT INFO
^ ¢NEp.� Consultant Fees Paid by Applicant(Initial) BLDG E,LEEC,T/PLUMP MECH
11/11I• (00 2) Lir ❑ ❑SED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
l I am licensed under provisions ofChapter 9(,,an done „ JOB DESCRIPTION
DaZ amn3orWe ersinlsa and Pr,fead,aev Code,dart my liecnsoix (-- RESIDENTIAL:
aW 00 wi PERMH ISSUANCE
FW.. ifullf...candefJea ,`��S ❑SFDWL ❑KITCHEN REMODEL
�UU licervve Cl C- Lie.# r APPLIANCP,S-RESIDBN'TIAL ❑ADDITION ❑PLUMBINGRE-PIPH
H Z w Uwe Cnmracppr
m¢y ❑MULTI-UNIT E:1 STRUCTURAL
ARCHITECI"S DECLARATION
FVOi'y I understand my plane snail be used ns public eam s s PANELS MODIFICATION
Ozast0 UI'T021N1,1MP5 -1 INTERIOR El CHIMNEY REPAIR
F N,."u� Licensed Professional 201-In00 AMPS _ IMPROVEMEMr I]SWIMMING POOLS
OWNERBUILDERDECLARATION S4WOVER list)AMPS El BATH RP.MODELIRGPAIR El DEMOLITION
1 hereby affirm the I am exempt from the Contractor's Liecnse Law for the
��(0 y following reason.(Section 911315,Business and Pmfasaians Code:Any city of county SIGNS ELECTRICAL. OI BIER
P13 Wia which requires a permit 1.construct,aheq impnwe,demorsb,or repair any emucmle
Ricards itsI. q th p1lfi,pra onotsbFirmnin,file i,i,radarmater, SPECIAL CIRCULEMISC.
tbar hous itch-clorroon,.he p prof'be Conviction,License T' (Chapter 9
onnamenciativalln Septum)000) fD' 3ofEv Businessland P f .C e)or 'IHMP METER OR POLE INS'n COMMERCIAL
d ty cthat he is exempt 1hemir n and Ne bus for the alleged exempt n.Any violation of El BLDG/ADDITION ❑DHMOLI'1'ION
X^]I Section?H31.5 by anyappBcanl lien a permit suniects the applicant o a doll penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not apple than Eve hundred dollars($500). [MPROVEMG
F50
C]Los ownonofine property,otiny employee,with wages as inch lialnriantumn, SWIMMING POOL ELECTRIC
p: [I OTHER
of 11 do the work,and We structure is not intended or olferal hassle(SecJ7044,Bmint,,
3 and Professions Code:The Contractor's I icemae Law docs nor apply to an owner of OUTLETS-SWITCHES-ITS I ORES
.. property who builds or improves pioneer,and who docs such work himself or through
his owa cmple,ces,provided that such improvlmenps arc nal imported proffered fur NEW RESIDENTIAL ELECTR SQ FT
sale.11,howevepme bulldingon improcarmat is sold withinore yeartfi mane.tom the SQ.PT.FLOOR AREA .S/SQ.PC.
tooter-hwlder will have the harden hf proving that he did nal build or improve for pur-
e se,I'sale.). .
1,to owner of(be propery,am exclusively contracting with licensed contracpm m TOTAL: ST 20
construct the pn9ect(Sec.9044,Business and Professions Code:)The Gmtraaors Li- I
ce Ldr
acs ds not apply to an owner of Property who indictor improves fare and QTY. 'P MBING PERMIT FEE tfr A p
who ammmk borsucb projoae with aaatraemdv)liamsed pursmnnothe Cnnwpmare A 6'
License Law. PEI2 SEANCE AI
E] I am exempt undo Ser.Sm. .B&P C foreasonis reason /��
Owner Dap ALTIVDR VENT-WATER IEA) L
WORKER'S COMPENSA9lON DECLARATION BACK FLAW PR D- ICE r i� 1v V
I hereby affirm under Penalty of perjury one of the Iauthor ng ea:lamtions: y
I baso and will maintain a Certificate of ComsapLm self-insure for Worker's Cnmpen- pkA1NS-FLOOR,ROOF, nA D. STORIES TYPE CONSTRUCTION
velem,as proi
vded for by See....3'!00 of(be Labor Code,for the performance of We
prk su
for which this permit is ised. PIX'I'URES-PER TRAP
I have apt]will neriar in Worker's Compensation Insurance,as required by Section
3700 of Op Labor Code,for the performance dDlm work I,,,,whish mispannit k s,mal. GAS-P,A.SYSTEM-I INC.4 DO I'LBTS OCC,GROUP APN
MyWorIt�[pC��mn,C.enwlinn lny�n ecerria ted Policy nu(IWcr ori.
