S 0318 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' ICTY OI%CUPERTINO BUILDING-E.ECTRICAh 1'1!uMl'1'No, O
tU1LDINC DIVISION APPLICA'PION/P6RMIT PLUMBING-.'1rECHANIC L JC
-,I, BUILDING I'RO]N:(TTIDh:N'I'IFICA'fIDN
318
BUILDING ADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DA'I'1'.
ZZ '1 22
OWN RN MF PIION e: CONTRA 'ORS NAME: c LIC.NO
N/C C/ONTHOL a///'''���
'HITI!CT/EN HE I.ICNO, A ) S (�� - ❑ �/ _
,ON CT: /�,�rnns/PHONE: ) BUILDING PERMIT'INFO
KG' 6 . El70 lfZConsultant Fees Paid by Applicant(Initial) tI.DG Iaatcr PLUh MECH
- LLIIGG _ ❑
LICENSI!DCONTRACH)R'SDI!CLARATION QTY, r FLECPRIC PER ( s FEE„t •
I n by aE rm llt 1 l ,svd 1 p of a Pt 19Imran tg _' . - , J'. + .IOH ffSCRI111TION
OCZ cob I 71100),rD 3 nhc Ru' al f n .crd d ytir RESIDENTIAL
WOO xn PERMIT ISSUANCE
F 0.+ ofull f cc and 0•rt ❑SIrDWI. ❑KITCHEN REMODEL
aUU E¢ I.ILM APPLIANCI:5 NF,SIUEN'1'IAL [-]ADDITION ❑I'LUBING RI PIPE
N Q y Onla
th.ctor _
ARCHITECTS D' ARANO ❑MULTI-UNIT ❑STRUCTURAL.
F'H Z 1 understand my plans shall he used ox public records PANELS MODIFICATION
UP TO 200 AMPS
OZ1� - [I INTERIOR CHIMNEY REPAIR
F,N., Lmmrsed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNERBUILDERDECLARATION' OVER 1000AMPS ❑HATHRE Djzjklli li OI'HON
C W Q 1 hereby affirm J,at I l 5exempt from the Cssions r.s License Law for nhc
O y U which
llowing m,san permit
tt 7 construct.
aimms and Pref siore Code:Any shy nr roomy SIGNS I1LEC'I'RICAh ❑OTHER '
3
tai-1 prior
r t reyuims a permit to eme,meL alter,improve,demolish, file
repair any marmot
��0� prior In i¢issuance,also rtquirtsthe applicant for such pennilmfileaxigned vmemem SPECIAL CIRCUIT/AMSC.
mal he is licensed pmrmmn ,,the provivion,of the Contractor',License Low(Chapter 9
ADO mal(commencing with Sem1on 7000)of Division 3 ofthe Business unit Prulessions Code)or TEMAMETERORI'OLEINSL COMMERCIAL:
d cy� this he is ammpn therefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X m W Section 7011,5 by any applicant fur ua permit sob ers the applic ml u a civil ponohy of POWER DEVICES��� mmorc than five hundred dollars(SSW). ❑'fENAN'I' OFOOD SEIdVICE
E+Z P IMPROVEMEN T
C0 []I.asownerofthe property,or my employees with wages as theirsole compematinn, SWIMMING POOL ELECTRIC
"it do the wori themortiore ix act imendedirollend for,ole(Set.]MJ,limincv, — 91 HER
ad m and Pmfecsions Cele:The Conttacmis License Law aces not apply to an owner of OUTLETS-SWITCHES-FIX'rums
c.3.. property who bullas or improves thereon,and who does such work himself or through
his own employee,,provided that such impmvcments are nal Imondcol or olTened fin - NEW RESIDENTIAL FLECI'R SOFT
sada.ILhowevet fhmbuildingor improvement is void withinone yearnfcomploiom the SQ.FL FLOOR AREA $/SQ IT
cr-build,,will have the burden of proving than he did mol build or improve for Pur-
pose of sal,J,
❑1,as ownermf the property,am endusively conwding with liecnemd rommemrs u, 'I OrAi.:
mmmet the pmjeG(Sec.]IHC,Business and Pmm,,,rrm Csal,p The Cpnlmctnra
cruse Low does not apply it)an owner of properly who hand,or Improves thereon,and QTY.' PLUMEINO'PERMII; ”;i' r i jf'FJ:E: -
who conthas for such projects with a contractors)licensed pursuant to the Contractors •t
Liewee Law, PERM['('ISSUANCE!
