B 0444 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IfUll,UING-ELECTRICAL PERMIT NO. 0
BUILDING DIVISION APPLICATIONIPF,RMIT )IN(3 PROOF,MECHANICAL. S00
nuu.umr,rko)F,cr u)P:crlFlcnlluN
444
SANITARY NO. APPLICATION SUBMITTAL DAT'.
BUILDING ADDRESS:
GW SNAME: PfIONIi; CONTRACTOR'S RAMC; 'LICloj'/� N/C CONTROL#
7
ARCHI ECT/L GINEC:R: LIC NO: DURESS �5
77
CONTACT: PHONE: Q 5 13UILDING PERMITINFO
❑ Cunsultanl Fecs Paid by Applicant(Initial) BLDG ELECT UM MECH
❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION QTY ELEcril PERMIT FEE JOB DESCRIPTION
1 hereby alarm that 1 am licensed under provisions of Chapter 9(commencing
p�Z with Section]10107 of DivisionJdf the Easiness and Profusions Cade,and my license is II I° TI I'
W p PERMIT ISSUANCE
E-LL� in full farce and elle,. SPUWI. ❑KI'TCHIiN REMODEL
aUU Licc.w Cn, Lie' AYI'1.IANCES-NCSIDIiNT1AL ADDITION ❑PLUMBING RI3-PIPE
y�W Dam f/- 1i Contractor ❑MULTI-INIT ❑SI'NUC'I'URAL
FFARCHI'I'ECI'S DECLARATION PANELS MODIIICAIION
ZOy?„ Iunderamnd any plan,shell he used a.Public recoMs
OZ—m Up TO 2g1AMl'S C1 INTERIOR ❑CIIIA1NI3V REPAIR
F•vs F'LL Licensed Professional 201-1000AMPS IMI'NUV13M13NT (]SWIMMING POOLS
OWNER.BUILDEH DECLARATION OVER II00AMP5 BATHkIiMOD �EDIi
pVpIR ❑ MQI.ITI)N
C inQ 1 hereby affirm Thal I ten exempt from the Contractor's License Law for the B'HEk `�! '#1 ^T��
56xpLV
following reason.(Section 7031.5.Businea and Profes,irnrs Code:Any city or county SIGNS ELECTRICAL
F. LL y which requires a Icouit m a ic,the cher.improve,h perand a fi mrmil any atererc
F'4'p� prinnoits issuance.also myuimv the applicum fonucn permiun Cle aligned stammeml SPECIAL CIRCUIT/MISC. —�
f } That he is Isenwd pursuant to the provisions of the Contractors License Law(Chapter 9 -
"CC (anonencing with Section]IXXIIof lu,eluo 3 of the Ba,lne,sand Pr..lcisions C:alelor TEMP.MI!1'IiR ON IK)LIiINST.
dW E5 X e a
that Ile is Cnem Y here ian and ant liheba`s ter the alleged exemption.Any violmiml ul' ❑NNW BLDG/ADDITIO.N ❑DIIMOhI'1'ION
P
W2.
Section 7031.5 by rank subjects lac uPPlicam wncivil pmaulty of I'OWHH DEVICES 'T13NAN'I' E3];()Of)SERVICE
not mire than live hundred dnllam(S51NB, IMPROV?MLN1'
fSG ❑Lavowneroflhe,speny,only entpinyccv with wagce us their sole aonspensmimt, SWIMMING IDOL ULE ❑Q'THI?k
N will do the work,and the stactum is not intended or offered for sale(See,9144,Business
W•�w and Professions Cash,The Contractor's License Law does not apply to an owner of 011'f1.ITs-SWITCHES-FI%TURES
a 3 property who builds or improves Inercnn.and who does such work himself nn through NEW RESIDENI'IAh r;LECfR SQ Pf.
his awn employees,provided flat such impmvemels nme not intended or offered for )0R AREA $IS().I.T.
