S 1360 (2) 7 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
/ CITY OF CUI'ERTINO BUILDING..ELEC1R1CAL P1i IT NO
f uUu.nING nIVIS1oN APPLICATION/PERMIT PLUMBING-MECHANICAL 1360
IUII.II PItOJRCT IDEN 1IFICAIION
111111.U1NGA RISS: " � SANITARY NO. APPLICATION SUBMITTAL DATE
070
NF.R'S NAME' 111003!. COM'RA Sµ\ LIC NO:
_ Mika wee A a6I Gj f NIC CONTROLp
ARCHITIiCT/FfGI f�t 'v LIC NO: ADDRFbS: ❑
CONTACT PHONE: 13UILIJING PERMIT INFO
409-25,,-2-9'9
1 J^ 9— II5,,-2 t9'tom- ❑ Cunsuhant Pecs Paid by Applicant(Initial) BLII(K i EufCy 1•LU❑MI{ MECH
T L 1 LJ/ CdJ
LICENSED CONTRACI OR'S DEC QTY ELECTRIC PERMIT FEE
I hereby of ton that I ant licensed under provisions of chapter 9(commencing JOB DESCRIPTION
OZZ wiI,Sc,liun](XXpnfDlvision3ol'0w Bosincs'and Prom,aion'Gdc,Intl lily liccnw is RESIDENTIAL
W C)c r PERIOD ISSUANCE.
f—w. in full force and effect. ❑lzim, ❑KITCHEN REMODEL
QUV I,icensecim' Lic.N APPLIANCES-RESIDENTIAL (-]ADDITION ❑PLUMBING R:-PIPE
m '
❑STRUCTURAL
WUComracmrC ARCD13CISDECLARAHON [I MULTI-UNIT
JPANI14 MODIFICATION
ZOyZ Iundersmndmy phowlidl he us
C)Z UPTU2g1AhIS ❑INTERIOR ❑CHIMNEY REPAIR
R
F�,F..W LicenxJ Prue...unal 201-10XIAMPSIMPkOVIiMENT C)SWIMMING Pi
a AlEJ OWNER-HOLDER DEOLARA4'ION OVER I(NXIAMI'S ❑HATH RE UDE1JREPAIR ❑DEMOLITION
E C W Q 1 hereby of..that 1 am exempt from the Contractor'.License Law,for the
X O um,.F following reason.(Section 7031.5,Business and Professions Gvle:Any city or amnly SIGNS ELECTRICAL [J OTHER
bc, y which"o",a'canal m v .mat.other,improve,demolish,or rt it any sn'cmrc
CQ prior to ilia issuance.also requires the applicant for such permit to fiats ignedsmtemenl SPECIAL CIRC 1)1'1'/MISC.
��cthat he is licensed pursuannothe prodsionsof,hc Control License Llw(Chapmr) COMMERCIAL:
Of (commencing with Section 7(XX)Iof Division 3 ofthe Businesslnd Profssions Cothfor rEMR MEER OR POLH INST.
a p,o C mol he is c-rom,here&nm and the hall,lin the alleged cxcntplion.Any violwlnn or C]NEW HhUG/ADDI'T'ION C]DEMOhITION
1L�m
Section 7031.5 by any applicant for a permit subjects the applicant a civil Penally of POWER DEVICES ❑'TENANT ❑1'001)SERVICE
1 more than Live hundred dollars($5W). IMPROVEMENT
EFOI(ll.nx owner nftM properly,nr my cnapinyccs with wages ax mon —nolimali,n, SWIMMING POOL ELECTRIC
If
11 diwink,andow,ho mreknot In lemdcdmoliondforenle($ec.]14q.Hunmese DOTTER
Y 3 ae and Professions Gds:The Contractor's License Law does not apply In an owner of OUTIAH'S-SW ITCHES-FIXTURES
pmpcny who build,or improves thereon,and who does such work himself or thmugh
Lis own clnploycee,fooidod mal such impmvcmcnls nor tun;mended or official for NEW RLSIDENfIAL ELECTS SQ f ..
%ale.If.lnmsvea me building or impma
vnent is sold within one ar il
yel completion,the SQ,FT FLOOR AREA 5/SQ.I'I'.
