99170101 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CJ
CITY OF CUPERTINO BUILDING-KLECFRIL'AL ERA 11
BUILDING DIVISION APPLICATIONIPERMIT PLUMPING-MECHANICAL.
BUILDING PROJF,f.T Fill IF'ICA'L'ION
SANT IARY NO. nl'PLICAI'ION SUIt M1tI FTA(,DAT
x1111.DING ADDRESS:
20 31 �* 64(G05 60MT
NAME: PHONE: CO C ( F LIC NO:
NIC CONTROL 9
Al C IIT Ii. /lied �INCI: LIC NO: �UURESS: ❑ 7
NO L� c —
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MCCH
EE!r
LICENSED CON'TRACI OR'S DECLAHA'IION QTY. ELECTRIC PERMIT FEE' JOB DESCRIPTION
1 hereby mTn t Nen l am licensed under provisions of Chapter 9(commencing
with Section 7AXB of Division3 ofdc Business and Professions Code.and my license is RF-ID
W p I`fiRMIT ISSUANCE
ENTIAL
FW� in toll tinea and ettcct. ❑SFDWI. CD KITCHEN REMODEL�
aUU Lmcnsc Class Lia# APPLIANCLS-RESIDENT'[Al. UIl'ION ❑PLUMBING RE-PIPE
Has Doc Conlractof ❑MULTI-UNIT Ll STRUCTURAL
ARCIIITEC1-S DECLARATION PANELS MODIFICATION
zo�z I undenWnd my plans shall he used as public records
Oil 1'021XIAMPS
[D INTERIOR ❑CHIMNEY R1711AIR
Licensed Pro2s.saurd 201-I000AMPS IMPROVEMENT C)SWIMMING POOLS
OWNER BUILDER DECLARA'DON OVI7R 1000 AMPS ❑PATH REMODEL/REPAIR [I DEMOLITION
C C Q I hemby amt am flidol I exemptn
from Ice C-ater'.,License Law lis the
LU following reason.(Section 9031.5.Business and Pnd'essdons Code:Any city or county SIGNS ELECTRICAL C3 OTHERLL13 W N which myuiax n permit Int umvlruct,oiler,iinprnve,demolish,or npur any xwclure
poor to its issuance,also requires Sy' lheepplicant for such Permian file a signed statement SPECIAL Cl RCU I'1'/M ISC.oy Nat he is licensed pursuannu the provismnx of de Commctne,License Law(Chapter 9 COMMERCIAL:
Irl�'��O Icununencivg wish Sedinn 70)(Eif Oi nio6 Jof the RmAnexsand Ponesvions Cale)in THAI P.MLT ER OR POLE(NAT
d d e c Nul he is t empt NereEam and the bails For the alleged excnlpBun.Any violation of NEW nhUG/AIJIJITION ❑OI!MOhI'UON
W^co Section 7031.5 by any applicant for a permitxuhjMts the applicant to a civil penalty of POWER DEVICES ❑TENANT' E3 FOOD SERVICE
of more than live hundred dollars($500), IMPROVEMENT
=Q Fl1,nxowncrof the propcny,or my employees wilt,wages as lluen sole clon,111mina. SWIMMING 11001.ELECTRIC
F. will do the work,and do eradum is no.imcnJeJ onslTcaJfor wle(See 704,1 Business ❑OTHIiR
3 m and Ihnfessin is Code:The Contractor's License Law does not uppty In an owner ofLC
OITI'LEI'S-SWITCHES-IlX'TURI!S
propcny who builds or improves thaw a,and who does such work himself or through
his own employees,provided that such improvements art nal intended or oficmd for NEW RESIDENTIAL,FLECI'R SQ IT.
wle.If.b^wcver,the building or improvementissssld within one year of completion,the SQ FT FLOOR nNIin S/SQ.IrI'.
ewher-buider will have the burden of proving that he did not build or improve For par- ) /^ !•s /
puce sale.). TOTAL: C•Ij S (ll(
r of the pmpcn,um cadusivdy cummcling with IicenuJ contraclars to
construct the project(Sec.9114,Business and Professions Code:)The Conuactnrs Li-
lawdoesnotapplytoanownerofpropertywhoan
buildsorlmprove,thereon. d QTY. PL MBI IHR IT FEF.
whoho contracts for such projects with a concessions)IicemeJ pursuant o the Contnuhar
4ccnw L.. PBRMIT ISSUANCE
❑Tum cxempl under Sec. ,It&PCI rthix cusp
ALTER-DRAIN&VENT-WATE VALUAf1ON
owner
Date
WORKER'S COMPENSAHON 1 ,'LARAIION BACK FI,OW PROIECL DEV
I hereby athmt under penalty of perjury nn f de following Jedan.ions: G�
(have avdwillmaimain a Cenifcaeof Consent In elf-inmas for Welon"Compen- DR R. AREA.CON ST(RIES 'TYPE CONSTRUCIIO
ration,as provided for by Section 37(0 of do La so,Code,for the perfmmmae of'be
work f or which this permit is issu.J. 19XI'UHliti-PI
I have and will mamain Wndce,Compensation lasamnce,as reympesd by Section GAS-EA.SYSTLM-I INC.S�1" IT.
