31171 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOd I UILDING-ELECTRICAL .RMI'r No
,..BUILDING DIVISION ,.x$�470APPLICATION/PERMIT PLUMBING-MECHANICALz. 31171
BUILDING PROJECT IDENTIFICATION
DDRESS 1 pp��L �� SANITARYO.NAPI LICATIDN SUBMITTAL.Lim
OWNER'S NAME _ PHONE: ACI ORS NAME - LIC NO:'Movil
- NIC
CON'I'ROI.x
CHf1'ECTIENGINEHR: LIC 'SS: � q )
t E SSmG � G O'I Z(o!v vrVV
CONTACT:L( `•�I(TI P�SNtE: BUILDING PERMIT INFO
J11� 113 Consultant Fees Paid by Applicant(Initial) ` B�jJ�[I I•N ELECT PLUMB MF:CH
F) SSq- 2n Z2 / `
LICENSED CONTRACTORS DECLARATIONQTY ELECTRIC PERMIT FEE x 41I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Sectinn]IXNp of Divisinnlnfthe Business and Pr.fesxinns Cade,and my)teen>e is
OO in full buce and effect. PERMIT ISSUANCE, IDENTIAL
GF U U License ChowsLic.p WL C1 KITCHEN REMODEL
NzW Dae Cameron APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
A RCH i'I I?CI'S DECLA RATION ❑MULT-UNIT ❑SI'RUCfURAL
z0a,z Iunderstand my phim,hall be used as Public immol PANELS MODIFICATION
OZ—O UPTO200AMIS ❑INTERIOR ❑CHIMN17Y REPAIR
F.E'W Licensed Professional 2111-I(NNIAMI'S IMPROVEMENT
aa'CC� OWNER-BUILDER DECLARATION OVER IIXpAMPS CI BATH REMODEUREPAIR FI DEMOLITION
yy �Q 1 hereby affirm that 1 am exempt form the Common"'License Law for the
pe 3 d F 11,11—in,reason.(Section 7031.5.Business and Professions Code Any city or....mySIGNS BLBCIRICAI, C1 OTHER
YY11 u.y which requires o permit to emi,ma al¢r,improve,demolish.or repair any swctum a
,F[,4to prior in its issuance.also requires the applicant for such permiuo file a signed Sentiment SPECIAL CIRCUIT/M ISC.
sssss �.� to.'heisliceaalporan,1.ehepnrvmmnudeh.Cnntracmr'sLienselaw(Chnprsr9 REP 0 6 2( 01
S/-OWL
CC OO fcommencin6 with S«'ion l0olq of Division3ofine Business and Prnlbssi...Code)no TEMP.METER OR PULE INST, COMMERCIAL
1qx c C 'hal he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Way Section703 L5 by any applicanl tin.perunt suhiecte the applicantto a.ivilpmwlry of POWER DEVICES R1 III I ENANT ❑FOOD SERVICE
'more than five hanJ¢d dollars($50().
~ C ❑I,as owner of the pmpcny.or my cmpinyeeswithwages¢s theirsole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the smamm is not intended or offered for sale(Sce 7044,tlusiness ❑OTHER
W and Probes....Ede:The Contractors License law does nm apply m an owner of OU'rLEI'S-SWITCHES-PINT'GRES
6 3^ properly who builds or improves thereon,and who docs.such work himself or through
his awn employees,provided that such Improvcmcros am not intended or offered for NEW RESIDENTIAL ELECTR SQEf
sale.If,however.me building or improvement is sold within one yew of completion.the SQ.FT FLOOR AREA $/SQ,FII
owner-builder will have the burden of proving that he did not build or improve for par- •�y �T
cofsaleJ. _ I 1 •1 �/ 5 19 �J•�
I,its owner of the pmpehy,am exclusively mwrnw
noong with licensed ncom,u' �II441 W�
o.memn the project(Seo.7044.Raine.,and Prnresxi...Coal The Camrvcmr',Li- Z Cif Q 2 ".� •
ceou Low does not apply to an owner of property who builds or improves do,mo,and QTY. PLUMBING PERMIT FEE
ismeomracest ch pmjecrs withuttsmramortsl licence)pursuantmme Conuacior'n
❑ Ire a in , crS ,B&P C for tbleresun PERMIT ISSUAN
Dam ALTER-DRAIN -V"I'-WN ' (EA) VALUATION
W RKER'S ( PE ION ECLARATION BACK FLOW PR TE ICE
