31112 (2) APP,LICANTTO FILL IN INFORMATION WITHIN:RED LINES-USE BALL POINT PEN ONLY r -
CITY OF CUPERTINO- • ` 'i - - BUILDING-ELECTRICAL a PERMIT NO..�a a .�
BUILDING DIVISION APPLICATIONIPERMIT, PLUMBING-MECHANICAL ... J{"111-2
1'sC�' I, BUILDING PROJECT IDENTIFICATION - -
-, ' BUILDIN;ADBESSph Lo�1IT r•� ,., r I - r SANITARY NO, APPLICATION SUBMITTAL DATE
I/ OWN22'SNBME:x ONTRACTORSN M LICN J
p, ►b O N/C �a CONTROLM
aRCHI CI'/ENGI E : LIC Is ADDRES
-. COrrrA/c—l'.:�; ;- HONE: - BUILDING PERMIT INFO
' 't/-... / Crinsultant Fees Paid by Applicant(Initial) _
Q/ BLDG ELECT PLUMB MECH
' X
LICENSE CONTRACTORS DECL A ION QTY. ELECTRIC PERMIT FEE
I hereby a81rm that I am licensed unde 11 p revisions of Chapter9( mmencing JOB DESCRIPTION
Cp withSection 7001 Di 3.f theBcarri 'd Prwfast"IEC de d ylicense's
[aypl in full force and of '' PERMITISSUANCE
a V�1�'J" License CI ' Lie M - - L D KITCHEN REMODEL
FZW Da Contractor APPLIANCES-RESIDENTIAL
y y - ?AD1IT1'0I D PLUMBING R&PIPE,.
[F.. a A ITECTS OECLARATI PANELS - ULTI-UNIT DSTRUCTURAL.
OOz S/}7�,. I understand tand my plans shall be used as public records ' MODIFICATION..
:t UPTO 200AMPS' DINTERIOR ❑CHIMNEY REPAIR
'�„�„I"J y���J LmensedP fssmnnl IMPROVEMENT
g� - 201-IWOAMPS
hE' OWNER-BUILDER DECLARATION ' -
WW I hereby affirm that I am exempt from the Commerce;License Law for the OVER IOW AMPS ❑BATH REMODEI,(REPAIR�0 DEMOLITION
U following reason.(Section"/031.5,Business and Professiuns Code:Any city or county �- SIGNS ELECTRICAL D OTHER �7
I- FN¢ which req Permit in aroulloner,site pr ve do I h r pair an,anductme - s -
w.]
print to itsi.oence Iso hataires the applicant for inch permit file a signed stationeent SPECIAL CIRCUIT/MISC - - -
y
that he licensed prtment to the parvisionI,of the Contractors License La (Chapter 9
C
hemonscricang with Sect 7")of DivEilon i of the Business and Professions Cade)or - ,TEMP METER OR POLE INST. '
4 p,M tq that h t exempt therefromand the basis f [h alleged exemption.Any licit n of - -D NE" � G(ADDIT 09B5(OLITION
iC W Sectio 903Eg.by pe J pp penulty f COMME
r' ',POWER DEVICES 6/
any epplm If first n subjects IM1<a I vnnoacivd �, q
h- y not therF hand redi llars($50s - t [ITENAN'I' r' (d�r FOODSERVICE
p Q ❑I a.own' fthepropeny o yemployeeswith- g as their solecompensatin, y SWIMMING POOLELECfRIC IMPROVEMENT �MQiryU -
y�/,J- o willd the wok and the st lure' not intended reofferedf sale(Sec 7044 Business DOTHER
C6C6C6 ee and Profession,Code:The Contractors License,Law does not apply to an owner f OUTLETS-SWITCHES-FIXTURES
�' .. property who builds or improves thereon,and who does'euch work himself or through -
his own employees,provided that such improvements'I not intended or offered for NEW RESIDENTIAL ELECTR SEI
sale.If,however,the building or improvement is sold within one year of completion,the SQ.PI'.PLODR AREA - $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve far par- 0 91#1111. - s�,�
as
poseofarda). , , ' _
• ❑1,as owner of the Moody,am exclusively contracting with licensed contractors m
contractile project(Sec]044,Business and Professions Coda)The Cenuaeter(.,Li-
wase
LLcense Law does not apply to on owneref progeny who b'ullda ar improves thereon,and: QTY PLUMBING PERMIT FEE
who contracts for such meets with Z
thamm u
P J reel s licensed pursuant the o
Liwnse Lay. - K) P Cmianofs
D 1 me exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE -
Owner - - ALTER'-DRAIN&VENT-WATER(EA)
Date / VALUATION
WORKER S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. 1 ��. ��1
f h reby affirm unde penalty f p Bury, f the following de 1 t ns: as '
❑Ihave and llnwim Cerifica¢ofC t to self-iname,fierviviorkers Compenl. DRAINS-FLOOR,ROOF.AREA,CON DI t
LI as provided for by Section 3710 of theLatie Code,for Ne performance of the STORIES TYPE CONSTRUCTION
wakfarwhichmispermi.sissued. 1 1 FIXTURES-PER TRAP' _
D I have and will mountain Workers Compensation Insurvnce is required by Section .
