99090121III APPLECANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPH RTINO BUHI):NC - F-LECI'RICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUM1IRINC MECHANICAL
BUILDING. PROJECT IDENTIFICATION
PERMIT NO.
BUILDING ADDRESS: \ , 1
tl
SANITARY N(l.
APPLICATION SUBMITTAL DATE
9-2049
WE @'S NAME: PHON is
CO M1 R R'S NA IE: LIC NO:
NIC
❑
CONTROLp
RCH ITEC'TI! GIN ,, LIC NO:
-S':
2&Wn CC 61,c
CONTACT : PHONE:
, `_ t' 1
J, `-t
❑Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELhCj7 PLUMB MECFI
zf-
LICCENSED`CON'I'RACfOR'S 1`ECLARA'I]ON
I hereby amrin that 1 am licensed under provision, of Chapter 9 (commenlmg
QTY ELECTRIC PERMIT PEE
JOB DESCRIPTION
/ PERMIT ISSUANCE
with Section gap) of Division 3 of the Business and l'rofvsions Code. and my license is
in full force an feet
RESIDENTIAL:
❑SFDWL KITCHIiN REMODEL
APPLIANCES-RCSIDENTIAL
I.iccns Class Lic.tlil
Dae L"'at mtr
ARC[ fTLCI"5 DI?ChARAT10
1 understand my plan. smell be used as ohlo, records
❑ADDITION El PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
PANELS
UP TO 200 AMPS
Licensed Professional
2061000AMPS
OWNER-RUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following moon. (Section 7031.5, nosiness and Prnlcssions Coral: Any city or county
❑ BATH REMODF.DRupAIR ❑DEMOLITION
❑ OTHER
OVER IWOAMPS
SIGNS ELECTRICAL
which requires it permit to construct, nitem improve, demolish, or repair any structure
SPECIAL CIRCUIGh
pri.r its isw:mec, aGo acquires he applicant forsuch permit to rlcesigneJ zmtennent
that he is licensed pursuant o the provisions of the Contractor's License laav, (Chapter 9
(commencing with Section]1XXp of Division 3nf the Easiness and Professions C.de)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
TEMP. MITER OR �
/A N ❑ DEMOLITION
Section ](31.5 by any applicant for a Permit subjects the applicant to a civil penalty of
POWER DEVICESElFOOD
SERVICE
rn mom Inc. five hundred dollars 15500).
❑Lionwnerofthe pm,ry,nriny employees with wages ax theirmle mmpeneution,
SWIMMING POOL ELECT IC
SEE
will do the work, and the suucturc is not intended or offered for sale Ilea ]FFM, Business
and Professions Cade: The Contractor's License law does not opply to an owner of
OUTLITS-SWITCHES-
NEW RM1DENTLA R
)R
LSQ. FT'
propcny who builds or improves thereon, and who does such work himself or thrnugl
his own employees, provided that such impoocart tx me not intended or offered for
sale. If, however, building ori^Wmvement is sold within one year ofcomplelion.the
er-hander will have the bnnlrn of proving that he did not huild or Impooe for pur-
p su of salu.L
I. as owner of the property, ant exclusively contracting with licensed contractors In
'TOTAL:
consam u the project (Sec. WFW, nosiness and Professions Cade:) The Contractors
cerise
QTY PLUMBING PERMIT FEE
who contracts for such protects with a cmnraaor(s) licensed pursuant to the Comrietor's
PERMITISSUANCE
License Law.
❑ Ism uxcn,d under site .B& 1' C for this natant
ALTER - DRAIN & VENT- WATER (EA)
Data
VALUATION
2 2 -
n
WORKER'S COM1IPENSATION DECLARATION
BACK ICON' PROTECT. DEVICE
1 hereby affirm under pcnAty of perjury one of the folhrving declarations.
❑ l have and will maintain a Certificate of Covennoself-inure for Workers Cmnpcn-
sation, its provided for by Section 3701 of the Lahor Code, for the pafmmnote of the
work for which this permit is iaucd.
DRAINS- FLUOR, ROOF. AREA, COND.
