S 2327 (2) AF LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RULED ING-FB.b:CI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATIC, MIT PLUM1IBING-hIRG11ANIGAI. C
BUILDING FROJI?CI'IDNN'1'1PFGCf10N J
2327
HUH.fi1NGADDRESS: SANITARY NO, APPLICA'LION SUBMITI'gl.DAIh
Ddc Vjy4vv /o--5 -78
OWNERS NAME: _ �n PI NI': ^ A CCppppqryryry�tJTTTTR�ACTLOR'SNAME: LIC NO:
�snl-�u 1�1AYIYw gIcN N/C CON'1'ROLN
RCI II'rIiCT/P.NGINLEIL NO: •� ADORES:
KAr s'I, ❑
a a . . Q►� ck f
CONTACT: PHONE: BUILDING 1'E•RMIT INFO
�c�IN CAoSSKA/� Lkls)348-u7s ❑ CometitantFeesPaidbyApplicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby amrm Nm 1 am licensed under provisiomc of Chapter 9 Icmm�rewing JOB DESCRIPTION
O�Z with Section 7000)of Division 34 the 11.1mer'lad Pmficui.ns Calc, dmylieenseis RESIDENTIAL,
00 I FERMI'f ISSUANCE
n dal(nrco arta eticet. (" ❑SNDWL ❑KITCHEN REMODEL
�UU License Class 1.ic.k gp19.lANCES—RFSID2NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FZaI lac Cnntmctor J'f14 �aN�T:
NQ0. ❑MULTI-UNIT ❑STRUCTURAL.
Fin ARCHO'IiC'1"S DIiCLA ATION MODIFICATION
Z Om2 Iunderstundmyplan..shall berwdmpublic records , PANIiIS j�
OZ-, UP TO 2W AMPS V ❑INTERIOR ❑CHIMNEY REPAIR
a4amu] Licemed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
al YXJ _ OWNER-BUILDER DECLARATION OVER I000Ah1PS ❑BATH REMODEUREPAIR 0DFMOLITION
S Q I herehy affirm that I am exempt from the C.urrebr's License Law for the
�0.06 U following mason.(Seen..7011.5,Business and Profusion.Gde:Any city or county SIGNS f:LECTRICAL ❑OTHER
D13 C y which mems,,,a permit m corimmet,alter,improve,demolish,or repair any all
prior to its issuance,also requircithc applicant far such permit file Fi signed stat S:GC'AI.CIRCUIT/MISC.
y that he is licenced loometm to the provisions M the Contractor's License Law(Chapter 9
(cotntnendng Fsuh SadiF,u7XXLulDlvl.h6u3o(Ihe Buvin.,F IPuFm,AFaFCode)nrTIiMP MFIER OR POLE INST. COMMERCIAL,
that he is exempt therefrom Find the basin for the alleged exemption Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
I
W Ian Section 1031.5 by any applicant for a permit subjects the applumat IF.civil penaltyof POWER DEVICES 'RUENANT ❑FOOD SERVICE
F Z Y not more than five hundred JoHm r($500). IMPROVEMENT
f 0 01,a owner of the pmpcny..r my mgq.yl,es with wages m awirmc enmpcmmion. SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the swdu a is nut imendedor-olrered for sale(Sce.1044,Business
6 3 and Professions Code:The Control License Law does nm apply rt an owned of ll' OUTI.ISI'S—SWITCHES-19XTURP_S
propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nor iwended or offered for NEW RESIDENTIAL F.LEC?'R SQ Pr.
sale.I however,the building or intpmve.mm is sold within one year of completion,the SQ.Fr.FLOOR AREA 9SQ.Fr.
owner,hudder will have the broken of proving that he did not build or improve for pur-
I ol,ofsale).
