S0001 B0380r 1^A "ITT"' cD I ru LNctlChn ATEl1N WITHIN aleft I INFA . IICF BALL POINT PEN ONLY
.... �........ .�..��.._.... _........ _..�`f
CITY OF-CUPERTINO BUILDING. ELECTRICAL
. BUILDING, DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDEN'LTF'ICA'1'10N
}orf
PERMIT NO. O wJ V O
SOOOI1
BUILDING ADDRESS
-79S. SUWVES2LAND �Rti./E, CJPeR?IN0
SANITARYN
APPLICKH INSUBMI'PI'ALDAT
r i1i
W I�A4MI K►RTt�Np PI�Or,� �13�
CONTRACTORS NAME: LIC NO',
N/C
❑
CONTROL
ARCIII FECI/RNGINEER: LIC NO:
ADDRESS:
CON 'FACT. PHONE,
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BhDG ELECI PLUMB MECU
LICENSED CONIRAC 'FOR :S DECLARATION
I hereby affirms ma 1 am ns licensed under provisbof Chapter, v (comencnaing
with Scclio 1701XBof Division 3ol the Business:mJ Professions Cvdc'mal my lkemei s
in lull force and effort.
QTY ELECTRIC PER M IT FEB
JOB DESCRIPTION
I SIDFNTIAI:
OSFDWL O KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES-RFSIDEN'1'[A].
PANELS
UP TO 200 AMPS
License Class Lic.A
Y Dae Contractor
ARCH) 1'ECTS DECLARATION
.. I understand my plans shall he used as public recools
[]ADDITION 01'LUMBING RF. -PIPE
GMDI,TI-UNIT 05'1'RUCfUkAL
MODH;ICA1'ION
�INTI3RIOR OGHIM1INEY REPAIR
/SIM I'ROVEMEN' GSWIMMING POOLS
❑ RATH REMODHUREPAIR GDI3MDLITIQN
❑ OTHER
p Licensed Professional
OWNER -BUILDER DECLARATION
S 1 hereby oRtm that I am exempt from the Contractor's License Law for the
following reason. 70315. Business and Professions Code: Any city or county
201-1000AMPS
OVER fn0AMPS
SIGNS ELECTRICAL
which requires a permit to conslmd alta, improve, demolish, or repair any .welme
file a signed statement
prior to also requires the. applicant for such pemtinm
Lha be is license, pmomm tome pmvrunasinine Conan nr s License Ltw' (Chapter 9
Iemtnuencing with Section 9(XX)) of Division 3 ofthc Rosiness and Professions Code) or
Y that he is exempt therefrom and the basis for the alleged exemption. Any violation OI
nSecann7031S by any applicant for a permit subjects the applicant to a civil peexlyof
SPECIAL CIRCUIT/MISe C.
TEMP. MITER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION CI DEMOLITION
0117NANT 0FOOD SERVICE
POWER DEVICES
of mom than Eve hundred dollars ($500)
01, as owner of the property. or my employees with wages as their sale compensation.
will dothe work, and the structure Is not intended m ollemd for sale (Sec. 7144, Bminc s
n and Professions Ode: The Contractors License law don not apply to an mvnce Of
IMPROVEMENT
❑ OTf{I3R
SWIMMING POOL ELECFRIG
OUTLETS-$WITCIIIi.S-19%l'U _
NEW RESIDENTIAL ELITUR
property who huilds Or improves darecon, sad wha docs such work hinoollnr through
his own employes, provided that such improvements am not intended or oRered for
wle�'.however, he huildmg or itepmvemem is sold within one year of completion, the
n -builder will have the harden of proving that he did not build or improve for ped
SQ. Pr. FLOOR AREA &SQ. 17r.
'1'(yrA ..
I, ofvule,).
r of the progeny, am exclusively contracting wiN licenwd c nimcmrs to
cansauci the prject ISce. 7144. Itasincss and Pofcssiom Code'.) The Convector's la
e mLaw does not apply to an owner of property who builds or improves thereon.and
who contracts for Inch polecats with u convncmgs) licensed pursuant to the Contractors
��E
8
Fns�s [`1
6661 Z - Inr
QTY. PLUMBING PERMIT FE
PERMIT ISSUANCE
License Low.
