B 0192APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY CUPVISION BUILDING -
PERMIT NO,
MECHA ICACAL
BUILDING DIVISION APPLICATION/PF.RMIT PLUM1IBING. MECHANICAL
DI
,BUILDING PROJECT IDENTIFICATION
S000I 0192
BUILDING ADDRESS'.
2-1:X55- 5fevewf C/. -c% 131 Dai • 64 (ry.'-N % S/o-Ge6-o4
SANI'T'ARY NO:
APPLICATION SUBMITTAL DATE
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OWNER' E: a PHONE:
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CONTROL
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ARCHITI?LT/• INEER: , LIC NO:
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BUILDING PERMIT INFO
3 y /
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT' PLUMB/ MECH
U_
LICENS ) CONTRACTOR'S DECLARATION
I hereby affirm that I a... Ibesed under, provisions of Chapter 9lasmmeneh.g
with Section MOO) of Division 3 of the Business and Professions Code, and my acease is
in full mrec and efice],
License Clavas Lar.#
QTY ELECTRICPERMIT PEE
JO ESCRIPTION
.
❑SFDWL ❑ KITCHEN REMODEL
PERMIT ISSUANC13
] Dam Contractor
APPLIANCES —RGSIDF,NTIAL
❑ADDITI El PLUMBING RE -PIPE
❑(ULT NIT EI STRUCTURAL
MODIFICATION
❑1 ;RIOR ❑CHIMNEY REPAIR
1 PROV17MENT E]SWIMMINGI'UOLS
j ARCHITECTS DECLARATION
IunJemand my plans shall he used as public records
PANELS
UP TO 2W AMPS
Licensed Professional
t OWNHR-BUILDER DECLARATION
I
201-1000AMPS
OVER 1000AMPS
I hereby affimt that I am exempt from the Contractor's License Law for the
following reason Seca art 7001.5, Business and Prolesi.ns Core: Any city or county
which require a Permit ]o e m local, alma improve, demolish, or repair a, swemre
priorno its issuance, also requires the applicant for such Permit o file a signed statement
That le is licensed Transition to the provisions of the Contractor, License Law (Chapter 9
ATH REMODEUREPAIR ❑ DEMOLITION
OTHER
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. MET ER OR IDLE INST.
COMMERCIAL,
❑ NEW I11,DG/ADDITION ❑ DEMOLUION
❑TENANT' ❑FOOD SERVICE
(commedeing with Section 71X(1) of Division 3 of the Nosiness and Pndedsionx Code) or
that he is exempt therefrom amai the basis for tire al lcgN memelma, Any vlolalion of
Section 7131.5 by any applicant lire a permit amoss the applicannor civilpenully of
man are 'him five hundred dollars ($500).
POWER DEVICES
SWIMMING POOL ELECTRIC -
❑ Lus swncr of me pmpcny..r my employm with wages as mein xnk co.]pe..sution.
will do the work, and the structure is not intended or offered formdo, (Sec. 71H4. Business
IMPROVEMENT
❑ OTHER,
and Professions Code: The Contractor's License Law does not apply to an owner of
OUTLETS,—SWI'fCHIS—FIXTURES
properly, who builds or improves thereon, and who does such work himself or tbmugh
his own anph,.,, provided shut such improvements ore not intended or olfemd fur
NEW RESIDEN DAI. ELECTR SQ F.
2 I
sale. Il, however, the building or hapmvemedt is sold sd Bhinone year ofeontpletion,the
,wantondlift, will have the burden of proving that he did oat build or improve fimpm-
SQ. PI'. PLOORAIti?A
$/SQ. FI,.
poseofaaleJ. '
'ICTAL:
❑ 1, as snvner of the pmpeny, am v,wImively cramming with licensed commetors t.
concoct the pmjmt (Sec. 70,J, Business and Professions Cade:) The Contractor's Li-
QTY. PLUMBING PERM FEE
cense Law does not apply to an owner of properly who builds or improves ]hereon, and
who contracts forsueh projects with a conteaetodo licensed pumuam to the Cod]metors
TERM IT ISSUANCE,
License Law,
0 l am exempt under SeeB&PClin This reason
Owner Dam
ALTER — DRAIN M VENT— ATER IEA)
VALUATION
WORKERS COMPENSATION DECLARATION
I hereby atTirmunder penalty of p jury morafthe following declarations:
HACK FLOW PROTECT' EVICE
DRAINS — FLOOR, Oh, AREA, COND.
