S 2701 (2) -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALPI3RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NIECHANIC L O` O
BUILDING PROJECT IDEN'FIVICATION J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITI'ALDATL
fm - 194110 L i GZ 3 Q
OWNERS' NAME; PHONE: COMA CfOR'S NAME: LIC NO:
1//1 ly LNIC COVfROL#
❑HITECfININEEk: LIC NOADDRESS:
. // A
"')
CGNTACI 'PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) or ErL�E. PLUMB MECCHH
pC. 08-Z t� LT ❑ `CI
I.ICF.NSEDCONIRAC1'OR'S DECLARATION QTY EI.ECfRIC PERMIT FEE
hereby affirm that 1 no,licensed under pmviuions of Chapter 9(commencing JOB DESCRIPTION
O�+Z with Section 7001nuf Division 3nf the Husinen and Pothsvlons Codeandn,y I vett,,, RESIDENTIAL
i'13HMIT ISSDANCIi
Fly in full force and filen. .? �(2.3�/� ❑SFDWL ❑KITCIII3N kIiMODEI.
QUwj Licenu Clas u Conte APPLIANCES-RESIDENTIAL. ❑ADOPTION ❑PLUMBING RE-PIPE
rFa W6 Dare 2y, o/ Commnor Q�=R-" �c^4.AYG�1+
ARCHITECI-S DECLARNFION El MULTI-UNIT GSTRUCfURAL
,O y PANELS
Zc,.Z 1andentepIsoy pla�n�s,hall W malas public record, MODIFICATION
OZ`N-C /� UPTO2O0AMPS ❑INTFRIOR ❑CHIMN17Y REPAIR
I,,wnseJ Pmrifmal 2HI-IOdH1AMP$ IMPkOVEMENT ElSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IIXN)AMPS El BATH REMODEUREPAIR ❑DEMOLITION
k3CC 6'Q 1 hereby affirm that 1 am exempt from the Commcmr's License Law for the
6Q following reason,(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0 El OTHER
LL7 LL which requires a permit to comwn,alter,improve,demolish,or repair any smodure
0� prior o its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUI I C.
�y that he is licensedpursuanOnthepmvlsumsoftheContractor'.sLicenseLuw(Chapter9
g Q0�0 (contmunaing wit h Section 7000)of Division 3ofthe liuslnesa and Prnfmsinii,Cndc)nr '111M I'.M ETER Of I'( +JK" COMMERCIAL:
0. eC tom he is exempt therefrom and the basis for the alleged exemption.Any I olathm ofNEW BLDGIADDI'fl(IN ElDEMOLITION Piss
NSection 7031.5 by any applicantfor a permit subjects the applicaat to a civil penalty of MOWER DEVICES JIJ
not mufethan five hundred dollars Wo n. itiTENANT ❑FOOD FOODSERVICE
F=G ❑ Las ownerofthe propeny or tnycmployees with wages as theirwlecnm''an ❑OTHER
ion, SWIMMING POOL ELECTRIC IMPROVEMENT
f�F.. will do the work,and the structure is not intended or offered for sale(See.7(HOUTLETS-SWH'CHES-PIXTURI?S J
4,Business OTHEk
41 and It fis,ioos Code:no Conuaetides License Law does not apply w on owner of
'ou'ro,who huild,of improve,do"con,and who doe,ouch work hinot d n ,hmogh
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ IT
sale If,hnwcventhe building orintprovement itself within oneyearnfcompletion,'hc SQ.FT.FLOOR AREA 4JSQ.FT.
ner-builder will have the burden of proving that he did not Wild or improve for pur11
-
pose of sale.)