0 Inst a cm In der 'e . . R & PC for this reason
a Dae
VAh11'1
ALTER -DRAIN &V13N1'-WAI'13R IIIA)
WORKER'S C(IMPENSA'1'[ON DE ARATION
BACK FLOW IROI'ECT. DEVICE
_
1 hereby affirm under penally of perjury one of the following declaration
�lhavcamdwillm.intelnaCenificumnf ConsemtnselI lasurclor Workees Canpcn-
sation, as provided for by Section 37!X1 of the Labor Cale, for the performance of the
work for which This permit is issued
Fl I hove and will maintain WmAcrs Compensation Insurance, as reyvired by Seaton
371X1 UI the lsMn Cale.linlhe perlinmarsec of the work lin which tM1is permit i...... J,
DRAINS- FLOOR. ROOEAREA,COND'
STORIES
OCC GROUP
'1'YPI3 CONSTRUCHO
f'�/n'S�
F••
FUTURES - PER '1'RAP
GAS - EA. SYSTEM -I INCA OUTLlI'S
GAS-I3A. SYSTEM -OVER 4113A)
My Worker's Compensation Insurance carrier and Policy number ate:
C'arrief: Policy No.:
CERIIRCATE OF E%EMPITON FROM WORKERS
COMPENSATION INSURANCE
JA�
ry
GRFASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GRE)OIETRAI'
1'LANCHECK FI31i
(Thlssection need nm be completed if the permit is for one hamlrcd dollars ($100)
ns.)
on,eshelf
Loy That in Performance her for orbiretch o permit isissued.
nm cntpiny any person In any mmrner sn as to bemsmc mh,lcn w the Workers' Canpcn-
Z cation Laws If Califomia. Date
)
SEWER - SAN ITARY-S'FORh1 EA. 200 Isl'.
ENERGY Bili
WATER BEA'1'I?R W/VENT/ELECIR
GRADING PEE
Appheam
NOTICE TO APPLICANT: IL alter making this Ccaricam of Exemption, you should
become subject tome WOrkcrs Compcnsction provisions 0f the Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed revoked
WAFER SYSTI M/I REAPING
SOILS PEE
WATER SERVICE
.�.
a CONSTRUCTION LENDING AGENCY
.J I herchyaffnn that hem in a construction lending agency for the performance of
the work fee which this wrmit is issued (See 300. Co. C)
PAID
Dote He ipl M
I OTA1:
N13W RESIDENTIAL PLMB. SQ. Pr.
Lender's Name
U
LLl ladders Address
I certify that 1 have read this application and s,am that the above information is
ysdect. l agree to comply with all city and county ordinances and state laws edaingm
th
Z building cocoaraction. and hereby aaerize representatives of this city to enter upon v
TOTAL:
BUILDING Irfil:
QTY. MECHANICAL. PERMIT FEE
S171SN11C FEE
above-nrentioned sepedy lin inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino agains
Iiabiblin.judgmenu, costs and expenses which may in:my way accrue against said CitADD
11ANCli
TO MECH.
ELECTRIC Rif!
PLUMBING FEE
I. m,moce of the gr ming of Nis permit.
APPLICAN'1'UNDFRS"NDS AND WILL COMPLY WITH ALL NON-I'OININGUNIT
LTO 111,00(1 CPM)
MECHANICAL'!SOURCE
PPP///ICU[ TIO�
MUNIT
LING UNIT(OVER IBIXp CFM)
CONS' 1'RUCFIONI2/4HOOD(WMUCIG
MATERIAL S DISCLOSURE
WiIIIM upplicam nrfumre boilJingrccupan score nrhundlehamNous mu¢daNITf1T)1UL0IX113TU)as defined by the Cupenl— Municipal Code. Chapter 9.12, and the Heallh and SafetHGTING
Ode, Sa no 25532(x)'!
HOUSING MITIGATIO 1113HAZARDOUS
UNIT LOVER IIXI,IXX) RTU)
VENTILATION PAN (SINGLE RF,SIID
❑Yes n, No
PAID -
Date Rcc I B
Will the applicant or future bmidne,ovcmpaml ane cyei,ormor device., which
mit hazardous air commainana as defined by the Bay Area Air Quality Management
BOILER -COMP LHP OR IX).(XXt BTU)
'I OI'AI..
BOILER -COMP(OVLIR 1110,1X10 It IU)
District'
GYw 0Nn
AIRCONDRIONER
ISSUANCE DATIi
1 have read the Beams us materials "turco ani under Chapter 6.95 of the Cali-
NEW RESIDENf1At. MECH. SQ. IT,
fomiu Health & Salvay Code. Sections 25505, 25533 and 25534.1 ar derstgnd thus if the
but ccs not urrcm have. tenant. that it is my s nsihility t0 notify theaecti'm
Of-iit areh'
e i beR:rI I�,,G/VQ
nta Lssaaa:, tCcniE�`1
IA [ 1
TOTAL:
ISSUEDBY,
0 1 rm authenzcvon D—T, o
OFFICE