1jelIhemny affirm under Panaltyo(Purjuryone the followingdeclaceeion \O O Ox
O l have and will mountain aCenifica,ofCamsenttowlbinmm for WorkersCompcn DRAINS-FLOOR.R AN STORIES TYPE CONSTRUCTION
saran,as provided for by Section 3700 of the labor Cade,for the performance or the
work for which'his permit is issued FIXTURES-Plitt TRAP
1 have and will maintain Workers Compensation Insurance,a required by Section
37W orthe Latin Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTL I I txy�C.GROUP APN
My Workers Conspenrnnm
sa'ion lmacarrier end Policy needier are: rt(.- I 1
Cartier: Policy No.: GAS-G.SYSTEM-OVER 4(EA), I1I(n�'' ?0—/O—
CERTIIICATEOFEXEMPTION FROM WORKERS' II V�
COMPHNSAI'ION INSURANCE GREASIYINDUSTRL WASTE INTERCEPT
('Ibis section need not be completed ifthe permit is for one hundred dollars 1$100 ) UI V ISIfIN PI9iS
or less.) GREASE TRAP ),I71j.ON
CK �
certify thm in the perfnnnance of the work for which Chic pcnuil is:seal,l shall -anot employ any perm.in any hemmer so as m section,subject mine Worker Compen- SEWER-SANITARY-STORM P,A.201 FEZ Seton lawsofCaliferaw.Date WATER HEATER W/VENT/ELECIR'��--
Z O Applic.mIN FEE
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEM?RWING
become subjectto the Workers Compensation provisions of the labor Code,you mus' FEE
Iirlovahemnplywith,nch,ro,i i.,u,dr,Permh doill be dimmed rxvcdcd. WXIFk SERVICE
a �
CONSTRUCTION LF.NDINGAGENCY NEW RESIDENIAL PLMB. SQ,FC PACO
U O Inm.ny ammh the,retire ixawnwae.n lmmhng ag.mmy for the perrtinnnmme ar otic Nemdpta
D. '•' the work far which ark permit is i...ed(Sec.3091.Civ.C.)
O L) Lenders Name TOTAL:
W Isndmr'a AJdrexs T I f.:'
CL 1 cenify that I have read this app)icaeion and state that the above information is BUILDING FEEAFE
correct)agree to comply withal)city and county ondinanca and state laws relating to QTY. MECHANICAL PERMIT FEE buildingeonstruction,and hereby aahorim repmsenwtives ofthis city m enter nPw the SEISMIC FEF,above-mentionedpropertyfminspectionpurposes. PERMIT'ISSUANCE(W'e)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iifbilon.,.judgmenO.coaswd cxlwnsere which may many way.c,r.e againn.mid City ALTER OR ADD TO MECH.in consequence of the gmntng of this Perrin. PLUMBING I>EE
APPLICA UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,000 CFM) MC:CHANICAL FEI3R: AIR HANDLING UNIT(OVER 10AX)CPM) CONS'rRUCr10N TAXSi w er p ommcmr Ila. EXHAUST HOLD(W/DUCIIf10USING MITIGATIONHAZARDOUS MAI'IiRI .S UISCLOSURF, Sol
Will theapplicznlorfuture building emulator sm¢ur handle haaNtia.material HEATING UNIT(TO 100.00p BTU)
as ddincd by the Cupenino Municipal Gale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER I(X),11IX1 BTU)
❑Yes Fl No s/��,...y�LLc� VENTILATION PAN(S INGLE NESID) PAID
Will thea heart or future bulldm 'use. a fA14T1¢x which
Dole Receipt x
emit Rwandans a�anmitments as defined by the Ama Air n BOILER-COMPOHP OR IW,000 BTU)
e Diwric'l Y Y Mir Quality Management TOTAL:
[DYet F-1 No � BOILER-COMP(OVER I Oblast BTU) r,
q
AIR CONDITIONER
I have read the hwaNnus materials requiremcntx under Chapter 6.95 oft' ISSUANCE DATE
.in][ It &Safety Chile,Secti15505,25533 and 25534.1malerstandmmt elm NEWRESIDENTIALMECH. SQ.IT.ter 'F nmcmremny have a' era it is my re.pon.mifity to notify me recupant
rteinrmissmncc afaCenificutc of Occupancy.
,.,.at wou gem Date 1-. till I ISSUED BY:
OFFICE