S 0493 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
-ELECT RICA]. PERM
CITY OF CUPF.RTINO It IT NO
BUILDING.DIVISION APPI.ICA'1-ION/PERMIT PLUMPING PROJECT
IVIG S 0493
BUILDING YRIIJF:6T IUENI'I4'ICATION
SANITARY NO. AI'PLICA'1'ION SUNMII'ITh DATE
NUILDING ADDNESS:
/03/ rUU[
ER:S F. PHONE: CJlIRSNAMl-f �� iL'NO2 NIC ONI'ROI.M
`/`�6' S 30 /JGL,i 'fJ J
•ARCHITECDENGINEF.R: 1111 NO: -BtC/ I`ate s� s ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Crnsultant Fees Paid by Applicant(Initial) BLDG ELL—1' PLUMB MIFII
LICENSE[)CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE TLo1`_• JOB DESCRIPTION
�11u�,
1 hereby affirm That I an licen,ul under provisinm of Chapter Y(commencing
G PG ZO with Seclion](NNBoI'Division3ollbe lluninr_cs anJ fmm.sionn Ctdc.and my hereto,is RESIDENTIAL
FO full force and effect. I'13RMI'I'ISSUANCIi ❑STOWS, ❑KITCHEN REMODEL
CF-ut- in
NQ6 Dacn,e Clava Contractor APPLIANCE -RESIUIiNTIAL ❑ADDITION PLUMBING RIid'll'li
ARCHITECTS DECLARATION PANEIS ❑MDLI'I-0NI'I' ❑MODIFICSTIO
F',z l understand my plans shall he used as public records MODIFICATION
ZOt„� UP[0200 AMPS ❑INTERIOR El CHIMNEY REPAIR
OZ-M
MPROVEMENT SWIMMING POOIS
al Licensed Ymfcnniunul 201-1(XX)AMPS X)AM �-
�p�5� OWNER-❑IJIhDER DF:ChARAI'IVN 'I'll ltl?MODHIJRIiPAIk ❑DI?MOLIT[ON
C d 6 1 herdry uffm+that I oro exempt from the Contractor's Lkenne how for the OVER IINNtAMI'S
X 3 6 U following mason.(Section 9031.5,Bti,iness and Profession,Code:Any city or county SIGNS ELECfRICAI. (YfHER
W a which requires a permit to construct.ales,improve,demolish,or mpair any onachu,
prior to its issuance.also requires the applicant for such pcm Lto file a cigned,bament SPECIAL CIRCUITIMISC.
S try that he is licensed pursuant m the previsions of the Contractors License Law(Chapter 9 COMMERCIAL'
Wi (commencing with Section 7000)ot Divi cion 3 of the Business and Professions Cale)or 'TINRMF,TER OR POLE(NST. ANEW BhDGIADDITION ❑UEh101.1'1'ION
tY k e y shut he ix exempt thcrcf nin and Ne Enos far the alleged cxcmpeon.Any vinlmion of
1 Section 00315 by any applicant fm u permil vainest,the applicant m a civil psrnlyof POWER DEVICES ❑THNAN'I ❑FOODSERVICE
not more than five hundred dollars 18500. IMPROVEMILNT
I=E [] towner of the ProMnY�ontty cmpleya,witb waghs us their sole nnnpcnvtinn, SWIMMING P(H)1 1.1; RIC
will do the work.and the minallure is not imu ndcAm.Remit&usale(Sec.700.Business ❑OTHER
F OUTLErS-SW'ITCHE'S-FIKTURES
63 oma narhsh,n.Code: he camraaar.Lien Case d«., apply an wmer are
popery who builds Or improves Ihemm,and who does such work himself or through
his own employees provided that such improvements are not Intended or offered far NEW RESIDENTIAL ELIiCTR SQ F
$R I71'.I:hOON,N IiA :$/S(Q,17.
sener,however,ll has,
proven ithat it he ithlnoacywor impose n.
P� as
wn,of wiled.
will have the M1urdcn til proving that he did not build or impmvm li+r par- 'O
poseos wro 'TOTAL: SAr
❑Lac owner of the pmpeny,um exclusively contesting with licensed mmracutn m n,
Sconstruct the pmm Sec.70-W,,kaviiuss and Professions CWs:)The Contractile'Li- ^
s ,eLawdoeenmapplymanawnerofpropeaywhohuildsorimprovesthemon.and QTY. PLUMBINGPERMFEE l.��rLr` vV t
who contracts lot such projects with a commenn(s)licensed punvvm In the Conwemr's aIC
Liccn,e Lnw ,li&P C for fid,ea.,nn PENM.'1'ISSUANCE GrQ
❑ I ma exempt under Sce.
