S 1202 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DOE IAMNG-ButCTRICAL PE ITNO
1$UILDING HE
APPLICATION/PERMIT PLUMBING.MECHANICAL V 1202
BUILDING PROJECT IDKNTIF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
gh ®res;d1� Vr- Cw orfitlo 2tnto)
WNI!R:S NAME:S PHONE: i� CONTRACTORS NAME: LIC NO:'tPh t 111 I I —J NIC LONTROLM
I {T h
nI<rnrrrscT/, clNeck: lac NO. anDlxess: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
1 ❑ Consultant Feu Paid by Applicant(Initial) BLDstsi?G ELECT PLUMB M:CIT
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby v1Brm that 1 am licensed under provisions of Chapter 9(comnxncing JOB DESCRIPTION
OWZ with Section RX107 of0ivision3ofthe Businexs and Profen:ion.Code.and mylicense is - RESIDENTIAL:
WOO PERMIT ISSUANCE
CIF in full oriental effect. ❑smwi. LIKITCHEN RF.MODEI.
aVU Lmcnse Class LIC.M APPLIANCPS-RESIDEN'TEA], []ADDITION ❑PLUMBING RE Phil:
FW Ilam Contractor
mp vQi ARCH IT'EC'I'S DCCLAkA'ITON PANI!LS ❑MULTI-UNfI' ❑STRUCTURAL.
F NY andnretand my phos shell he used as public record, MODIFICATION
ZOyp
oz—, UPTO200AMPS
[D INTERIOR ❑S IMMINGP OL
�+� ul Licensed Rafessinml 201-IfNIBAMI'S IMPROVEMENT' E]SWIMMING P001.S
OWNER-ItUILUIik DECLARATION OVER 1000 AMT'S ATH REMODEUREPAIR ❑DEMOLITION
C
herehy affirm that 1 am exempt from the Contractors License Law for the
13 1- Br1 llnwing rcuson.(Section 7031.5.Business and profession,Code Any city or cnuntY SIGNS ELBCI'RICAI. OTHER
y¢ which requires a permit m ermarma.rnor,inrpmve.demolish,or repair any ourro re
�y'OJ prior to its issuance,she reclaim the applicant for such permit to file a signed statement SPECIAL CIRCLE TOM ISC.
ftp". that he is licensed Pursuant to the provioorsof the Comracmex license Law(CTaper9
�CpO mommcnc!ng with Section]00yal Oil slim J of the Business and Professions CedMor TEMP..17ER OR 1'01.1!INST. COMMERCIAL:
d y o 5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�4G7 Yy Scelion](IJLS M1yanyapplicant Tam Per it mocedlheapplicam macwt penupyof POWER DEVICIlS ❑TENANT ❑FOOD SERVICE
2qtat more than five hundred dollars($5(0). IMPROVEMI:N'I'
F� ❑ I,uxnwner of the pmpcny,nr nryempinyccs with wages uvthdranle nnnpeciation, SWIMMING POOL HLECfRIC
will it,,the work.and m
thestcture is not In cal,d oroffcred for si le(Se,7044,lIminesv ❑OTHER
ly and Professions Code:The Comnctnr's Liceme Law does not apply to an owner,cIOUTLETS-SWITCI ITS-PI%'TURES
properly who builds or improves therunn,.nd who does such work himself or fling,
his own employees,provided that such lmpawermats arc not intended mourned for NEW RESIDENT'I'[AT,ELECT R SQ
A le sale.If hithe building or improvement is sold within one yearofcompletion,the �O
ar- �/T.�1,t AREA SISQ.IrI'.
rwnechuilder will have the burden of proving that he did not build or improve for p
pose of sale.).
Flw
1,as rner of the progeny,am exclusively contracting with licensed contractors or TOTAL: n�
construct the project(Sec.]M4,Bu.xines.and Professions-oui the Cranmctoh Li- FEB fIIY�sO
se law does not apply m an owner of property wrho builds or improves thereon, QTy, PLUMBING PERMIT FEE
1 who contracts for such Projects with a urmrmaods)licensed Pursuant o the Contractor's
Liccnm Law. PERMIT ISSUANCI!