37M of the Labor Code fnhe pedmance of the work for which this permit is coed. GAS-EA.SYSTEM-1 INC.4 0 OCC.GROUP DPN' .
My Workers Compensation I ranc Cartier end P 1 cy mere - '
Carrier P 1' yNo.:^j}'�, GAS EA.SYSTEM-OVER6(EA) -
CERTIFICATEOFEXEMPTIONFROMIs Rl..R�
COMPENSATION INSURANCE - 'n GREASE/INDUSTRLWASTEINTERCEPTOR '
This section need no[be completed if the pemihis forma hundred dollare(SI00) � � - DI ION FEES
or less.) -". GREASETRAP PLANCH EE
Icer fy thaunthe pert rm of the work hih thsp "tis' ved lshll SEWER-SANITARY-STORM FA:2WPI'.
On 3
not employ any pe on in any o as to ho'care subject o theW kers Co.peii ENERGY
z ,cation LawsofC I'fomrb Date O EK
- v WATER HEATER WNEFCEMLECTR GRADING FEE
y O Applicdiil
G Ie, NOTICE TO APPLICANT If,after making @i.Cert(care of Exemption,you should
WATER SYSTEM/1'REATING
a become subject the Wo to Compensation revisions of the Labor Code.you mus[ SOILS PEE
W foMw th comply' ih'euch p isions or this perms shall be deemed revoked. WATER SERVICE / r
z d CONSTRUCTION LENDING AGENCY i NEW RESIDENTIAL PLMB. •SQ.FT. PAID' -
U O Thereby affirm that there is a construction lending agency for the performance of Da[ eced,
L4 Hthe work far which this permit is issued(Sec.3097,Civ.C.)
'Lenders Name-' '
.O Lends Address
i,, - " - TOOTAL.
LL 'I certify that 1 have read this appm
liean and"state that the b formation is T BUILDI 22 _.
rr N correct I agree to comply with all city and county ordinances and state laws relating to, QTY. MECHANICAL PERMIT FEE
U building conative[ion,Lord hereby authorize representatives of this city maniac upon the SETSIC
., above-mentioned property for inspection lmdpases..
P[RMIT ISSUANCE "r
(We)agree to save,indemnify and keep harmless the City accrue
Cupertino d City' - ELECTRIC FE
incons Judgmentse granting
oexpensesmith aymanyway against said City ALTER ORADDTO MECH. '
n APPLICANT
LIC ice f the gram g f this permit - r pLUMBIN E sCM
-
SOURCANTULATIONAND NO WILL.COMPLY WITH A NON DINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE EGULATION. MECHANICAL
L— AIR HANDLING Ulh(OVER 10.(IOOCF&I CON
Signal
Signal of pant/ manioc', 'S 7 ate: EXHAUST HOOD OVIDUCT) ryOUSING MITIGATIONE
HAZARDOUS MATERIALS DISCLOSURE -'
will the apphI or future budding occupant store or handle hazardous material HEATING UNIT(TO HE,"BTU) ,as defined by 4he Capron?Municipal Code,Chapter 9.12,and the Health and SaPoty -
Code,Section 25532(e)? °^ - HEATING ONIT(OVER 100,000 BTU)El '
Yes v, ❑No - _ VENTILATION FAN(SINGLE RESID) PAID x '
Willits,applicant or fire building oceepaut use equipment or devices which - - Date Receipt M:
tlatenhous an contamn tsas defined by the Bay Area Air Quality Management- BOILER-COMP(3HE OR IWpO(I BTU)•
District? -i TA
DYes ❑NBOILER-COMP(OVER100,00i
AIR CONDITIONER i., e -
Is 1 h arz
e read the hrdous tered,req ata under Chapter 6.95 of the Cali- ISSUANCE DATE
forma Health&Safety Code Sections 25505 25533 and 25534.1 undentand that if the SQFT.
NEW RESIDENTIAL'MECH:, - , '
• building does not Currently haw a tenant,that itis my possibility,to maty the occupeam of ire requirements which most be met pilon to issuance of a Cenifcma of Occupwey
Ownero rinanuAagent - - Date .v 'Ta V 1J•/ISSUED BY.
BY.
OFFICE -
TM
d .