er-builder will have the burden of proving that be did not Wild or intpmve for pur-
puseo(nlJc.). TOTAL:
E]1,n owner nrfile properly, on Ivelunlvely'initialing'ill,liac,cnl colau'l ors la
construct the project(See 9140,Business and Profession, -larl lana Conttacoa l Li"
uc Law docs not apply us an owner at property who builds or improves thereon,and QTY.El
PLUMBING PERMIT FEE
wshc e,nmLLt'Im such prolentx with a cnn'mn aF)licenced pio uum ut the Cmm�lttor,
hicensc law. UANCEl amcunptu Icr Stt. .H d P C for thf.c msmn AIN&VENT-WATIiR(. 7 VAL WCI'IUNurvm ze-u.__q_� O oWORKERS COMPENSATION DECLARATION PRUTEC7L DEVICE Q1 hereby affirm under penalty of Perjury one of the folLowing deelam ions:QIhuvc unJ will nu'inminaCertiEcum nl'Cnnmmrater(-inxurc for Wnrkcr's Cninam- LOOR,ROOF,AREA.COND. STDRIE TYPE CONSTRUCTION
satin,,as provided for by Seolion 3](X1 ofthe Laior Coll.,for the pertmance of"[bcwork fur which this panni,is ism cd. -PER TRAP1 have and will maintain Wodefs Compensolion Insurance.as require)by Section37Moflhe Luh,,Codes ln'hepnr0aman,vol he'irk fur which this pond ix i....tL SYSTEM-1 NC.401f1'I.ETS OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy numher are: SYSTEM"OVER 4 HiA)
III Carrie Policy No.:
CF.RI'[FICA[1:OF EXEMPTION FROM WORKERS' GRI;AST%INDUSTRLWASTEINTERCEPTOR
IOMPENSAHO N INSURANCE BUILDING DIVISION FRES
(Ihisss,inn Necel not be atmplcmJ ifthc pemtit is Lx Inc huntlmd Jolla,ISIfX)1 GRHASETRAP
or lees) PLANCHF:CK FEE
Iccedymat d ra,vrllnnlanceot'the walk For which this pennil is issued,,'half SEWVR-SANITARY-SIORMHA,200Pr.
nil maphly any Person in any manner so as to become sufyvaf to the Workers Cmnpen- ENERGY FEC
Z sall..Law's of California.Duro WATER HEADER WNENT/EI.EMIt GRADING FIE
.N. NOTCH 10 APPLICANttT:H.alar,takiog'his Ccrtiticnm if EscntPlion,yon should "It'll'SYS Ili
> become subject the Worker'Compensation provision..of the Lalan Cade,you ms uSOILS FEE
i., forthwith comply with such provisions or this pcmtit shall be deemed revoked WAILR SERVICE
[� PAID
CONS'I'RUCfION LENDING AGENCY NEW RESIDENTIAL PI,MB. SQ,IT. Dia c' a4
UQ l hereby affirm that there is a construction lending agency for the Performance of
W F the work fill whilh'his on,,is icmed(Sec.301],Civ.C.) TOTAL:
OULender's Nano
Isndcr',Addrts' 'I'UI'AL:
>. D3 1 entity thud l have lead this application and,arethat the nbove information is IN 1:2n' 6 TY M17CHANICAL PERMIT FEE
N correct 1 omlr ni comply with all city; county o ali'll of and slate Taws relating he Q SEISMIC IiL
(� 7. building cnns'rnc'Inn,and hereby uu'horiec reprcxcnmlivex of Geis city mcmcn'pun the I
abtwe"mentiuneJ property lin inspection pug'ncs. PERMIT ISSUANCE F_k�Rhf Ppliid l l l IQ
(We)agree ht save,indemnify uad keep harmless file City of Cipcnin l against
liabilities,judg'mens,atslsandcspctnes which ntay in any waynecrucagains,.slid City AIXP.R OR AODTO MECIL PLUMBING.PEE
on rwapi reill the Starling of this permit.
APPLICANT UNDERSTANDS AND W ifl,COMPLY WITH ALL NON-POINT AIR HANDLING CHIT CPO R.IXXI CFM) MECHANICAL PER.
SOURCE REGULATIONS. /J
M,-1 , /^� Alit HANDLING UNIT'(OVER 111•INA CFM) CONSTRUCION'TAX
Signumrc of Applica 'rmranor Dam EXHAUST FOOD(W/DUCI) HOUSING ADriGAIION ILC
A%AR) S MAIHRIAIS DISCLOSURE
Will the applicant or future haltering occupant store in handle ha'ard ato inolcolil IIIiA'1'ING 1JNIT(9t)1(X),(XN)II'IU)
as definal by the Cupertino Municipal Ctde,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER llod"II'1 U)
Cole,Section 25532(x)t
E]Ya, PAID
IiUILIR=1UN PnN IS] Dole ReeeitH
VI1N'IB,n
Will the applicant or(chum,building occupant use equipment or device..which OILCOMP(3111'OR 1(NIWD RTU)
,til h:vardou.c air comuntiamm as defined by the Bay Arca Air Qualify Management TOT
Dkoill? `'`` COMP(OVER 100,1roH RTC)
❑Yes ei<n
I ooemadd, c,adon,ncomb roduccnmtn,ander Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DA 117,
brain Distill N Safety Ctdc,Sees.....25505.25533 and 25530.1 nndcrs'anJ limit,he NEW RESIDENTIAL MLCII. SQ.F1'. ��/ Z y
building d«s not currently have a tenant.that if is my rtrytnsibili,y to nntily the occupant C/
of filer 4u meal)J.:If�I must lie sol prior o:,,mace of a Cca`3alc t [ ly� T
(juvser or aught IN a¢i1Ti(7d' 5 GUmc x T(TI'AL: ISSUEU It Y:��� 1 �-
OFFICE
Pacific Gas and Electric Company
Peninsula Division Gas and Electric Safety Team �� 5,--) /,J
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_ INSPECTION I?EPr 'i �G�
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