S 4318 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EIJSUTRICAL PI!RMIT NO.
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MRCIIANICAL S 4318
BUILDING PROJECT IDENTIFICATION
'A6DIMJADDRISS: SANITARY NO. APPLICATION SUBMITTAL.DATE
7 N�L-• Piks; 0?-, Z3 Q I
OWyY�BSMYSMI:: �� ZPHONE5r_7 CONTRA DR'S N D`I l `^ j'I(jJ()/
lff.�.� /lYnaV �JJ/U NIC CONTROLn
r CHITECI'/ENIG INf:[R: LIC NO: AUDRESS:�_ O� C ❑
l r !I /
)NTAC'1': ••''////�� PHONEdU1hUING PERMIT INFO
�-w U�t S y V 1 V 7 ❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT PLUMB i MECH
ftr
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE L'J( Lexn7/`
1 hereby affirm that 1 am licensed under provi,mr,of Chapter 9(commencing JOB DESCRIPTION
OCZ with Soad i701NBofDiem t3ofihe Boot:,, tdI fc..imtn C�> nadmyli,mor is 3 ^ RESIDENTIAL:
F"� in full lora avd dT PERMIT ISSUANCE V ❑SFDWL ITCHICN REMODEL
QUV )am
Lens re"
APPLIANCES-RESIDENTIAL (]ADDITION ❑PLUMBING RE-PIPE,
Q 1 Uu1c I"S DECLARATION
ARCIII'fISC'1'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z tom Z 1 mabb,"my plans shall be used az public records MODIFICATION
oz— UY'T02(MIAMPS
❑INTERIOR ❑CHIMN17Y REPAIR
F W Licensed Nol'essionul 201-I000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I0IM)AMPS GIBATH REMODEUREPAIR ❑DEMOLITION
q C C 6 1 hereby ail!.that I am exempt from the Commemr's License Law fnr the
x 3 L U following rcawn.(Section 7031.5.Business.nd Professions GMe:Any city or(aunty SIGNS ELECTRICAL ❑OTHER
LL LL in which requires a Par in to conarvcl,alter,improve.demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MING.
That he is licensed punoznuo the provisionsofthe Contractors License law(Cbaprer9
ck: COMMERCIAL
IY (commencing with$eW.v)IXNB of Dlvinion Sof the Buxinexe and Ynilexxinnv Crde)nr TEMP.METIiR OR 1411.E INS9'.
a a ca IY that he is exempt fla refr.m and the basis far the alleged exonpunn.Any vmll of ❑NEW BLDG/ADDITION ❑DEMOLITION
kmLL Section 7031.5 by any applicant permit subjects the applicant macrvil pcnulty of POWER DEVICES
X-" ❑TENANT ❑FOODSERVICE.
n mom than five Iandred Jollurs($50().
f2� n I,as owner of roe progeny.or my employees with wages as their sole compensation, SWIMMING POOL.ELECTRIC IMPROVEMENT
E- will do the work.and the structure isnot intetidedmoffered formic(Scc.704TBusinexx 'T� [I OTHER
G 3 0o and Professions Code:The Contractor's Tierney law does not apply to an owner of OUI1FfS-SWITCHES-FIXTURES V
properly wbo builds or improves thereon,and Min does such work himself nr Ihrcag
his own anployces,provided that such improventenn art nut intended.r offered for NEW RESIDENTIAL ELECTR SQ FI'.
sale.IL however,the building or improvement is sold within one yearof completion'he
owner-builikar will1' the burden f provingthth did nothuildini...... for pr- 1 \\]
po. of ). ����
0 h a f thep i,try am exclusively ely t t Th g i s I t ands 1. T lie I /
.wtthe protect(S 7144 Bu' :.and P f . Cod JTh t C ct —clot � JUN 2 3 19 9
ox Law does notapply tone fp ,par w ho h 'Ip tit anprovevth d QTY. PLUMBING PERMIT FEF.
