S 0930 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUu.OING-ELECTRICA L 1115 IT NO. O O
BUILDING DIVISION APPLICA•1'IONFPFRMIT PLUMBING-MECHANICAL.
BUILDING PROJECT I DF.N'1'I F•ICA'1'ION
BUILDING ADDRESS. Ph1- ' SAN I'IAItY NU. APPLICATION SUBMITTAL DATIi
' "7 .7y Or r
(OWNER'S NAME: PHO CONTRACTOR'S NAME: LIC NO: NIC CONTROL-if
4J 0 9 ❑
ARCHITECIAINGINEHIC _LIC No ADDRESS / 4t-
CONTACT: 1-lAJO'fVC�' PHONE: 4>Icew
""LL BUI LI I ET PER LU (NEO
,` . /I Xy.� :Consultant Fees Paid by Applicant(Initial) BL���ix1II) ELIiCr PLUMB M[CH
V -'NUGS'l ❑ ❑ ❑LICENSED CONTHACTOR:S UIiC1ARAl'ION ELECTRIC PERMIT FEEJOg DESCRIPTION
I hereby affirm that 1 am licensed under pmvidons of Chapter��Z with Section 90lXB ofDivision)nfthe no nnas. Rofcs.ionsCrile.aRR NIDAWoO in full forceunJ cliff ) ` PERMIT ISSUANCE SFDWI ❑KITCHENREMODEL
QUr, icense Class - Lic.M 6API'LIANCFS-R65IHENTIAL ❑ADDITION ❑PLUh1RINGRF-PIPE
(Filzw Date 'C'u ❑MUI,TI.UNIT EISTRUCTURAL
ARCM rECPS DECLARATIONPANELS MODIFICATION
F y Z 1 understand my plans shall be used as public records
OZ�� UPT02MAMPS ❑INTERIOR JaCHIMNF;Y'REPAIR
W I.ivenxJ pmlbsxional 2014000AMPS
IMPROVEMENT (]SWIMMING POOLS .
j OWNER-BUILDER DECLARATION OVER RXIOAMCS ❑BA'I'HREMOOEL'RF,PAIR ❑D17NIOLITION
C C Q 1 hereby affirm that 1 um exempt Orion the Contractor's License law for the ()1'l1I:R �n J ti
LL U following reason,(Section 9031 S,Business and Pmfcssions Calc:Any city m eounty SIGNS ELECTRICAL
IE 3 k.F which requires a pc uit or conotomil, Iter,iniprow.doemolish.or repairy structure
E4 Prior t also 4 the applicant such ill 11 ¢mem _c
gi,daSPECIALCHICUIT/MISC. �yp1�
NOJ _{8•
CIh.,h I dl)a^' n theP ,^ fIn c t t r' I 1 (Chapter 9 COMMERCIAL'
a C O (commencing with Sect 7000)of Il it n 3 1 hefl . oess J 1 slessmnsCodel..r TEMP.METER OR POLE INS .
❑
ayx ca that he Is exempt therefrom and the breis for the alleged exemption Any violation of NEW IIIAG/AUDITION [I DEMOLITION
W N Section 9031.5 by any upph,ant I'or a pamni,.objeO,the uPplicam nor civil Plushy of POWER DEVICES ❑'1'I;ryAN9' ❑FOOD SERVICE.
nm noorc thafn vc hundred Anllurs 185 W 1, IMPROVEMENT
WIMMING POOL. .ECPRIC
st O 1,nsnwnerofthe prol,ely,or illy employees with wages as their.sole conopcnsoti..n, S ❑O'TI I ITR
will do the work.anti the slacaure Isnot lnwndal.....Iluted l e,ole(Set.9144,8® s
1LETS
W u^d Pmfersions Core:'Phe Conaria....Lies7tec Law dtea nut apply ,e,nn owner of OU' -1 Cl II?S-I I i5
pmleoy who milds or improves thenor,and why,tines such work hi still ,,through
his own entploysws,ptavided(hut such impro"I'lenb arc out intended or ith red for NEW RE' IiNf1AL ELEC'I'R :Q 1'.