Carrier. !lid [tl.1.FW.rm Policy Na: �t9�1 GAS-[:A.SYS'rBM-OVRR4(P.A)
CERTIFICATE OF EXEMPTION FROM W ORKE tS'
COMPENSATION INSURANCE GREASE/INDUSI'RLWASTE INTERCEPTOR
BUILDING UIVISION PPA
(Thiseectipn need mol bewmplelW iftha permit is for one hundred t]nllvrs($1011) GREASE TRAP
or leas.) - PLANCHIiCK FP.P. k,-. -��
(ccttify that in lheperfnnnvnw Ofthe work forwhicM1 Onispamil is isxned.l shall SEWER-SANITARY-S'I'ORM EA.200 FT.
not umum
pioyony person in any hmer so as to become subjecNor the Workers'Cnmpen- ENERGYFEE • 1p
Q7 z slitiou Luws el California.Dale WA'IHR HEATER WNENT/ELECfli GRADING FEE Q Applicant
Uj NOTICE TO APPLICANT:IL after making this CatiBcme of Exemption,you should WATER SYS'PEM/TREATING SOILS PEE
eP'Y ,become subject to the Worker's Compemmtion provisions ,I lop Lubor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WRIER SERVICE
i Q
zaz CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. I
PAID Dud Reeip
hereby affinh Imp Were Is a constriction lending agency name perfnmaparent
U - the work for which this permit is i.ti<ncd(See 3097,Cie C.)
C) F•' Lenders Num, 'IOfAL:
U Lenders Addrev. TOTAL:
'1 11.1 - BUIIAING FEE
1 ccttify mat 1 have mad thLv application and dumber the above information is
Vii correct,I agree to comply with all city and eounry ordinances and style laws rdodng 10 QTY. - MECHANICAL PERMIT TEE
U z onuses=prtstmcdnn,aw hereby annnpdzcrepm.emawes ponds city memerupon the
SEISMIC FeIi
shop e.....planned prapcny for Inspection purposes PERMI'P ISSUANCE
(We)agree ma shop,indemnify and keep harmless the City of Cupprnn,against SLHCTRIC FP.P. 7,
Iiabililies,judgmems,costs and expenses which may In any wayoccme Optimal still City ALTER OR ADD TO MECH,
PLUMBING FEE
In u
eve plea,or the granting of this penult,
APPLICANT UNIERSTANDS ANp WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCIf 'CUL ONS. /y�� /Q Q MECHANICAL PEG
Y NS. I S AIR HANDLING UNIT(GVHR 10,000 CFM) CONSTRUCTION TAX
Signature fApplicanV nates Dam EXHAUST HOOD(WIDUCD HOUSP I'1'IGATION SEE
HAZARDOUS MATERIALS DISCLOSURE
Will the uppllion Or furore bulldingoccupanlstop of herdic hoarduus material HEATING UNIT CEO 100,00 BT1J)
as deflnee by the Caption)Municipal Code,Chapter 9.12,and the IRerllh and Safely
Code,Section 25532(a)9 HEATING UNIT 10VER 100,000 BU)
Yes
•dVn VBN'IILA'1'ION PAN(SINGLE RESID) PAID Date kw t#
Will the hpplfccut or brute funding occupant use cgnfpmenl or desk..which
mit hazardous air contaminants as defined br the Hay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
Di-xdclP I101IAR-COMP(OVER IIq,INq B'1'U)
❑Y=w �' 2 3. -3-Y
AIR CONDIIIONEk
� Ihmelead the haztnlonx materials requirements mat]cr Chapter 6.95 of the CJi- ISSUANCE DATE
name e Health&Safety Crap,Sections 25505,25533 and 25534.1 undeevmnd Wvt if the NEW RESIDENTIAL MECH. SQ.FT
building dues mol natty haven tenant,that it is my rosponsihlligReality mehccupam
of the requirement ed the pr to iseuan -a Cendjcopof Oecup.mc- ,
� ee S, IN-9�l Sze �s
Ownaonp�agent Date 'rOIAL: ISSUED BY. ti7Jti-yCe,
OFFICE