sale.If,however.the building or improvement is said within one year efcompetion,the
ownerdailder will have the burden of proving that head not build or improve for pur-
grse nfmlcJ. I'
I as owner of the pr pedy ly contracting with licensed contractors m
construct the prap,et(Sec.7144 R .:and limfessione,Code:)Th C I o I s l: Y
scow Law olue,no,apply locaucone,of p p rtY what Wild, p :fficircon.and QTY I'I,UMB FSP RMIT„ 1
wbe convmis for vaeh prgecl,w'"It,11 t(maor(s)hccn.ed puma,O as Co eavl m v
License Law. PERMIT
I am esentpt undm See. ,B&PC bar Thi,.,un I
AUI-EK— AIN&VE —W, R 7 VALUATION
Owner Date ll )
WORKER'S COMPENSATION DECLARATION RACK FL( DEVICE SOV
Q-
I hereby afkrm ander pmeal y of perjury ole of the following declaetioue
have and will mainlam aCrnikcam of Cnnsenuo self-insure(err Workers Compel- DRAINS—FLOOR.ROOF AREA,COND. STORIES 'I'V PIi C0NS'I KUCTIO
sation,a,provided for by Section 39011 of the Labor Code,for the performance of the
w k fm
IT..which this petif is issued. FIXTURES—PER'THAP
1 I have and will mummin Wnrkcf's C.... cation Imaofnce,a,mill ired by Section
KA OUTLET$
nCode home he Labor Cofw
o me pe,ho, mcolthe ink for whGAS—I3A.SYS'1'F:M11-
ichthis permit is i...To. I INCOCC GROUP AI'N
My Wnrky'vC In'uren'//gk joined Policy nun c t CASA-13A,SYS'T13MOVBR4(EA)
Curricnr�' y ��'✓'�f ""`�P'dicy Nu.: r
CERTBlCAT1;OF EXEMPTION PROM WORKERSGRI3ASY]INUUS'I'RI.WASTE INTERCHVH)N
COMI'IiNSAIION INSURANCE ❑111LDING DIVISION L EES
(This section red not becnmplcled iffhe permit is for one hundred dollars(SIM) GREASE TRAP PLANCHEC'K ITT,
or los.7
I ccnifY Na imhe perfonmanee of the work for whirl this permit is izued.l shall :QTY, �Ml"ECHANICAL
—SANITARY—STORM EA.?WFT. ENERGY PIiIi
not employ any Person in any manner so us m become subject the Workers'Compen-
sation Laws of California.Dae H13N'CN W/VLNT/ELECIR �D. GRADING PIi
ZO Applicant 3
H NOTICE TO APPLICANT:It,.atter making this Cen ficac of Exemption.You shouldSYS'I'IIM TREATING SOILS FEE
L•a hea..mm suhjorf m the Worker,Compensation pmvisice,of the la rte talc,you malt
ami l dhwith comply with ouch pawkioms or this permit shall be deemed revoked. SERVICE
Y
Q GONS'I'RUC'IION LENDING AGENCY SIDEN'I'SAL PLMB. SQ.Irk PAID
U Z >a Raciplp
U O hereby,room mm mneisncett.wnnln lending rte me prrrdrinance err
", the work for whichthis permit is issued(Sea.3119].Civ.C.)
0 U Lender'.,Name TOTAL: S(�
tenders Address BUILDING ITE
a 1 readily that I have read this application and stag that the,trove information is
l correct.l agree to comply with all city and county ordinances and same laws refusing 10 MECHANICAL PERMIT FEE SEISMIC ITE
U Z building construction,and hereby authmirc repremnetives of this city to enter upon theabove-mentioed property far inspection purposes. ISSUANCE 13 YI RIC PEE
(We)agree to save,im letmtify and keep harmless the City of Cupedino againstlinbililics,judgments,costs and enPcases which may in any way aceme against said CityOH AUD TO MECH. PLUMBING FEE
looe,acnce of the granting of las permit.A1.111.ICAN'I'UNDERS'I'AN US AN O W I LL COMPLY W I'I I I ALL N(N.I'O I N'I' NDLI NG U Nil(10 I b,mo I CPM) MHCUANICAI,F.3
NDLING UNIT(OVER 10,000 CPM) CO SIR IN '
a On
Jlgneturc ol'Apphc V nm nor Doc PXHAUS'r HOOD IW/DUGT) 11OUSIN G LOS FEE
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant or home Wilding aecupart store ry handle haeardou,material HEATING UNIT(TO 1110.000 BTU)
as defined by the Cuperan t Municipal Cade.Chapter 9.12.and the Health and Safety HEATING UNH'(OVER M,000 BTU)
Code.Section 25534(o)'I PAID
❑Yes ❑No VEN'rH.AT1ON FAN(SINGLE R&SID) Dale Receipt 9
Will the applicant or future building occupant use equipment or devices which 11011,13E—COMP'(311P OR W 100 BTU)( mil nvunlonsair commninums as dullard by the Bary Area Air Quality Managrn too IOIAL:
D'minidP BOILER—COMP(OVER 100.003 R'IU) rl
❑Yes ❑No
2�/
AIH CONDITIONER ISSUANCE DATIi
1 nava read Inc Code,Se materials 15505.25533
ander .I and b.95 of the date
hmtia I does&Safety Castel Sections 25585.25533 mW 255J4.1 I nmodify d an::t date NEW RESIDI3NTIAI.MECII, SQ.PI'.
builJingJ«s not carne hav rnaamll��pa.shat is is my responsihiliry In modify the,,pant l
of the account, h t f be mel pie to issuance ofa Cmifcae of(k<upallcy.
Owner err author agent
r /7 Dee T(YI'AL: ISSUED BY: O
OFFICE