S 1947 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICAL Pli IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1947
BUILDING PROJECT IDF.NfIFICAI'ION
BUIL06I 3RSSs "r 1 � SANi"fARY NO. APPLICATION SUBMI'ITAL DATE
^V^V_11kD�//-����JJ `-/p1``7 `CIIc1/✓_l)C`Yrr] � - 3 0R 9
OWN NAME./ PHONE: CONoffec I' ALPO 'S NAM^ C O'
V � w NIC CON'IHOLp
.• ARCHITECT/ENGINEER: LIC NO: At) 3 w ❑
CONI' T: PHONE: (�'J BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BO ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTy, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby ofGrmt that I ten licensed under provisions of Chapter 9(commmncing
OMZ with Section of Division 3 of the Business and Professions Code.en no,he eaf, RESIDENTIAL,
WO, PERMIT'ISSUANCE
FSO in full force and eR _ C. OSFDWL ❑KITCHEN REMODEL
aU� License Class Lice a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
Q z ul Date ContmCmr
64 ❑MULTI-UNIT []STRUCTURAL❑m ARPANELS
z Ofz�z I understand my plain shall be used an public records UP T02W AMPS MODIFICATION
CHIT[CI'S DF,CLA ION
OZ—� ❑INTERIOR ❑CHIMNEY REPAIR
Q`-,1qq'LLl Licensed Profesaionai - 201-100TAMPS IMPROVEMENT E)SWIMMING POOLS
C�Z-4 OWNER-BUILDER DECLARATIONOVER IIXNIAMT'S
06 ❑BATH REMODEUREPAIR [I DEMOLITION
C W< I hereby of ren that 1 am exempt from the Cnmmctar's License Law for the
�y( U fallowing reason.(Section]031.5,Business and Professions Gale:Any city or county SIGNS HLECTRICAL [I OTHER
Yl a 4-y
which r 9 p t u c ro Ito p demolish, rep y structure ------yyy
O� poort t iso 1 req Napplicantf such Permit fl signed wtemenl SPECIAL CIRCUITMISC.
f`to 'hath licensedp tt thep fo Contractor's L L (Chapter 1) r
W (eenmencltg with Swuon]INNhrf Division.1 ofthe Business unit Profecx'om Code)(it TEMP.MEEIR OR POLE INS'f. COMMERCIAL,
kco C dot he is exempt IhereRnm and Ne basis for the alleged exemption.Any violation of ❑NEW RLDGIADDITION ❑DEMOLITION
W-^t,•LLN• Section 7031.5 by any applicant for a permit subjects the applicant m a civil pewlty of POWER DEVICES El TENANT ❑FOOD SERVICE
=o .,it mare than five hundred dollars(S5Nh. IMPROVEMENT
pt,as owner of the props or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
h will Jo the work,and the structure is not intended or offered for sale(Sce,7014.Business ❑OTHER
W �
and Professions Code:The Commom,License Luw does nut apply m an owner of OUTLETS-SWITCHES-PIX'fURF_S
n
tY pmpeny who builds of improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECPR FT.
sale.If however,the Imidingor improem
vent is sold withinum,yea tifmmpled.n.the SQ.Ff.FLOOR AREA b/SQ.IT
owner-builder will have the burden of proving that he did not build or improve for pur-
se of sala).