37(OofNeLebo'Gcle,forlhe perfnrmnncc nfde wed for which Nis permit is issued OCC.CROUP (T-Aped-I
MyWsnkcrsCnmpcnwtion lnmrancc carie,and Policy mother arc GAS-135.SYSTEM. °H FA) 7 JQ
Carrier: Findley No.: -
CERHI'ICATEOFEXEMPTION FROMWORKERS' (1RF.ASO[NUUS"I'RLW ."T ER d'POR
COMI117NSATION INSURANCExI111,U1NC OI VISION('BER
(This seen.need non be csnnpldN if de permit is Rmsne hundred dollars Is IIXq GREASETRAP PEE
IECK I..i
or less.)
lay any lhelint he ped uronmc 1--1 as
which Nix penultisix'Cooper-hall SEWER-5ANIT'ARY-$'IUHIM EA.21N11'I'. I!NI3RGV PI3E
not employ any pctmn m any manner w us to become subject w'he Workers'Compen-
x cation laws of California.Dae WATER HEATER WNEN'T/CLECTR GRADING FEE
Z O Applicant 1
Z
r_N-s NOTICE TO APPLICANT:If,after making this Cenificale of Exemption,you should WATER SYS'I EM/TJU&NI INC
F" Monne suhject to the Worker's Compensation provision,of the Iall Coda you mus. SOILS FEE
Ci fordwlin emnply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a �
CONSTRUCTION(,ENDING AGENCY NEW RESIDENT IAL PLMH. SQ.17 I'AN -'
D a-�"�Rccc'pi A'
U� l hereby affirm that dere iso conxwction lending agency for the performance of i.\ t r,1
the work for which this Remain is issued(Sec.3097.Civ.C.) '1 , ��.=�� UI,HAI�
O U IsLender's Name T
fl
ndcrs AdJrc..s OTAL:
r Liz 1 eerily that I have read this app..cation and stem Nm the above inti nisminn is IIIJII:DING F13Ii
eorrsa.Iagmem comply withal.city and county ordinances and some laws mining to QTY. MECHANICAL PERMIT FEF Ib)LfI4Ml'
UZ nwwmga msnadinn.umd herobytmdndr.erepreem:nmcs of city to enter upon the
a'wc mentinnW pngrcry fur inspediun purpascX MW
UANCE E. C' PILE
(We)agree to save,indemnify and keep harmless the City W Cuperdo against
Iiabilicicsjudgments.costs and cxpcnue which may in any way accrac against said CityDD TO MECIL PLUMBINGNG FEE
nncyucncc of the grmting of Ibis�wrmit. s Irv- -_
'APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NONd'OIN'IING UNIT 110 RI,INX)CI'M) MEC(I AN(CAI.PT:13
SOURCE REGULATIONS, ING UNIT(OVER 111,1X0 CFAH
X612,4
/\ // CONSTRUCTION FAX
Signature,u(Appllaant/Coulnnn (r Date HOOD(W/DUCT) HOUSING ME IIGATION FEE
IIAZ ROOUS AIN FTRIAL.' ISCL(ISUREWill theupplicunl or fiumrc huildin6'xcupI nwmnr handle hmurdonx mu.onalNIT(TO IIbmd III IT
as defined by the Cupertino Municipal Com,Chvpar 9.12,and the Heald and Safety HEATING UNIT(OVER IW.B(K)BTU(
Cale,Section 25532(mV
[3 Yes C]No VENTILATION PAN(SINGLE RESID) PAID
Use Receipts
Will the applicant or future building occupant use equipment or devices which
BOILER_COMP UHP OR IIX),gU)
Xl BT
club Immmanateas
rdars sir......es defined by the[bay Arca Air Quality Munugcmcnl 'DOTAL:
District", BOILER-COM('(OVER IIX j X)R,U)
[2 Yea 0 N
A IR CON DI I'IIINER ISSUANC. TP
1 hit:read ice h edc.S s rams T5505quiaoa ra under Ch.,,,,I nder 95 tang but Cali- { n
Esmia Health K Safely Code.SectionsT5505,25533 255JJ and 255]].1 umlemasd Net if the NEW RESIDENTIAL M11[Cfi. SQ.FT.
Inl'mg docs notes rm.y hove u lca, A'et it is my reslmnsihi lyy//.c motif It upanl IIIAAA
of the rryuir Tn 'ch roue he coluCs fisfr2<Kcupancy.
Cif" rxu O'I�TjY7
Own uulh� iuA ngnm
Una TOTAL: ISSUED BY:
OFFICE