S 1464 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO, 1464
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`
BUILDING PROJECT IDENTIF'ICAB'OlN
BU....I+y0 AI I P SANITARY N(I. APPLICA'HON SUBMITIA.DATE
OWN" 1 PH NT' N'1' L1�OlD'
L ZLL Q [ G 6 �S N/C CONlBOI.g
'AItC II'I'ECf/IiN, CER: LIC (l: /�{I{ItfiS)'V lr 0 /`e.* V
CONTACT: PHONE: 4 �(` u BUILDING PERMIT INFO
Consul� B Fins III.—.."..,by pant Iniliap BLUCy HLFiCf PLUMB MECH
LLIIICCEENN`SSEDCCONTRAM ORIS DECLARATION TY ELECTRIC PERMIT FEE
1 hereby affirth
m at I am licensed under provisions of Chapter 9(canamencing JOB DESCRIPTION
OmZ with Section 7")of Division 3 of the Businexsn Profess i ndnryhcemelx I:
RFSIDENTIA
W OO PHRMI'TISSIANCIi
F-W� In Tull fnnr and eBecr.T� ( ❑SFDWI. ❑KITCHEN It IiMODEL
�UU Lwenxa Class i.J Li'.k APPLIANCES-RHSIDITS TIAL ❑ADDHION ❑PLUMBING R Iz_P1PH
tFZul Dam Cnnno,fit
6FF
F n ❑MUCfhUNIT ❑ '
w ARCIUTHC'I'S DECLARATION PANELS MODIFICAHO
N
Z O h 1 nndecswnd my plans shall be used us pnbllc records
OZ`"--1n UP TO 2(NIAMPS []INTERIOR ❑CHIMNIiS'RfiPAIR
FYd.F',W Licensed Prof e..mind 201-10MAMP$ 'ROVEMFNT SWIMMING POOLS
OWNER BUILDER DECLARATION OVFiR I(NNIAMI'S HREMODEUREPAIR ❑DEMOLITION
tY Q 1 hereby affirm rho 1 ton exempt from the Commetors Liceme Law for the
1S�(O a V following rem-nn.(Serino 1O3L5.Business and Professions Cede:Any city nr county
SIGNS ELECTRICAL 0 )TIILR
+++3 W y which requires a permit ro aonswn.:Jgr,impmvc,demolish,nr repair any ewaure
.F.^NOat prior to its emence,also requires the applicant for such proof to file a signedmagramin SPECIAL C IRCUIT/M ISC.
W� that he is licensed parmanno the Provisions of me Commctors License Law(Cludder9
0 (cnnunencing with Section 7000)of Division 3n ft he Business and Professions Code)... 'TEM R M B'I'ER OR POLE I NST. COMMERCIAL:
M p+o eG thin he is exempt thereliun and the huxis for the alleged exemption.Any wit Irmo n or ❑NEW IU.UG/ADDITION ❑DEMOLITION
kX1 IrN• Section 70.315 hyanyapplicimfor;permit"'I'iectsthe npplaint onoivil Penalty est POWIIR DHVICIIS ❑TE'NAN'T' El moi)SHRViCE
3 y of more than five hundred dollars I$SBOL IMPROVEMENT
Q Lus owner of the prnpeny.onny en+ployees with rages us their sole con+persation, SWIMMING POOLELF.CTRIC
E G will dothework.rodthemmcga,Now iatendedofoBBredfo...le(See JMY Business ❑OTHER
m
W and Professions Cade:The Contractor's Licensw Law does not apply to an owner of OLO LIST'S-SWITCHES-FIXTURES
a 3 propsny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvement arc not ingndcd or aBemd for NI7W RESIDENTIAL F.LECTR SQ ET
sake.If.hwaevee the Wilding()I improvement is sold within oneycarnl a+mpldion,Ne SQ.1-7.FLOOR AREA ESQ.F1'.
msomrbuili will have the burden of proving that he did not build or improve for pur-
,ecorod'.).