0 I,as owner of the property,am colmlively contracting with licensed contractors in T*-: I
on....a the project(Sec.7W4,Iloslnexs and Profs,inn,Cade:)The Contractor's Ll-
cm,e Law dnc,son apply ,,aoowoer„fpmpeny who build.nr improve,mermnt.and QTY. ING PERMIT FEE
whoammets unseen projects with acommemq')licensor Putman h]the Contender,
License Law. PERMIT IS. A .13
❑I an exempt under Sec. .B&P C for this Tewson
Data '
ALTER-D T-W'f;R(EA) VALUATION
WORKERS COMPENSATION DECLARATION
coving HACK PLOW PR(Y T.DEV I:
I hcrchy td0rm under peruhy of perjury ono of ell fn me Le declanr's Co Q
❑..as undwiBt fee
Labor Codenontfor rfumaeCon,pche pItA1N5-FLOOR,ROOF R13A. 'O ). 'ORIP.S TYPE CONSTRUCTION
nasion,as which
for mi Section 37Mof @e Labor Cale,on the performance of the
work for which tills permit is issued. FIXTURES-PER TRA
❑1 have old La will ode,for
nhe Korn Carte of thew work
%e,h required M1y Section
the Code,fonhe perinrntancirr in] work for which this permit is issued. CAS-EA.SYSTIiM-1 INC. UTl.li l' OCC CROUP APN
My Wnrkur', ompnm'minn lnsunmcc currier nnA Polley WY he
Currier: Policy Nn.: "a��765 GAS-EA.SYS'1'HM-OVER 4fEA)
Cli TIFICAI UP 1311?MPTION FROM WORKERS'
COMI'13NSADON INSURANCE GREASFANUUSTI I.WASTE IN'IINCEPTOR
BUILDING DIVISION F13L•S
(This section need not W completed ifthe pcmtit is Torous hundred Jnllarx(SIM) '--
GREASLTRAI' /
or less) PLANCH[CK FEE
I cenify ihm in the performanecurthe work fur which this permit in issued,[,hall r
SI3WEN-SANITARY-STORM EA.21N1IT.
urn employ any person in any intoner so as w hennnc subject n,the Workers'Cloutier. HNEHGV FP.P. O
',Z nation Lawa(it Cullrornla.Dme WAIERHEXIERWNIN'VELECIR
y�C) Applicant GRADING PEE
F7 q NOTICE TO APPLICANT.If,after making this Cenilicate of Exemption,you should WATER SYSTIEvIaR SATING
a 7 become subject u,the Worke(a Compensation previsions of the Ia or Cole,you must SOILS PEE.
forthwith comply with such provisions or this pcmaitxhall he deemed revoked. WATER SERVICE
aQ
UO CONSTRIICI'ION LENDING AGENCY NEW RESIDENT Al,PLMB. SQ,FT, PAID
Data Receipt#
1 hot ich do dhmthere al(See i3y1C,Cim agency fonhe perli,nnonec sur
H
Leworknders
lin woiuh Lois permit ix ievucJ lSee.3097,Civ.C.)
0 Lenders Name TOTAL:
� �V I'nfer's Address TOTAL:
1 cenify that 1 have read this appiicatiun and slam that the above information is BUILDING FEE
o-Fi N when.I agree to comply witha11 city and countyoulinances and scale law,reining to QTY. MSCI IANICAL PERMIT FEE
U Z building convmc0on,and herebyauthaiu represenmtives ofihis tidy to emarupon the SEISMI
show-mnntieumd property for Inspatlnn purposes.
(We)agree to s ,indenmil'y and arm
keep hless the City of Ctrourd n.,at.,( PERMIT ISSUANCE L'LGCfRIC P
ave ' S�
liabilities,judgnieno,costs and expenses which may many way arrive against said City // ALT ER OR ADD TO h1ECH. `
in coaaequence of the granting of this permit. b to PLUMBI E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO I0.O00CFM1
SOURCE REGULATIONS. MECIIANI L �F: � g
�/) AIR HANDLING UNI'f1OVER 10,IXq CPM) CONST RU. TAX
Siga rom u1Appheanl/Come etor •�! hue EXHAUST HOOD DODUC'O H tt G MI* N Il3E
HAZARDOUS MAITIUALS DISCLOSURE P'
Wilidw. plicand offame WTWingsaceusantemrcorhandlehaland dna anal BEATING UNIT('11)10.0O0 BTU) d
as defined by the Cupertino Municiyyyal Cak.Chapter H.12,and the Health anJ Safety
Code,Seetien 255E2(a)P / HEATING UNIT(OVER 10ko 10 BTU) ', —MAR-1 Q
El Yep �( VIINTILA'1'IDN PAN fSINO1.H R1351U) P ) MAR
Dmc Re
Will the applicant or future huifired occupant use Area
Air u m device,which
omh hazaNnu,air wnmminants u' chnal by the Ray Arca Air Qualify Managmnend BOILER-COMP(JHP OR I(q.INlll B'fll)
D0v
istrict? BOILER-COMP(OVER 100,0110 BTU)
❑Yes
I have rend the hazardum naucoals requiretnems order Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomiu ficalth&Safety Code,Sections 25505,25533 trod 25534.1 umlemtnnd that d the NEW RESIDI3NI'IAL ML If SQ.FF
building does nmcurmody haven dethm6 foul it is my resptm,ihilityI not' he occupier �j'-
oftherequiret whichmustln mpnnrmisamidenlaCeri Occupancy.
Own agent Dna OT L' 70 1 ISSUED BY:
OFFICE _ _