I wo eximrpI uncle sec. ,B&P C for this re:ooVALUATION n Uf uW'LrT UJ
- ALTER-DRAIN&VHN'I'-WATER(EA) VALUATION
nam
WORKERS COM PHNSA'1'ION DECLARATION BACK FLOW PRGI ECT.DEVICE
have
and women under penally to ofComaneofthefnBowingdem:
❑Ihave prowled far
etion 37vm of Connery Cade,
fol-Worker's ncof the
URAINS-FLOUR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
swion,as provided for by is issi J]W orf the tabu Cale,for the performubce of the
work for which ills pemtai is issued. FIXTURF_S-PER TRAP
1 have and will maintain Workers ence of the%Insurance,h required t i Section
3710 of the faMrCaigfonhe perlinmance of the work for which this pemtit is:sated, GAS-EA.SYSTEM-I INCA OUTLETS OCC GROUP APN
My Workers Compensation Insurance carrier Emit Pal icy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CP.RTI PICATE OF EXAM PTION FROM WORKERS' GRP.ASPIINDUS'I'RI.WASTE INTERCEPTORCOMPENSATION INSURANCE 11 U 11.DI NO DIVISION FEES
(T his section mcdo,be a i,lemd if thopenmitls fora.handiest dell ars($100) GREASHTRAP
nr
less) FLANCHBCK FI!1i
I certify that in the performance of the work far which this email is issued,Lshvll SEWER-SANITARY-S'I'OEM EA.2(X)FT
not employ any person in any manner a as to become subject o the Wnrkerq Compen- ENERGY FEE
Z nation laws of Calimmiu.Date WATER HEATER W/VItIMLECTR
O Applicata GRADING F02
z h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'ITh aREATING SOILS FEE
f" become subject to the Workers Compreommn provis!mo of the tabor Code,you must
forthwith comply with,a,h puskimsor this permit shall or deemede,voked. WATER SERVICE
Q
CONSTRUCTION[.ENDING AGENCY NEW RBSIDENI'1A1.I'LMH. SQ.Ff.NAID
I her.1hichdi that them issued( et.N len ding agwoy for parlimmm�a of I n wlptM
O F the wmksilroc eh this permit is issued(See.J(xJ],Civ.C.)
Q U
Lcoccr,Name 'TOTAL:
Isndds AAJrcss TOTAL
1 certify that 1 have read this application and state that the above informalom is ILDING FI'.
EF. rq correct.l agree to comply with all city and county ordinances and state lows reining to QTY. MECHANICAL PERMIT
UZ, building conswction,and hereby aulhorim representatives of this city to enter nrymthe ISMIC IL'
vNrvementione l properly for inspection purposes. PERMIT ISSUANCIi
(We)ag.o.save,indemnify and keep harmless the City of Cupertino against ECITtICF li
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADDTU MI!CH.
UhIBINGI aiin PLICANT Nthegrunting Sthis DCWELAPPLICANT UNDERSTANDS AND WIL1.COMPLY WITH ALL NON-I'OIN'1' qIR HANDLING UNIT LTO 1(I,IMd CFMICHANIC .FI!liSOURCE RF,GULATIONS.
AIR HANDLING 11N1'I'(OVER 10,1100 CFM) NSTRUCf NTAX
Signa�,dby
com/Comractor Doc EXHAUST'HooD(W/U11C'f) USING MI' IGAI'ION FEH
HAZARDOUS MXHERIAI S DISCLOSURE
pplan:norfumre halldingaeempmnl atemmrhirdle nw.ardousmuveriol HEATING ON[T'fTO 01),0NI RTU)
us Jd Cmpedino Municipal Code.Clmpmr 9.12,and the fleallh unit Sulmy
Cod.Section 23532(.)^ HBArING UNIT(OV HR IfiuTX)I BTU)
❑Yee -1 No VENTILATION FAN(SINGLE RESID) PAID
• Uam Receipt
Wilt the air contaminants
or future building by he B use equipment or devices which
snit Irarardeas air camaminams os JcEnW by the Bay Area Air Quality Management BOILER-COMP OHI'OR IIIO.IXtO BTU) TOI'AI.
Distria9 BOILER-COMP(OVER 100,001)BTU)
❑Yes 0N
I have rind the haeardous Enutminls rapdrenmms undo Chnpmr6.95 of the Cali- AIR CONDE HONER ISSUANCE DATE
fonow I Icuhh&Salbty Cede,Soetlnns 25585,25533 and 25534.I underatnnd tbut if the NEW RI:S JOE rUAL MHCI I. SQ.Pr
l kilo'drxserncurtmntly laneuwnunE that it is my mrymsibllity mramify Jm cecnpnnt
of yair entsevh:�h mQslh inciprionolssuanceofa Cenilicamof(U ney.
to
rI� �� 4 TOTAL: ISSUED BY:
.(Ti rte uruthorized agent Date
OFFICE