I,as owner of the property.:.n exclusively contracting with licensed rintraeors to 1 DIAL. 13 95
ntsulter the project(See 7044,Business and Pntfessiona Ccda)'Um Cmalexmr's Li-
clo
ncLaw does not apply manowner ofproperty who builds or imprnvmdmmon,and QTY PLUMBING PE IT FEE
who contracts for such projects with a commortoms)licensed pursuant it)the Coloratura T
Licence Low. PERMIT ISSUANCE ( v
❑1 am cxempr under See. .B&PCI his recon
AUFFR—DRAIN&VENT—WATEREIA) s VALUATION
1w.l,r one _
WORKER'S COMPENSATION DECLARATION BACK HAW PROTE D NICE O 01
n O O
I hereby a1Rrm under pemtlty of perjury one of the following de hood ons: V
I have mW will maintain a Ccuilicate of Consent to set Finsme for Workers Compen- DRAINS—FLOOR, O' EA,CON 1). STORIES I PE CONSTRUCTION
Fill ,ns provided for by Seednn 31118 of the Labor Code,der the Iwrhvmanca of the
war our which this permit is issued. FIXTURES—PER TRAP LC+
have and will tomradn Worker's Gtmpemation In.surumc,ns required by Section
3 I of the Labor Code,for the performance of the work for which�th�is permitis i�ssued, GAS—EA.SYSTFM-ZINC. IiTS (xRQUp ppN
My Wnrker�f�f�r�p9y pins rote cauierand Policy nuJJlIjj� l,-7— GAS—EA.. -OVER 4(F.A)
Cattier:Y iII��I PanicPolicPolicy
7.jr12a V
CERTIFICATE OI'EXI?MPTION FROMW KERS' GREASFIINDIISTRL WASTE INTERCEPTOR COMPENSATION INSURANCE' /BUILDING DIVISION FEES _
(This suite.need not becomphutc!if the per mit is femme hundred dollars(SIM) GRGISETRAP
Fir less) I' C FEF. O
I certify that in the crfonnametof the work for which this permit is issued,I shall SEWER—SANITARY—STORM HA.200FT. /
not cntpinY any perss nusAlrcit ant li 'EG V 3z �(�
Oz xminn Lrw.v of CvliB la.Dem to e 1 I iH 14 A'fER WNENT/ELI?CTR ( p' GPEC
NUTICF.TO APP aOennW'iFg thin enilicala of xenl inn.yt ho '1'IiR. "TEM/TREATING
a [�"
become suhjed to th Fir .Com
pe prion p - f r ah a SOI . FEE
W G fnnbwirh comply wi uch pmvisFr in is pe tshull heJ me vnke TIiR: VICE.
Q
d
ION f tG AGEN ted DISNTIALI'LMfl. SQ,
V 0 the. afMnthat there isunmswctinn ending agent for parlor Date ec O
rhe work for which this permit is issued(Sec.3091,Civ.C.)
V. ULender's Name TOTAL:
W Lender's Address
Icy+ y� I Fruity that I have read this application and xmm hot the almvc Inli,rmwinn is UILDIN ( X
F� V1 Corr It.I agree m comply with u11 city and county ordimtncen mW xmtu Inwx relating to QTY, MECHANICAL.PERMIT FEE
V 7, building cureruction.and hereby umhoriAt representatives of this City to coloorpnn the 51?ISMIC
above-mentioned pmpeny for inspection purposes. PERMIT'ISSUANCE
(We)agree to save,indennily and kap hamdess the City of Cupertino against bLbCT .E G
liabilities.judgments,costs and expenses which may in any way actual,against said City ALTER OR ADD TO MECH. x9 , 7O
in emsequence of the granting of this permit. PLUM FEE
APPLICANT UNDERSTAND . 'D WILT 'OMPLY VITH ALL NON-POINT AIR HANDLING UNIT TH In'"CPM) MECHA AL ME I q, o
;',
CE REGO 1.1
AIR HANDLING UNIT(OVER 11,000 CFM) CONSTRU ION TAX
tum fApplicanUCs omen., Dntn [;XIfAOST HOOD(W/UUCP) HOUSINGM GATION HE
HAZARDOUS MATERIALS DISCLOSURE,Will thenpPltcant or ltlle building necuptmt store ollnumie hneurdnus material HEA'T'ING UNI'f(TO 100,00011 IU)
tined by the Capeninn Municipal Gale,Chapter 9.12.and the Health and S:dcty Section 25532(ayt HHAHNG UNIT(OVER 10O. 111 B'IV)
❑Yes ❑No VENTILATION FAN(SINGLE RES1D) PAID
Dateec<iptpWill Ne applicant or future building.ceapad,use equipment or devices which BOILER—COMP(3HP OR 100.001)BTU)
hareNos air comaminanm as defined by Ne Bay Area Air Quality Management DetBOILER—COMP(OVER 100.0(XIBTID 2_
❑Yes 0 N
I have re ad the hreardmusmamrill,requiiemern,ander Chapter fins of the CFili- AIR CONDITIONER ISSUANCE DATE
t'mrria Health&Safety Code,Sections 25585,25533 and 25574.I ur lemmnd that if the NEW RESIDENTIAL MECH, SQ.FI'.
bantling doer,not currently have o mous that it Is my respmsihi Illy m anti fy the oec.pont
.f the¢quirememc which nlon be tad prior at issuance of a Cir ill.at of Occupancy.
Owner or authorized agent Dam y TGTA ISSUED BY: `
OFFICE
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