I haveand will maintain aCenifcateof Comcm mself-insumforWmkcr's Comped-
a on, as provided for by Section 37M of the Labor Code, for the perlunname of the
STURIIS
'TYPE CONSI'RUC'I'ION
FIX' I' ot
work Ibr which this permit Is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
-
3700.1 ]he lalm,Code, for the perlonaameof Ne work for which mi.a perm;] is issued.
My WorkeA'a Cpmpensetier� mncec er and lbli
Carrier. %1 f = //nsu 'ro Policy.":
GAS— .SY '•M -I Io4C. 4 OUTLET'S
® GAS— 4 ) eC comp
R .: aCCep
GFA _ QQ
Glt A, ��G toga
sµr•
Pjaumne Drspen- .s
WAf
OCC. GROUP
tion
Nl11fDING DIVISION
APPS
FEES
CERTIFICATE? OF EXEMPTION FROM W RKERg'
. COMPENSATION INSURANCE
(ellinstai
rlwxI'hissecom need not heamtpleted lfthepermit is foronehnndreddollms($100)
in the penimmance ofine work for which this permit is issued,I shall
rot employ any person in any manner so as to become subject o me Warkers'Cum
satin. Laws of California. Date
Applicant
HECK PERIcentuythat
ENERGY PER
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
WAT
SOILS FEE
ftmhwith comply withsuch Insieiodsor this permit Shull be deemed revoked.
WA'1" •RVICB
CONSTRUCTION LENDING AGENCY
I hereby M. that is a consauction lending agency for the perfonnan of
NEWR
PAN
Dae Receipt#
the work for which this permit is ismed (Sec. 3097. Ci, C.)
'T(TI'AL:
BUILDING FEE o act
Lenders Nanta
Lender's Address
1 certify that 1 have read this application and state ]hat the above inti nation is
- reset. I agme to comply with all city and county on inances and emtn low Tdutin to
g cons you p
buildin traction, and hereb mmize remoot,mlves of thisci]y to terupm me
_
t / o
QT'Y� HRMI'P ispl:"(
CFPD
abowc-memiond propcny far inspersion purposes.
(We) agree m save, indemnify and -keep hurmle" the Ciry of Amino againsr
liabilitie.a,judgments. costs and expenses which may in any way are ainst said City
suento g
in eq ce of the granting of this permit.
PERMIT ISSUANCE
ELECTRIC ITiE
ALTER OR ADU TO MECH.
PLUMBING FEE
APPLICAN"IUNDERSTANDS AND WILL COMPLY WITH 1.1, NON -POINT
SOURCI7 REGULATIONS.
AIR HANDLING Good I'(TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING ON[ 'I'(OVER 10,000CF1)
CONST' RUCTION TAX
Signature of ApplicamiCommacrorDate
HAZARDOUS NIATERIALS DISCLO RE
EXHAUST IIM])(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT 00100.1100 BTU)
William applicant., future building.ccomen marc handle harraft. mamma
9.1 , and the Health and Safety
as defined by the Cupertino Municipal Cad/,incints
Code. Section 25532(.)7
HEATING UNIT (OVER 100,000 BTU)
C] Yea ❑No
Will the applicant or furore buildinguse equipment .r devices which
emit hamrJous air c.nmminams m definedy AreaAirQualityManagementC
DIs1I]C17
❑Yes ❑Nohave
PAID
Dom Brescia0
VENTILATION PAN (SINGLE RESID)
BOILER-GOM11P (3III'QR IOO,IXIO BTU)
d
BOILER — COMP(OVER 100.(100 BTU)
AIRCONDDIONER
read me harantoux nwterals runder Chapter h.95 o1' the Cali-
ISSUANCE DATE
NEW RESNEN'IIALMECH.r—�building
d 25534.1understandthatIf]he
docs noteutrently have a tensa, Thatponsibilitymnotifytheoccupant
(
ofmcreuirementswhichmumhmc]primofa Cciificam.f Occupancy.
A
ISSUED B17:3 �f� •' ^ ' t O
Owner r authorized agent Date
TOTAL:
OFFICE