Fl1,.owner it the pmpeny,am exclusively contracting with licensed contractors o TOTAL:
constma the project(Sec.]Did.Business and Professions CMM:)The Contractors Li-
cause Low does not apply to an owner of property who builds or Improves thereon,and QTY, PLUMBING PER. IT FEE
who contmets for such projects with a vontmcmr(s)licensed pursuanl m the Commetor'.s
License Low. PERMIT ISSUANCE
F7 I um exmnpt under Sec. ,B&1'C By this.,on
ALTER-DRAIN&VENT-WATER(13A) - VALUATION
Owner DateIs
• Wm under P COM PLNSurry on DECLARATION BACK FLOW PROI'fiCT.DEVICE
1 hereby affirm under Penalty Certificate
one of the following tied er's Co:
❑ Ihave and will birth,Sv fiou37M.fmc I.unmself-infor,he Workers Cooper. DRAINS-BOOR,ROUE AREA,COND. STORIES TYPE CONSTRUCTION
action,as provided fin by Section 41811 of thu LaM1nr Code,for the perfnrmonea of Thu
work for which this permit is issued. FIXTURES-PER TRAP `
Fl 1 have and will maintain Workers Coopeasatimihe
work
eo,as required i i Section
3]IN)of the Lahnr GrJe,for the perlirrmnnce ml the work for which this permit is iaaueJ. GAS-EA.SYSTEM-I INC.4OUTLETS31 A (]CC.GROUT' APN
My Worker's Compensation Insurance canter and Policy nmidWc are:
Cameo Policy Na: GAS-EA.SYSTEM-OVER 4(G)
CIiROFICA'IT,,OP EXEM PTION FROM WORKERSGREASEANDUSTRLWA$THINTERCB I kl Vi'LI'1
COMPENSATION INSURANCE BUILDING DIVISION PEWS
or It,,,.)(This section need not Wcompleted lfthe permit is forme Inhibited dollars(SIM) GREASP,TRAP PLANCIIECK FEL ,
I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2M FT.
nm em Io n non in a soar sn as t c 'kers'Com ENERGY FEE
p y u y pe y my 9q lac 116Wo pcn-
0 Z moonant. rniu(ZJ4- l� `( 2S WATER HEA'I'IiR WIVENT/1].IiCfR GRADING PLIi
7Zr 0 Applicant ' edf,'r1 ANT:I
F" y NOTICE TO APPLICANT:CANT:IL after m king this Certificate of Exemption,you should WATER SVSTIiMRRLATING /� SOILS FEE
1a' haeme subjecttothe Worker's Compcnsuhispor provisions hal ol"the Lobar Code,you moot v
forthwith comply with such Transitions.,his permit shall he Jecmed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,ET. PID
L)z Ihereby unn that de.is a conmmction lending ma
agency for the performance
of .1-: AD/ Rcreiplp
ffi
F Inc w lifor which this permit is issued(Sec.3097.Civ.C.) "/ 1`
TOTAL:
O U Lender' L
Lenders Name
Lenders Address O`'V AA,,......
C1 verify that I have read this application and ainto that the above infmmution is '- B Llreat,rfJi
VA cnnect.l agree m comply with all city and county rtdimseces and swat laws relating m QTY. MECHANICAL PERMITJ EPEE•
V Z building construction,and hereby audiencerepresentutives of this city m enter upon the C ] SEISh11C FLli
ahove-mentioned pmpeny for inspection Palo.. PERMIT ISSUANCE vDECfjtIC FIiF.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way weruc against said City ALTER OR ADD TO MECH. L/f1M�TNG FEB•.,
inttmsequence nl the 6r;uttlng of tbpiyAIR HANDLING UNIf(TO RI,00007M) MECHANICAL FEEAPPLICANT U ' I L COMPLY WITH ALL NON-POINT
SOUR LAT N
C\ AIR HANDLING UNIT(OVER 1403I CFM) CONS'fRUCITON TAX
Si nater fApPc mu nA Date EXHAUST HOOD W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or more building occupant store or handle hmardons material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 45532(x)' HEATING UNIT(OVER IIXk00)BTU)
❑Yes 0 N tBOILER-COMPTHPOR
FA
N(SINGLE ) PAID
Date Receipr e
•
Will the applicant or future building occupant use euuipment or devices which TU)emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTALDisvicft U)Yea, ❑No1have read the hazardous matenaRrquirements under Chapter695 ofthe Cnli- I$ EDATTE
loran Health&Safey CnJe,Sections255115,2553)and 25534.1 understand that'dthe SQ.FP.
huildingJms ten currcndy huveotenan',drat it is my respansibiliy mnodfy lheuttupam '-T/ --�a�9
of the rcquircmen¢which mum rte met pnnnoissmnm ofa Cenifcme of Occupancy.
66 nn ([>
Ownermsfulanzed agent Date A ISSUED BY rr
OFFICE