❑I,an owner of the progeny,am exclusively contracting with licensed comrucnax to TRIAL PAID'
mxtrael the pngect(Sec.TAU Business and Professions Codc)'Me Coomwou'a Li- P IY D
to Law docs not apply to an owner of property who builds or aq+roves nmmon.and QTY PL.UMBINL �RMIT FEE
who contracts for such projects with n mmruclonO hecnxel pi nmano the Cnnonetor's ®n n
License Law. PERMIT ISSUANCE APR 2 ANS-D
❑ I oto exempt under Sec. ,B&P C far this«aed A
ALTER-DRAIN&VENT-WATE I b Ur VALUATION
Owner Dare I I�U��
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alfinn under penalty of perjury one of rhe following declarations:
I have and will maintain a Certificate of Consent o self-insure for Workefs Compen- DRAINS-FLOOR,ROOF,AREA.GOND, STORIES TYPE CONS'FRULTION
cation,as provided for by Section 3701 of the labor Code,for the performance mf the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I hove and will maintain Workers Cmnpensation Insurance,as required by Senion
17N)of the Labor Gale,forthe)wrfonnance nal the work forwhich thispeonal is issued, GAS-IIA.SYS'I Em.I INC.4 OUTLE9'S (ICC.GROUP AI'N
My Worker's Compensation Inssnnncc comer and Entry number arc:
Curie,: Policy Na: GAS-EA.SYS] 3MAVER 4(EA)
CERTIFICATE OF EXEMI9'ION FROM WORKERS'
COMPENSATION INSURANCE ORIASIUINDUS'TRL WASTE INTERCEPIOR
BUILDING DIVISION FOES
' (This section need not be completed if the permit is Torose hundred doilw($I(N) GREASE TRAP
nr less.) PIANCIIECK FF.E
y at in me performance ofthe work for which Nis permit is issued,]shall SEWER-SANITARY-STORM EA.2M FT.
not em y o m o Iveco a subject ai the Workerz Comped ENERGY ITHE
Z wtionU manAsnor WATER HEATER WN13W/ELECR
Applic' GRADING THE
y
NOTICE'1'O APPLICANT:If,aper awkgg this Cenif+cate of Exemption,you should WATER SYSTEM/TREATING SOILS FRH
ahavn+c suhjea o the Worker's CompemnJg+provisions of the Labor Code,you must
Da Iimhwith ototd,with such pnry dammer tb6l.emit shall W deemed revoked. WATER SERVICE
Q n
is
CONSTRUCTIONsit ma LENDING AGENCY NEW RESIUIiN('IAI.PLMB, SQ.IrI'. PAID
( C.)0 Thereby off rte rhuure arnnathemninn lending agency Ba rhe perfnrmmnce of ]lugIj. c prN
the work far which this permit is issued(Sec.3097,Civ.C.)
0 F-'L) Leader's Name TOTAL: TOTAL:
Lender's Address
1 certify that 1 have read this application and slag that the above infmrmaion is BUILDING RB
t F Ile-
In enrrect.l agree o romply with ell city nnJ enemy ordinances unJ stem laws rciming m Q MECHANICAL PERMIT FEE
U building convection,and hereby authorise representatives ofthis city to enterupon the SEISMIC ITE
nbmvomgnioned property for ira,awine umpose"' PERMIT ISSUANCE(We)ugrce m save,indemnify nand keep harmless the City oI Cupaninn tgaimt ELECTRI I?
IiabiliBea,judgment,costs anA cxpcnrc bath may in any way accrueaminxtsnid City ALTERORADD TO MECH. '
w ena of the peougg of this pe a PLUMBING ITIS
AP CAN'T'UNDERSTANDS AND WILT. MPLY WITH ALL N� NT AIR HANDLING UNIT(TO 100)( rid)
OH '
2 MECfIANICAL 'EE
AIR HANDLING UNIT(OVER 10,000CF1,11) CONSTRUCT INTAX
Signature ofApplicanJConmanor Date EXHAUST HOOD(W/DUCT) HOUSING S TIGA'TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture Wilding ocupam store or handle hmanlous material HEATING ON]]'(TO I W.(100 BTU)
as defined by the Captain.Mm+icipal Code,Chapter 9.12,wad the Health and Safety
Code,Section 25532(a)P HHA'I'ING UNIT(OVER 100,0010 BTU)
❑Yes ❑No VHNU LAI ON PAN(SINGLE RESH)) PAID
R ipI X
Will the at, tuna or mtore building i by the B use equipment or devices which
mnir hunrtdoue air conwminams os delineA by the❑nay Area Air Ugllty Munagmmm� BOILHit-cGMP(.111P OR 1011,00XI BTU) Iiyi'AI.
Dirrictf
E]yes No BOILER-COM 11(OVER I00,01MBTU)
I have revel the 1uuNog mmenals requirement umier Chapter 695 of the Cali.. AIR CONDITIONER $SUANCE DATE
farm.Health&Safety Code.Sections 25585.25577 and 25534.1 understand that if the NEW RESIDIII IAL MECH. SQ.FT.
building does no currently have a annual.that it is my responsibility to only the oecup m
mf the requirements which must be met poor to issuance of a Certificate of Occupancy.
Owner or molummd agent Duo TOTAL ISSUED BY:
OFFICE