S 0402 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOb-CUP'RT[NO BUILDING-ELECTRICAL PF§IT NO
BuamNG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 0402
_BUILDING PROJECT IDENT111ICAT10 't
BUILDING ADDRESS: - llaM^ ti�/•� a SANITARY NO. APPLICATION SUBMITTAL DAL
OWFE 'S N M [ / PHO E. CON'TRACTOR'S NAME: stir LICNO: NIC CONTROL#
L. ARCf1ITIiCTl1iNGINITER: f -LIC NO: ADDRESS: ❑
CONTACT. / PHONE: I !"I,t BUILDING PIiRMIT.INFO
i5- ❑ Consultant Fees Paid by Applicant(Initial) BLDG. Butcr rl.unul MECH
LICCNSIDCONTRAC ORSUFCIARAIION Q9V el,i L-I.ECTRIC PERMI91 r ). Ih i'. FEL''
I hereby nlfrm loll licensed l p : !Chapter 9(comm g JOB DESCRIPTION
O C'z with Section]Ikk)oln 3,t the Businessanal rafcskt nsende and my licenses RESIDENTIAL:
PERU I1 ISSUANCI
��� in full force and effect. ❑SI'DWI, ❑KITCHEN REMODHI.
1c U Littnse Clms iia# - APPLIANCES-RESIDENIAL ❑AUDITION ❑PLUMBING RI-PIPE
tli1Q GW, Date Contactor
ARCHI'I'F.CT'S DIiCLAHATION ❑MULTI-UNIT [I STRUCTURAL
~ m I understand my plans shall be used as public recoNs PANELS MODIFICATION
Z O,-za
IOz,,,Q UPT021X1AMPS [I INTERIOR ❑CHIMNEY REPAIR
Licemed lhofecsimol 201-1000AMPS IMPROVEMENT E]SWIMMING POOIS
OWNER-UUIhUER DF.CLARA'1'ION OVER I000AMPS ❑BATH REMODEUREPAIR 0DEMOLIT[ON
a Q I hereby affirm that 1 am exempt train the Contractors License Law for the
7p5�O y U following reams.(Section 70315,Bushes and Poa
fesvions Code:Any city or Canty SIGNS HLE,C'I RICA[, Eli OTHER
i- which requires a gemtd an construct,alter,improve,demolish,or repair any ramnter. —
prior toiuissuance,nim requires the applicnm tersuch pemlOn fleasigned atimmem SPECIAL CIRCUIT IMISC. 11 01 40
} that he is licensed putmanl to the provisions n]'the Commi Liviesse Law(Chapter 9
� 000 (commencing with Sscdon700knof Di vision 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAI:
a q e K that he is exempt themfram and the basis for the alleged exemption.Any violaJon of .- ❑NEW BLDG/ADDITION ❑DEMOLITION
YXl an Section 7031.5 by any applicant for a permitsubjeats the applicant to u civil penalty of POWER DEVICES ❑TENANT C1 FOOD SERVICE
❑~❑R6actinium actinme than fee hundred dollars($50(1), - IMPROVEMENT
I,as owner ofthc m norm employees with woes as their sole ana tion, SWIMMING PCOI,ELECTRIC -
2 G ❑ worthe so Y my intended
nt Y 6 pens,
wJl do andThe
eContcom ra ons License La do es rotale pply a M,owner of
❑O'I'HIiN
G a� and ery who
Codec The eves th mo License Law Aces not apply m an owner of OUTLITS-SWITCIIFS-FI%TUR&S
property woo bulls,or improves t uch i and who does such net
d d or of no
shisid own employees,e provided thus such improvements are not ire moI or nliemd for NEW RESIDENTIAL IiLItCTR SQ I'll -
sele.l¢however.the huilding or impmvemem lx sold within one year of citntpletinn,the SQ.FT FLOOR AREA S1SQ.ITT
.
hod r will have the burden of proving that he did not build or improve Torpur-
ej,
ece owear of the property,am exclusively contracting with licensed continuous m 'fOIAL: �S n p ' D
ennswsl the engem(Sec,71YM,Ilmntnen P f:.inns C 1 )I'I C ntrucl 'x Li- r M
mase Law does not apply ro an owner ofp pent h build p :therm.anal QTY. PLUMBING PERMIT f' i I.� � FEE- .
