S0039 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM..No,
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING ICUT fy�y� �/JLJiV:.��.!-siJ�
Nf111.DING 1'HIIJEC'T IUEp'pIFICATIUN SWC/
BUILDING ADDRESS: SANITARY NO. ]APPLICAIjON SUBMITTAL DALI
2� tk lI�Q6R��C'C' Ste- Z�IA 1OWNIiR'S NAME: 'ilONy �� COMfHACT :S LIC NII: N/C N'fI1Ol.p
OL AHCIIITF.CT/ENCINC:. 1- 'NO: AUUHE55:
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) RLDG E 11% MECH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECT RIC PERMIT FEE FrJX`
I hcmhy aptrm mat I am Iwanted ander caoi,.ows alChapter 9 0rammenoing -JOB DESCRIPTION
�07. wilh Scclinn9IXNgoIDivisinnlof the liusinessvnd Pnml'csx nnx CodcmnJ mylianw lx PERMIT ISSUANCE RESIDENTIAL:
�WO In full foreemal effccl. ❑M'DWI. ❑KIICIIIiN REMODEL
License Class Lic.# APPLIANCES-RPSIDEM'IAL 14DDITION ❑PLOMIUNG RE-PIPE
I-i Q i Dart—Cmdaw or
ARCHITECTS DECLARATION ❑h1U1,T1-UNIT ❑MODIFIVHAL
F m Z 1 undersand my plans shall be used as public mentis 1 ANELS MODIFICATION
ZOZ HQ UPT0200AMPS C3 INTERIOR ❑CHIMNEYRERAIR
II--W Liecmcd Professional 201-1000AMPS INUIROVEMENT []SWIMMING POOLS
CY ; OWNER-BUILDER DECLARATION OVER I(XIB AMPS ❑BATA RF,MODELREPAIR ❑D4:MOLITION
pp..0 Q I hereby affix that no cxcmpt from the Contracmr.s License Law bathe
X d U lidlowing rwwm.(Section 7031.5.0wita,"and Rnfeainnx Code:Any city or county SIGNS ELECTRICAL �01111.
W 3
U.1- which rer,roes a punotil .I.....snout,vhcr,Improve,dc..udixh,err repair any slmmare
F"�WQ, pno,mrsi..... .also reyvircs the applicant for such permit o file it signed statement SPECIAL CIRCUIT/MISC.
E N that he is licensed personal tothe pmii'imrcofdre Comoro Lkence Law(Chapter 9 COMMERCIAL'
�Y�Q Ittomntcicing with Section7XXBmf Division 3 ofibe Busincsnand Professions Cede)or TUhME METER OR POLI;INST.
A.a M z than he is exempt aM1emfmm and the basis for the alleged exemption.Any violation of ❑NIiW'BCUG/AUDITION ❑DIiMO1,ITION
�m Section 7031.5byany vpplicamfor apermil subjects lheapplicanrto a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
FZ} not mote Nn Eve hundred dollars(S5(XH. IMPROVEMENT
�SD Fjhac ownero(the prnpeny.or mycmployees wilt wages us thcirxole cumpcnsainn, SWIMMING POOL ELECTRIC
W�^m
will do nn work,and the slmclaw is not tnmnded or offered fm sale(Sec.700,Business OU'fhS-SWITCHES-PIX'fURES
❑OTfiER
3�
and Pnolessiann Csslc'I he Contractor's License Law docs not apply to en owner of
properly who builds or improves Icrcun,and who docs Inch work himself or through
hk own empfoyce........Jcd thal such imprnvmnentx me not intended nr offered for E RE DENTIAI.Ii1,EC1'µ 5Q I°I:
ssfe.If.however,the building orimprovetnena in sold within one year ofcompfeaion,the SQPI'.FLOOR AREA 5/SQ.4T
.
owner-builder will have the burden of proving that he did not build or improve for par- PAID D
P'^e of sale.), 119AI, T f
❑1,as ownerof are pa"Ity,am exclusively remaining with licensed...amours m
construct me pmjsct(Sec.7H 1.Business and Professions CrNcJ The Contractor's Li.venMAY 127
k law does not apply it)un owner of propery who builds or improves thereon,and QTY. MBIN .RMIT FEE
who contracts for such pmjens with v commamr(s)licensed pursuant m the Commerce%
License Law. PER M IT ISSUAN E CI'I _
i] I on cxcmpt ander Scu. .11&P C for this retsam _ I Ur
ALTIiR-DRAIN&VENT'- TER(EA)
ulfr-
Uwncr Dom
WO KER'S 1117NSATION DECLARATION BACK FLOW I'k(ffT:Cr.DEVICE
tcmby affirm under penalty of perjury one of the following declarations:
��Ihavc and will mainmin vCmifcate ofConunuoself-insure for Worker's Compen. DRAINS-FLOOR.ROOF.AREA.COND. S'roRIIS TY PE CONSTRUCTED:
ation.as provided for by Section 37M of the I-her Cure.for the performance of the
wfor which Nis permit is issued. FIXTURES`-PER THAN
ork
1 have and will maintain Workds Compensation Insurance,as required by Section
3900 of the Labor Cote,for the pmformvnce ofthe work for which this permit w issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wnrlar'I Conlmenion Jose mnce comc—ral Policy mroberam: GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy No.