sola:ll',bowcvcr,the budding...impnw^mem issold within unu rearol ,,rodei I.the
ter-hailer will have the henle^of pnwing nna he did not build or improve fur pe,
poofwle.). TOTAL: MH r�,�YTV1 +do
❑ I,as twoer of the pmpemy,non caclusivdy eontracrng wild licensed convumms to
onsmuet the project(See.9044.Ru,mc,1 and Pnaasio^s Core:)The Cutnmcmrs,Li-
censcUawdues not apply u-nowncrot ptaperty whohmhhrrimproves thereon.and QTY. PLUMBING PERMIT I°IiF,
who contracts for such pmjecns with a cenuact000)licensed pursuant to the Contractor's k
Liccnw Law. PERMIT ISSUANCE
❑ 1 an,exempt under See. .B&P C for this reason
ALTER-DRAIN&VF.MT-WATER(GA) VALUATION
Owba, ) (lata ..Tt�
WflRKl s COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE - /S3, V�+
I hereby infirm under Penalty of perjury one of the following dMmotions, 1,v
�❑I have and will maintain a Cenificu¢of Cousenno elf-insure for Worke/s Coupon- DRAINS-FLOOR,ROOF.AREA.CONN, STORIP_S TYPECONSTRUCOUC
satin.,as Provided for by Section 31110 of the"(her Cale.for the po fomance of the
work for.which this permit is issued. FIXTURES-PER TRAP
Ihave and will maintain Worke/s Compensation Insurance.as nonevent by Scction
..AWof the laNuCde,forthe performaun peanuts the work for which this peoit is issued. GAS-EA.SYSTEM-1 INC 40UTLI!' OCC.GROUP AI'N
My Workers Cs'm,menion uraoux,c d Policy num
Caoricc a- ' m Policy No.: � �r��nC//o Q� GAS-FA.SYSTGM-OVER 4IFA
CENTIPICA'I' OFE%PMI'TION FROM WORKERS' B7y�P GREASCIINDUSTRLLNASTE 'ERCEMOR
COMPENSATION INSURANCE BUILDING DIVISION PEI '
(Thi%s tionncNnotMcomplemJiftheNmilisfo,,,.h.Wh d.liv (SIW) GREASETRAP PLANCHECK FEE
or less.)
Loy any that in the an,rommocc..HbeIwork
nvermrwhicbthi,,Pe.Ili iaismed,Ishall SEWER-SANITARY TORN EA.2110IlL ENERGY Plili
nal employ any Par^n in any rammer an as m become uubjen m the Workcri Campem
Z smiun laws nl Cailnrnia.Ilmc WATER HEATER W LNI'/ELECTR GRAVING I'lili
Z Applicant i
NOTICE.TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTE /1'REA'rING SOLI S PB1i
become subject to the Worker's C^mpenmtien provisions or the Labor Code,you mut
try
forthwith Comply with such provisions or this pcnnitshill he deemed revoked. WATERSE ICE
aQ
CONSTRUCTION LENDING AGENCY NEW RE DENIAL PLMB. SQ.PT. ('AID
N
Omc cocipt p
1 hereby"(firm that is a construction lending agency Pathe paR........ of
LUt.H the work for which this permit is issued(Sec.30oi Civ.C.) 'TOIAI.:
0Lcuder's Name TOTAL:
�s WLcndcr's Add.... BUILDING IT
�y L cem y that 1 hive read Otis npplicalu m and state Ism the ab ve information is
correct I
rrectl Ilimcomply with all city and county ordinances:mJ state laws relating to QTY. MECHANICAL PERMIT hF' SEISMIC JoLE
U Z building constntetlat,I I hereby tnuhorim representntivm of this city.renter upon the
above-nentioned property for impaction purpose, PERMIT ISSUANCE E ECI'RIC 1711E
(Wc)agroc m xavo,'mdetnnify and 1,111 Imunless the City of Cupertino against
. li^bilidce juJgnenmi,iox a^J capenscu whicltreque anywtoy....uea,unetcdJCmy ALTER OR ADD'IT)MECI I. 1'01 MBING 171111
in nscyuenCm of tire you ling ri this pc.mh.
API'LICAN'I'UNDERSTANDS AND WILL COMPLY LAI Ili ALL NON-POINT AIR HANDLING UNIT IT 010.0g)CItM) MBCHANICN.FEE.
SOURCE RIiGULAI'IONS. _
NR HANDLING UNIT(OVER 111,(NNI 7M) CONS IHUCfIUN']AS
Signature of Appllcent/Contlucmr Dme F;XHAUSTHOOD(W/DUCT} HOUSING MITIGATION II?I?
HA%ARDOUS MAIFRIAIS DISCLOSURE
Will lneap111cunt or mmrc buildingtesmPm smtour handle h....der,material HEATING UNIT IT 0100.( N'TU)
us ddinW by the Cuperino Municipal Calc.Chapter 9,L2.and the Ilcahh and Safety HEAPING UNIT(OV' 100,000 BTU)
CMe,Secli^n 255320)?
❑YesS]1No' VENTILATION N(SINGLE RESIDI PAID
l' Date Remipt p
Will the applicant or future handing tecupanl use equipment or devices which BOILER- )MP(3HP OR80.000 BTU)
emit ha>nd
aous air consultant,as defined by the Bay Arca Air Quality Management 1GTXL
Domict? BOI . -COM VER 101.000 BTU)
❑Yes No
R CONDITIONER SAUANCE DATE
I nave ad the by mlous matmde
ials l,musems under Chapter 6.95 of the Cali- f ISS
famia Pire
ca d,A Safety Code.Sections 255115.255)3 and 25534.I onderland that if the NEW RESIDENTIAL ME H. SQ.FT,
buildingdoes nal curently new a terunt.tial it is my elspmsibility a notify the eccupenl
of the mquimne which must be met issuurce of o Cenifcmc of pecu ecy
Owneroroulhodz gc
Date TOTAL] ISSUED BY:
OFFICE