S 0199 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL 1-17RMII NO,
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBUSG-MECHANICAL S 0199
BUILDING PR(IJECT IIIENTIMCATION
BUILDIN lR SS: SANITARY NO. APPLICATION SU13MI'TEAL HAITI
SR G z
OW 3RX AME: ,OWZ PHO !:, CON'TRACTIIR'S NAME: LIC NR
�No NIC CfIN'B(ll,a
IIITP I�N ER: IC
No AIlIlR1iSS: ❑
CONTA : PHONE: BUILDING PERMI'FINFO
❑ Consultant Fees Paid by Applicant(Initial) I` ` IiutJy 1'1.1 nuia
LICENSC:DCONTRACfORT DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under Sari of Chapter 9(commencing JOB DESCRIPI'ION
O�Z with Section 70(nof Do,kion 2 ofmhe Business and Pmfevsions Code.and my Swerve is RESIDENTIAL
Wp PF.RMI'I'ISSUANCC �S; WI. ❑KI'POSEN REMODEL
�_� LiceneClassce nd ulfccl. _— u
QUV License Class Lim. APPLIANCES-RESIDENTIAL l /DTIITION ❑PLUMBING BE PIPE
F Z W Dam Commcmr F
H Q or ❑ 1UI.TI-UNIT ❑STRICPDRAL
ARCHITECTS DECLARATIONPANELS
1DOATION
w UP102 CHIMEMODIFYREPA
vZ^ lunderslund my plmtx shall be uxeA us public,orris
I R
OZ�G, QP TO 20)AMI'S ❑IMPROVE []CHIMMINGPOOI_
F4~y1 LimIned Pmfca,mnal 201-100)AMPS IMPROVEMENT (]$WIMh11NG I'GQIS
�ac f" OWNER-BUILDER DECLARATION OVER 1g10AMPS ❑BAD]mIODEIIREPAIR A TION
?'C Q I hereby affirm mem Sam exempt from the Contractor's I.icwnse Law lin IM1e
W ❑OTf11:R/
jaj 3F following rcaxan.IScctinn 913 5,Rusinuss and Profession,Crdu:Any city or umnly SIGNS ELECTRICALlJ�
la.y which,egmrea a permit art construct,alter,improve.demolish.or repair any%fracture
1'=0Q prior it)its issuance.also requires the applicant for such permit m file a signed statement SPECIALCIRCUI'I'/MISC.
that he is licensed pursuant o the provisions of the Contractors License Law Chance
�..GCO fco. 700pofDivixion.3ofthw Business and Poolesdons CmIGa, TEM It M ITER OR POLE INS"I COMMERCIAL:
a L e y 'hut he is exempt therefrom and the basis for the alleged exemption.Any sedition of El N17
IILUGIADDIIION ❑DBMOLI'I'ION
�H Section 703 L5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑T17NANT ❑FOOD SIiHVICIi
not tame than live hundred dollars($500). Ih111ROVEMENT
C] 1,as owner of the property.or my employees with wages as fnirsolc compensation. SWIMMING POOL ELECTRIC
$�+F will dothe work.andthe structure is not intended orol'tcred rnrsale(See.70J4,Busincxs [:1 OTHER
W 3 m and Professions Code:The Contractors License
Law docs nor apply to an owner of OUTLETS-SN'ITCIIES-IgX'fURES
too,ay who builds to improves thereon,and who docs such work himself or through
his own cmploycm,provided that such intprovcmems art not intended or offered far NEW RESIDENTIAL ELECfR SQ FT
mit IL however,the building or improvemnenl is sold within one yca...I " pI,I 'the SQ.FE FLOOR AREA S/SQ.Irl'.
owner-builder will have the burden of proving that he did not build or improve liar per-
O 1 of sol TOTAL:
owner f the propcny, m exclusively contracting ith licensed cantracturs m
construct the project(Seo 764,1 Business and P f :Cei I he i-oninninsr'x I.,-
remit,Ls
i-tnwl.0 dcvv notapply l c flmpcny who builds or improves di m,and QTY. PLUMBING PERMIT FEE
who cord hpnI is 'th a n to the Commi
User w.