CERTIFICATE OF EXEMPTION PROM WORKERS' GET ASEANDUSTRL WAST 1:IN'TERCEFIOH
COMPENSATION INSURANCIi HULLOING DIVISION FEES
(This seelirmacedool hecmmpleled iflhepcnnit ixfortnehundreddollin,SIW) GREASETRAP
PLANC111iCK FEE
lets'.)
Loy any Natin the anymmnceo as
work for whichhisto permitsers'CoIshall SEWER-SANITARY-SITORM 13A.200 FT. ENERGY FGF:
not employ any person in any manner yr as to become subject to the Workers Compem
,Z smhm Laws of of Califomia.DoleWATER HEATER W/VENT/ECECfR GRADING FTE
Z2 Applicant )
Isco N
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should WATER SYSTEMnR17ATING
bearme sub act m the Worker's C..m lion f the Labor Code,you most "— j
1 Penna Pnrvi,shall
fonhwith comply with nuehpnwisions orthis permit..hull he dcenmd revoked. WAl1iR SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESTDEN"1'[Al.PI,MB. SQ.FI'.
7 'Z Ihercby affirm lM1m there I%a construction lending agency for the performance of pLUL- Ne work far which this permit is issued(Sec.3W7,Civ.C) OTAL:0 bender's Name TOTAL:
Lcurcrs Addmee 1 cenify that 1 have read this application rid sate thm the above infommmon is
rrto . reel.l agree m comply with all city and counryoNinances und.axte laws relating to QTY. MECHANICAL PERMIT FEE(..1Z building.manattion,and hit ambori>ercprescnati vel of this city to enter u'In theuMrvcmmttioned propenY lin innpc.an purrymsvl. PERMIT ISSUANCE
[Lac)..gree n.save,Indanmlfy and keep ham less licCity al Cupcminn ngvinnt
habilitics,judgmems.max and exierves which may many way acerae against said City AIA FR OR ADO TO MECH. qMITIGA110N
—
in asequence of the granting mf this Permit.
APPLICANT UNDERSTANDS A;JU WILL COMPLY WITH ALL NON-POhNT AIR HANDLING UNIT LTO IO.IXXO CFM) E
SOURCE REGULATIONS
���`-/� AIR HANDLING UNO'(OVER IO.IX10 CFM) 'fA%
Sipa ApphcanUComrvcurr �
EXHAUST HOOD(W/DULT') TION FE'f1AZARDOUS MATERIALS DISCLOSURE
Iclin Wiled hYNCCncaul or future building occepantsmrcor handle hazardous mmcaial HEATING UNIT('101( .000 BTU)
as pnMnnicipul Cnlc,Chvpmr 4.02.and the Houllh vnJ Sul'ctyCNc Section 255320)'/ HEATING UNIT'(OVEH IIX),fNI ITI'U)
❑Yes ON° VI3NTILATION FAN(SINGLE RIiSIDI Rccci #
WII the applienm nr future building wcuTam uu eyuipmem or Jevica which BOILER-COMP(3HP OR 101.000 BTU)
emit ha>ardous air nmmminams as definer by the liay Area Air Quality Managetnem TT(,I A L:
District! BOILER-COMP(OVER 100000 BTU)
❑Yes C]No
1 have rend the hu>mduw natcnuLs nquimmcnta under Chapter 6.95 of the Call-
AIR CONDH'IONIiR ISSUANCE DA'I'I:
`r Health&Sa25
fcty Code,Sections 25505, 533 tmd 25534.1 undcmtvnd III.,if the NEW kES1I>IiN'I'IAh MECIL SQ.I§t
ke,nal.amonly havenmount,tlut it ivory mnpun.ibllhy m notifythenccu, I
Beats which ntaa he act prior......ranee ol'a Cenificme of Occupancy.
1rd agent Date TOTAL: ISSUED HY:
S d/I _ OFFICE