whamse La .fnrsucM1 projects withucnmrnv'nn(a)liscns«I pnrsuam na the Cmnvumnr's 22 MCI)Liccnu law. PERMIT ISSUANCE AUGu til 1{�{!u
H'a ❑ Ino exempt under Sec. .B&PCfar this lensnn
ftahl Owner Dam l ALTER-DRAIN&VENT-WATIiR(EAI Gil
ur uurb4`1NOI
t WORKER'S COMPIiNSTION DECLARATION BACK PLOW PROTECT'.DIiVICIi N 1
LIl
I hereby altlrm under penalty of perlmry one of the following decimations:
❑Iharc and will mwmain aCenifcmenf Cnnsenlmulf-insure for Worker's Grmpen- DRAIN$-Ir1,WR,RGOF.AIiIiA.CDNU. STORIES 'I'VI'I!CONSTRUCT'ION
"alon,as p,a,ded for by Section 390X1 of the Lubar Code,for the perf Temic of the
work for which this permit is issued. FIX'I UR1iS-PERTRA I'
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37110 of the labor Code.for the performance of the walk for which this pennilin issued. GAS-I:A.SYSTEM-I INCA OU ILETS OCC.GROUP APN
My Worker's Compensation banner ec career and Policy number me:
Cartier. Policy No.: GAS-BA.SYS1I!M-OVER4(EA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE INTHRCEPTOR
COMPENSATION INSURANCE. _ BUILDING DIVISION FEES
('lies section need not be complualifthe permit is reruns hundreddmlars(SI00) GREASETRAP
or Iwrc.)' PLANCHECK FEE
I certify that in the performance of the work fnrwM1ich this permit ix issued,lshall SEWER—SANITARY—STORM EA.NIL FT.
I not employ any penrd in unymanner,ous to bcunme,Ajecno the Wmkcrt Contpen- ENERGY i
Z .ration laws of CuGfooiw DatcWATIiR HEATER N'NIiNT/I:LECIR GRADING FEE
z O Applicant
.Ns NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTEM/TREATING SOILS PIiE
hecomu subject to the Worker's Compeosohnn provision,of Iho Labor CnJq•ynu most
W forthwith comply with such provisions or this permit shall bedeemN revoked. 'WAIflR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESNEN'I'IAI.PLM 11, SQ.ITT. PND '
UO l hereby atctiffm there ism conaamon llendingogency Natiorfa
ixnteneenf Date Reccipl#
H the work far which this permit is issued(Sem.301 Civ.C.)
C)U lenders Nn rte 'DOTAL:
Lenders Address IOIAI:
- i BUILDING TEL!
Ic thatnlylh clth:application asst that 'h c'nt, n t . :; ) -'r{ /�
career.I Tigiven,comply with 11 any Tend county thisfirmser.ana.,am Iium,in Qfyl I t' t MECHANICAL PERMIT' FEE SEISMIC FEE
V Z nti ld' g nxwcl nn,uad herabyatthmi,emp t.ivs tltti:city t�sntc—lu 'he
ahave.memioned progeny for inspection puryu
os. '.PERMIT ISSUANCE(We)mgma In anus,indemnify and keep harmless the Cityof Cupcnino against ELECTRIC FEff
T X01
Iiabilitics,judgments,costs and expenses which soy in any way accrue against said City ALTER OR ADI)TO M ECI I. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING ONI'I'Ll,Id,R,)CPM)
_ SOI1Rryta'���ECULATI 1 - MIiCHANICA1.PEli
✓� i / /. /j)/y AIH HANDLING UNI'1'(OVI!R I(I,1N111 CPM1 CONS'IRUCfION'1'AX
Signumm of AppliconVCo rneemr G••y`/•t f Too,) / EXHAUSTHOOD(WIDUC'O HOUSING M I'I'IGRI'ION[TEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe.,dwum mfntreMolding oocupam.more or handle hazardousmmulul DEALING UNI T'(TO I(XkIXXI BTU)
as dellned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
-- Cale,Sutinn 25532c)1 HEA'L'ING UNIT(OVER 100,010111'rLD
Yes ED No
VF.NI'II.AI'ION PAN(SINGLE NESID) PAID Dote Receipts
Will the applicant or future building occupant use equipmetn or devices which BOILER-COMP UHPOR 100,00 BTU)
emil hcaunioua air cmnuminunts us defined by the Be,Arco Air Qmlhy Management' TOTAL
District? BOILER-COMP(OVER 100,0110 BTU)'
�-� ❑Yea ❑No
I have read the lou nrdous material%requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
farnia Health&Safety Code,Sections 25505,8533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.F1'.
building Jtro,nnl commit y base.Room,Iho it katy responsihllay to notify lhccecament
aft iivarian¢ ac exthe rad ti ofn Ce 1�TO,/J/u���f��'""
Owne,mauthon,vdagent 99 Data T(ITA h: ISSUED BY.
OFFICE