who contracts for such Projects with a contracmrfs)Icensed pursuant o the Conlon rs
License law. PERMIT ISSUANCE O
1 am oxempl under Sec. ,B&1'C fonhis reason
ALI ER-GRAINY&VENT-WATER(' CI -may
Iwner Dae
WORKERS COMPENSATION DECLARATION BACK FLOW PROTF:
I hereby atlirm under lwn.lty of penury enc of the fnlkova,dedamtians:
I have pm,nl fit,byna Ccrlific.mofCc Labor are,for for
erformsce Carolyn-the DRAINS O RISA.C0% 0O STORIES T�ONS'1'HlJCT10N
us pnd will fit,by Section scam of the Labor i Code,for the performance of the / NN//
nk fnr which Ihi.v pcnnil is is<ucd. T S ERT
1 have and will maintain Worker.v Compensation Insurance,as required b Sccti i
3700 nl the lrborCMe.fnr the perfo�m�nre�e of the work fm which lhi G S - C. UTI ' OCCROUP �ZAPN..,
Ca wnrkSy,T T/t lnxui=�1/AJ IIPad¢y Nrc)'n L
Caner l '' ' ' -Ii 'V 'M-0V J
CERI PHON FROM WOR RS' d
COMPENSATION INSURANCE GREASF/L U 1.WASTE INTERCEPTOR BUILDING DIVISION FEES
('ITis section need nal be cmtipincJ if lhcpn'mit iv for nneh dollars(3 ) RI!A$G TRAP
or Ie,l) PLANCI IECK 121:111I unify that in the performance ofthc work far which lbisK 1 11 SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any banner so as m become subject to the nmpem ENERGY FEE
� Z all lawaof Culikaniti'Dae MINOR HEAI'F,RW/VENTIELECTft GRADING PER O Applicant
N NOTICE TO APPLICANT:If,after making this Cenificae of Exemption,you should WATER SYSTEMaREATING
a 5 become subject to the Worker's Compensation provisinax of the Labor Code,you mast SOILS FEE
I'onhwith comply withsuch provisions or this permit shall he deemed revoked, WATER SERVICE
d
U •z CONSTRUCI]ON LENDING AGENCY NEW RESIUENTIALPLM1IB. SQ.Ff. PAID Dae Receipts
U O Ihereny tartan that room ixaamxwnian fnaingagenny torque peruinnancenf
W
f` the work for which this pcmailo issued(See307.Co,C.)
Lender's Name TOTAL
V Lender'.,AJdrtea 'f 'AL:
'�' LA 1 verify that 1 have rtait this application and sate that the il, ve micro jinn is BUILT
f^" N correct.l agree to comply x ith all city and county ordinances and state laws relating'. QTY. MECHANICAL PERMIT FEE /f
V Z building conswction,and bereby.authori re repnewnmtives of this city to enter open the SEISMIC y
.have-n rmi.ned progeny fnr aspect puHxwcs. PERMIT ISSUANCI!
(We)agree m save,inJemmfy and keep harmless the City of Cupeninn ugaiml / ✓ 13LECTRI FHIi
Iiabilitien.judgmertts,costs and expenses which may in anyway accrue against said City ALTERORADDTO MECH.
in uequeace of The granting of Ihix permit. PLUMBING ,
APPLICANT UNDERSTANDS AND WILL COMPLY WI ALL NOMINI AIR HANDLING UNIP(TO I1k000CFM)
SOURCE REG ILATI NS. CONSTRUCTION
T
./ AIR HANDLING UNIT(OVER 10,0110 CPM) CONSTRUCTION TAX
Sigmmurc of Applicvn C.mrachm Gaut, EXHAUS'1'{IOOD IW/UUCTI HOUSING MITIGATION FTE
HAZARDOUS MATERIAL S DISCLOSURE.
Will the applicam...Ware buildingnecupanto en,handle ha....does material HEATING UNIT TO 10(1000 HTU)
as Jel'med by be Cupertino Municipal Code,Chance 9.12,and the Health and Safety
Care,Section 2 332(a1P I HEATING UNIT(OVER 100,000 BTU)
E]Yex r7 No PAID
VI!NTILATION PAN(SINGI,I!NF.SID1 Dwe Rcc.iplp
Will the applicant or future building occupant use equipment or devices which
wNOILER-COMP(IUP OR IW.(100 BTU)
� iardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
gne17 BOILER-COMP(OVER 100j)(0,0131U)
❑Yes ❑Nm
I have read the hmallous materials requirements under Chapter 695 of the Cali AIN CONDITIONER ISSUANCE DATE
fnmi.Ilealm&Safety Calc.Sectinnx 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MF,CIL SQ.loll /
building does not curtenBy hove.mnun6 Na it is my res mxihiinylon tiff theacupmn (�
n thematic which tuunbe n nor to o% m aCenifcat of^cW(upi
Owner au1h 1 ag n c �GDYc OIAit ISSUED NY: —
OFFICE