I um exempt tinder Sec. .H&PC for Ibis reason
OwDDateALT ER-DRAIN&VENT-WATER TEA) VALUATION
ner
WORKER'S COMPENSATION DECLARATION RACK FLOW PROJECT.DEVICE
I hereby affirm under penalty of perjury one of the following deciemtiom: I
Lave nnJ will inuimainoCenificumnf Consent nn s,IGinwroGn'Werke/a Cnmpn,- DRAINS-H2OOR,13001',ARI?A.COND' STORIES 'IYPECONSIRIICTION
Vis,as provided lbr by Section 3)1X1 of the Labor Code.lir the performance of the '
work for which this Permit is issued FIX TURES-PER INAP
1 have and will maintain Worker's C...ha,nadtion Insurance,as,nimd by SmcJnn
3700 ofthe labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM I INC.4 OU'1'LHi S OCC.GROUT' APN
My Worker's Compensation Insurance carrier and Policy number art:
Currier: lIONy FROM
CAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF ESATI N INN ERAN W(IRKF.RS'
COMPENSATION INSURANCE GRI!ASF/INDUSTHI.WASTE IMIiHCEPIT)R
BUILDING DIVISION FEES
or less.)('I'hln eednot inn need he canplcteJ iDhepernJl is fur nnehundreJ Jollurs 1$111111
GRBASE THAI'
PLANCHIif 'De�
I evoi fythminthe perfmmarmof the work for which,h is permit is issued,I,Iw1 I SEW 1;R-SANITARY-STUNM EA.200 FT.
not employ any Parson finx�ny manners vibe ,, mthe Workers'C, No- - ENERGY FI !
,Z smian taws of Cali i(Ume WATER HEATER W/VENI'/131.F.C1'R
7�7 O Applicmr GRADING FEE
a IS ICE TO .CAN I: Bev making this Cmilicate of Exempllnn,you should WATER sys i-EM?HEATING
a , literatureeliteraturesuK m,hc WorkILer's ComPensminn Provisions of the IaMv Code,you max, SOILS IIF
W Bmhwith aunply withsnch provisions or this permit shall be deemed revoked WN1TIR SERVICE
ap
UO CONSTRUCTION LENDING AGENCY . NEW RESIDENTIAL PLMB. SQ.EC PAI Date RZ nptp y O
1 hereby.firm that lx a comion...on lending agency for the performer.if
O
u
the work for which this permit is issued(See.3097,Civ.C.)
u" E" Lender's Name - TOTAL:
O V honJcre AdJrcax 'BYGD,
}'It I certify that 1 have real this appl c i n d stomach ach theah information[ - t - BUILDING �"
cnrem l agree to complywthallcty and ty N ad none I Ifnbt QTY, MECHANICAL PERM IT'
U'� bn'IJ ngs mewed nn anA hereby.rthnriru xprs. Im,vex I'th ss'lyn uvu upon the "-(• -' s SEISMICFFH
alwve-mentioned property for inspection puireses. PERMIT ISSUANCE!
(We)agree m save,indemnify and keep harmless the City of Cupertino against _ .ECI'RIC IJ:H
Iinhilitics;Judgmama,costs unJexpenseswLich may in any way accrue aguin,i,aa Cily ALTER OR ADD TO MP.CII.
imconsequmncemilbegmnting fdispemtit. PLUMBING ITE
APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON['I'(TO IQfNNI CF �.
SSODUR/CE .GUILATI ^^ MECHANICAL PER
AIR HANDLING UNIT CONS I"RUCTION TAX
Si/ tum of Appliwnl/Cmnwclnr Dula' F.XIIAUS'IIIOOD(W/UGC'I')N,4V
HOUSINGMI'rIGA'TIONIT!R
HAZARDOUS MATERIALS DISCLOSURE:
Will ther,siicam or indoor,building occupant storm or handle hazardous nnamrial HEAT(NO UNIT(TO IW, (BTU) Ss
as defined by the Chanum,Municipal Code.Chapter 9.12,and the Health and Solhty
Code,Sarrion 25532(ap HG AT ING(INIT(OVIi1I ,N llm
❑Yrs 0 N VEN'I'ILA'IION FAN(SINGLE RESID) v PAID
Date Receipt a
Will,he applicant inanture ldefined by the B yA ea Air Qu lily Mhces which BOILER-COMP LBIP,OR 100,(X111 WITH
hazardous ulr mmuminnnts nx defined by 1M1c Iltry Arca Air Quality Mmugemcm q(Q
ttP
3 b
❑Yrs ❑Nm BOILER-COME(OVER JbE,hkR(ITU)
AIR C'ONDIT'IONER
I have read the hvardous materials requirements under Chapter 6V5 of the Cdl ISSUANCE DATE
fordo Health&Safety Code,Sec ium,25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAI.MECH SQ.IT.
huildingdnesnm,whon0y bevmam�an.NUI It linty rmeponsirinymnotify, lire occupant
of,he r quiremems which must be met prior Io issuance of a Cenlficam of(]ccopancy, �\
i
Owner or timhoriud agent Dote I 'I OTA I.: ISSUED BY: 0 QA
OFFICE
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