STORIES TYPE CONSTRUCTION
FIXTURES - PFRTRAP
1 have and will maintain Wnrker'.a Compcvati.n Insurance, as required by Section
3700.1' the labor Code. for the parfmarmareof the work for which this Permit is issued.
by Worker's Compensation Insurance carrier and Policy number art:
Camey: Policy No.:
OCC. GROUP J,,iC-y ^PN
v V a—
GAS - EA. SYSTEM -1 INC. J OUTLETS
GAS -EA SYSTEM -OVER 4 HIM
CERTINCA1'1: 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRIiASI%INUU59'Rh WASTE INIERCEI'IOR
:BUILDING DIVISION FBIS
(Thlss,ef Onacdom ecompined ifthcpcnnil is fc,mathoodredd.11-00n))
or less.)
CREASE 'IRAP
Ir, I.
FI,ANCHGI !•EEN U 1 1 i
t
SEW12R- SANITARY -STORM EA. 200 IT. `1
t
aEVO'IERGY ItE II
eofthewort c this permit is issueJ,lshall
1«r1i(y thQP
not employ any pcs as to ccuo th< Workers' Compen-
amine laws I u
WATER III?AIERW/VLNVEELECTN
`4 V 190'9 IJ
Applia:mt
GRADIN(`PEE
6Dl'ICE' 'emrcate nl Exrnt lion, you shnulJ P
subject toae pro sof the LeMnCale,youmust
WATER SYS'TF,M/fREAI'INCbecome
0SOILS PEEforthwith
comply nsor,hixpermitshallbedeemWmvoked.
WATER SERVICE
1
NEW RESIDENTIAL PLMB. SQ. ET.
CONS'IHUCTION LENDING AGENCY
Iherchyunion thatm. o,otramaiian lending agency llrnhu perfnrman«of
PAID --�—�—
-'"-'-Dote Receipt#
N TOTAL:
m. work 1'o, which or, penal is issued (Ser. 3097. Civ. CJ
Lender's Name
TOTAL:
Lenders AJdieex
BUILDING FEE
1 ccnify that I have read this application and state that the above information is
correct. i agree to comply with all city and county ordinances and state laws relating to
building eonstruction,'anti herchy mflu rise representatives of this city intoner upon the
QTY MECHANICAL PERMIT FEE
SF,ISMIC FEE
ISSUANCE(We)
ELECTRIC PEG
ob.vcmcallnned pmTroy for inxpcnion purpnsos.PHRMI'I'
agree to mvc, orientally and keep harmless the City of Cupertino against
ALTER OR ADDTO MECH.
PLUMBING F[E
Iiabilities.judgmen¢costs and expenses which may in any way accrue against said City
APPLICANTWITH ALL NON -POINT
RI :. A
in nsequcnce M;e
AIR HANDLING UNIT 0T010.000CFM)MECHANICALSOURCE
AIR HANDLING UNI '1'(OVER IQOa) CFM)
CONS' 1' RUC' TION TAX
19
Signature
EXHAUSTLOGO1 W/DUCT)
HOUSING MITIGATION PEE
rR1A1 S DISCLOSURE
HEATING UNIT (TO 1011.000 BTU)
W11 th applicant orfuture Paildmg.acupant xtoreorhandle hazalloux material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safe',
Cale. Seen 1255321x1'!
HEATING UNIT (OVER 10),001 BTU)
VEN'TILATIONPAN(SINGLERESID)
[:1 Yes [-1 No
PAID
Date ReceiptN
BOILI;R-COMPCHPOR E00.1100BTU)
Will the applicant or future building occupant use equipment or devices which
..it herabi air contanitions as defined by the Say Area Air Quality Alarmgement
TOTAL ,
BOILER-COMP(OVER 110.000BTU)
Dotrn,7
❑Yes C] No
AI It CONDITIONER
I have read It an" namcrods requirements under Chapter 6,95 of me Cali
'
ISSUANCE DATEfomia
NEW RP_SIDENTIAL MUCH. SQ. ET.
Llcahh & a cry S«tinns 25505, 25533 and 25534.1 aNcrssand that if the
.pmisibilirymnwilythevoripant
buildingmesn carentl3 a .mean in res
Yom- Z_
of thereyuire is w0us se p' to an nfaCe'au¢o (X<u n
1
ISSUED flY',
TO TAI:
d age Tie
OFFICE