,H& C to his rw: PERMIT ISSUANCE
1:
ALT -DRAIN&VFW-WADiR IEA) VALUAI'
Owner Dal
KEWS COMPENSATION DECLARATION BACK Iq.OW PROTECT.DEVICE
1 ere
storm under penalty ofperjuryoneoffhefollmingdeclamtinns
mt : / Y
Im c wlllntainmin nCcmficum of Content In xdl'-inuum lies Worker's Comre IN
peTRANS FLOOR,HOOF,AREA.COND. S Bit p/J'/fJCfINSTRUCI'I(IN
actin .a. ruvidcd rte by Sedion]71X1 of the Lumu Ctdc,rte rhe pwrformmen III he UpCAr JO"✓/�•`�1/„
wa whichthis permit is isued. FIX'TURES-PER'I'RAP /
have and will maintain Workers Compenwtfon Insurance,as required by Section
3700 ofthc Labor Code.for(he perfamomce offhe work for which this permit is issued. GAS-1iA.SYSTIiM-I INC.J OUTLETS OCC.GROUP AYN
My Workers Cipcnsrtioa In.vurance curie,and Policy number am:
Carries Polley No.: .GAS-I?A.SYS'I'HM-OVER q(HA)
C12RTIFICATI:OF EXEMPTION FROM WORKERSGREASHWNDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section newd not he completed it permit is for(Inc hundred dollars 0100) GRESE'IRAP
m lcsa.) PLANCHIiCK 19Ai
I cenifYfhminfhe performance ofthc work forwhich this pcnnit is iswrd.I shall SEWER-SANITARY-STORM IA.200 FI'.
not employ any Paton in any manner so as to become subject to the Worker:Compen. ENERGY FEE
Z ration laws of Cali Harries.Date WATER HEATER WNENC/17LECTR GRADING FEE
Z O Applicant m
y NOT ICE TO APPLICANT:If,after staking this Certificate,of Exemption.You should WATER SYSTEMGIREAI'ING SOII S Itlili
F become subject to the Worker's Compensation perwisions of the Labor Coi you must
�i forthwith comply with such pmvisiorso,his permit Shull be devoted nicked. WATER SERVICE
aQ
:D z CONSTRUCTION LENDING AGENCY NEW RESIDEN'I'I Al.I'LM11. SQ.F'I'. PAID
I hereby affirm that them is a construction lending agency for the perfunttance of Dan Roup p
Pthe work far which this pc mm,is iawed(Sec.3097.Civ.CJ
Q I,ndcrx Nano I(TIAL:
7OTAI.
L) Lender's Address '
tA. 1 terrify that 1 have read this application and slate mm the ahose information is BUILDING PEE
nFi (A correct.l agree to comply with all City and county ordinances and%late laws miming to QW.. MECHANICAL PERMI'P FEE SEISMIC FEE
U Z building comtmemion.and hereby authorim reprewounives of this city to enter upon the
above-manhood prmPcny for is,Ilam purWscx PEHMI'I'ISSUANCE 11111,C]RIC FEE
(We)o me to save,indemnify and keep harmless the Cil,of Caperinn against
livbilities,ju mots,coss and expenses which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
comequ ofthegmmit this permit.
All IG I' JNDERS'D AN)wit , _0 WITH ALL NON POINT AIR HANDLING 11NIT(T0111.[XI CFM) MECHANICAL F1!1!
SOU - SE ULM.
AIR HANDLING UNPr(OVER In.00)CFM) CONS'I'RUCfIONTAX
I mica serer tae EXHAUSTHOODOODUC`0 HOUSING MITIGATION HE
ALA DOUS MRI'ERIALS DISCLOSURE
n uWilhhe epplicamnr future ImIdingfncuvmI,Ineorbanmc harmousmaenal IH:A1ING ON]'I'(SO 10LdW It'I U)
v chd, it by the Cupenina Municipal Code.Chapter 9.12.and the Hvilfh and Safety HEAPING UNIT(OVER 101.001 BTI)
.sic.Section 25532W)!
El Ye" F7 No V EN'I LATION I'AN(SINGLE BASS D) PAID
cmc RccciPt p
Will the applicant nrfuture huilding..pan,use eynational or devices which BOICER-COMP I3BP OR III,Op13TU)
:mil hazardous air contaminants as defined by the Hay Area Air Quality Management TOTAL:
D'innot7 BOILER-COMP(OVER 11X100)BTU)
C3 Yes El No
I have teal the hcodouu materials remittances;under Chapter 6.95of the Cali- AIRCONDITIONER ISSUANCIi DAJIi
lbmia Health&Safety Code,Sections 8505,25533 and 255A.1 undeswnd that if the NEW RESIDENTIAL MECH. SQ.Fr.
naihihtgatte net arcmly nmre a Imnmm.mm h is cony re%vnnxinsay to mniry n)w nwwapl:m
of the mcuitennms which must be tact prior to kvuance of a Certificate of Occupancy.
Owner or amhmimd ages Dam TOTAL: ISSUED BY:
OFFICE