ALTER-DRAIN N VEN I'-WATER(EA) VALUAI
Owner Dae1 L
• WORKER'S COMPENSATION DECLARATION BACK IlOn'PN(YI'f:Cf.DEVICE {/� l
1 af0nn under penalty of peane of the following declarations:
❑ and w mrjury
(have and will maintain Cenitic;nead u
Con,enoulf-insure for WnrAc6 Cmnpen- DRAINS-F100R.ROOF.AREA,COND. STORIES Ell PC CONS'1'RUCI'ION
wuon,as provided for by Section 37M of the Labor Cid,hm the gmiormance of the p1X'IVNIiS-1'Lk"TRAP
work for which IM1is petm{I is issued.
1 have and will maintain Worker's Contpen,dam Insurance,as acquired by Seetinn
37M ofthe Labor
)Code.for the performance offlework lot which this pennitis i.wuca GAS-EA.SYSTEM4 INC.4 OUTLITS OCC.GROUP AI'N
My over f6.f'_'^L lnsualp SE jtt Po d PNayyytN'c{fy^3 7o� GAS-BA.SYSTEM-OVER 4(EA)
m 1Ct CERTIFICATE OFF EXEMPTION FROM WORKERS GRP.ASFIINDUS'I RL WASTE INTERCEPTOR
COMPENSATION INSURANCEBUILDING DIVISION PEES
('rhlx,oniunnecd not hecnm.cacdlfthe permit i,on otic hundred dol hex(SIM) GREASETRAP PLANCHFCK IIB:
orlcs,.)
Toy anythin
per int he any mmancc of the work for which this sernmithe W is issued.ompe1l SEWER-SANITARY-STORM EA.20()FE ENERGYIaili
not employ any perosm in any manner x+auo become suhjea m the Worker:Campcn-
1 0 IZ, scion Laws dCalifomia.hate WATER HEATER WNENT(ELECTR GRADING R
O Applicant
NOTICE TO APPLICANT:11,after making this Cenilicate of Exemption,you should WASTER SYSTEMn REATING SOILS FF I
a become s.h",f in the Workers Conipansallon pmv..inns of oro Labor Calc,you must
forthwith comply with such pnrvi.,inns or this lwrnal shah be decmcdrevnsed, WATER SERVICE
Lt
o,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.FT. PAID
= z time -c pt a
V� Ihercby^f0rte thin Them iso cnmwninn lending agency fur the petfonnance of
D. C-' the work for which this permit is issued(Sec.3097,Civ.C.) 'I AL:
O U Lenders Name 'TOTAL:
ULendd.AOdic, BUILDING '11
O. I emol hat I have recd this a"Plicadon and s,am that the above i^t'onnulian h
h ocarrect.l agree to comply with all city and countyOrdinances and state laws elating In QTY. MECHANICAL PERMIT EEE SEISMIC Il11:
V Z huildinge^^.ctrvetion.and hcmby aahoritt mpanx.nmive,ofthiscity toemcrupon the
ahsncmentloned progeny far Inspection purymes. PERMIT ISSUANCE; ELECTRIC FEE
agme to save,indemnify(We) and keep harmless the City of Cupenino egamst
ltabilitien,judgnatns,costs and expense.,which may in any way acetum again said City ALTER OR ADD TO MECH. PLUMBING FF,
in asequence of the grunting of this permit.
AP ANTI'UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNI'1'(10 PIPES CI'Ml MECHANICAL RE
[)RCL UIC JLATIONS.
7-,r.57 AIR HANDLING ON]'1'(OVER 10.0s)CI'M) CONS1'RUC ONTAX
Signameof ApplicanUContmnmr Dae EXHAUSTHOOD(WMUCT) HOUSING LITIGATION M.P.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building necupam store or handle hamrdou.namhal HEATING UNIT(TO 100,100 BTU)
as defined by the Cupertino Municipal Calc.Chapter 9.12,and the Iicalth unit Safety HEA'T.NG UNIT(OVER 10,00 BTU)
Cede.Section 25532(,)?
❑Yex ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam ccipt
Will the applicant ere furore(wilding occupant use equipment nr devices which BOILER-COMPOHPOR 100.000 BTU)
mit Situations air corarnim nt,as defined by the Bay Area Air Quality Monagememt OTAL:
District" BOILER-COMP(OVER 100,000 BE
❑YO, ❑No
AIR CONDITIONER ISSUANCE DATE
1 have Tc^d Ne has fou,roomfuls tcquie33 an cal,umler Chapter fvYS of the Cali-
bundi gdoes A Safety Coke.Sections 25505.25533 and 8534,i u unity the
tont if tM1c NIiW RFSIDENTIAI-MECH. SQ.IT.
buildi m,marmmr,which
have thmnatn.lhato is my or
erdimtmtifythecers"m
of the reyuirementt which moa h met pdono issuance of a Cenifcae of(kcupatmy.
Owner nr authori ld agum
-.tic DOTAL: ISSUED BY:
1 OFFICE