S 0432 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NG.
BUILDING DIVISION APPIACATION/PERMIT PLUMIIINC-.MECHANICAL. S 0432
BUILDING PRGJECP IDEMrIFICA'I'AIN
BUILDING ADDRESS: SANITARY NI APPLICATION SUBMITTAL DA'I'I
toql�bI C1
OWNARSNAME, - PHONE: CONTR '1g(: p .I.ICNO:
n ^N` N /iSO qiM /v`l n��"x` NIC CONTNOLp
TE
ARCHITECTANGINEER' lllX. LIC NO: ORF.SS: ^ 1 ❑
CONTAC'C PHONE: - 'll/wl aJ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECT PLUMn MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECFRIC PERMIT FEF: TI
JOB DESCRIPTION
I hereby alarm tha I am fcooud under pownion,of chapter 9 anmmcneing
Qa7. with Section'fash of Division 3 mine Bu.dncas and Professions Code,and licensers RESIDENTIAL:
in full farce anJ t. PERMIT ISSUANCE
yl 4S3 S�J4 GSFDWI. GKITCIiIiN REMGDIiI.
�U6 LicenseC s I.ic# APPLIANCES-RESIDEN'HAL GADDITION ❑PLUMBING RE-PIPE
aA Dme HITI=DECL
F y ARCtI1T1iLT5 DECLARATION PANELS ❑MULTI-UNIT GMODIPNRAL
z O Z 1 understand my plans shell he used as public records MOUII'ICATION
Oz 4Q UPT02N)AMPS 0INTERIOR GCIIIMNEY REPAIR
F44 � fc
Licensed Prossinnrt 201-I0G
X1AMPS IMPROVEMENT SWIMMING POOLS
�J OWNER-BUILDER DECLARATION OVER ItIlX1AMPS TH HI:MODI?IJREPAIR (_1 DEMOLITION
�yJy Q 1 hereby of on,iter 1 am neanpl tram the CmnlraciIia ilm
ar'x License Law
p(�6 U following reason,(Section 7031.5,Buxincss and Profesomnc Code:Any city err comity SIGNS ELECTRICAL. aT
Y 3 U. which requires a Permit to construct,alter,improve,demolish,or repair any ammure
0 pricirwitta.oantt..h."i{resthe applicant fursucb pc or to rleasigned smmnmm SPECIAL CIRCUITIMISC.
;!(} that he ix license)pursaam to the pmvinions of the CommctnYs License Law(Cnapotr9
.,GAO (commencing with Section?000)of Diskmn 3 ofthe Business and Professions Collor TEMENICERORPOLEINST. ME
that he is exempt therefrom and the basis fm the Actual cacurptiod.Any violation of ❑NEW BLDC/ADDITION G DEMOLITION
iLLC1 k, Section 7031.5 by any applimm her,permil sohiacts doopplicant to civil punnityuf POWER DEVICES [I TENANT El I,()()[)SERVICE
m not marc than live hundred dollars(S500).
ESQLesowncrnram rt.trrte b as with we'c..aahcir.wle mm irabon• SWIMMING POOL ELECT RIC IMPROVIiMIiN'P
0 ❑ Prilte Y Yc'enP Y 6 Ps.
$a F- will do the work,and the sinartme is not intended mrmRered foraAe(Sm.7044,Business ❑OTHER
41 .9 and Rifaeions Code:The Contrmne.License Low does urn apply It,an a vism of OUT'LIGS-SWITCHES-FIXTURES
ta'3 r property who builds or improves therein,and who aces such work himself or through
his own employees,provided that such improvements arc not intended or i0cmd for NEW RESIDENTIAL ELECTR SQ 1.7.
sale.It,however,the building or lrpowemmftt is sold within one your of coneplminn,the QK"VLIRRAREA SISQ.PT.
iter-builder will have the burden of proving that hn did not hui1J or improve it par- 'CO
form oi""Bode.).
G 1,as owner of the pmrcl
psn,.am exusively co mmranorsm
eeting with licensed ro , TOTAL: n[(I
nswct he project(Sec.7814.Business and Professions Code)The Contractor'a lu- SEP �[y
cause Law does not apply to as owner of property who builds or improves thereon,and QTY, P NG PI?RMIT FEE fa,11`
who contracts for such projects with a co. ntractors)licensed pursuant the Contractor's C�s 11„v
License Lit FERMI"r ISSU C. Cs,1 s Uf Quo
1 it.tuarl under Sec. 13&P C fir this reason V
Owner Date ACHR-DRAIN&VENT- TE 'A) VALUAq'ION
WORKERS COMPENSATION DECLARATION BACK Iq.OW PHOIEC,B BICE )
thereby affirm vaa Certify of perjuryinsofthefnsumfor Workc
Gonave and will maintaina Certificateio7of Consentr Comnsur the
Wmkelsce of the ❑NAINS-FLOOR.ROOF,AREA.COND STORIES "1'1'i'E CONSTRUCTIOD
;workas provided for by Section PIXI of the Labor Gde,for the perfonnnnce of the
work whiclthis permit is issueA. FI%TI1NF.5-PEk'r RAI'
µn
havhe Lawill maintraftWorkers
performance
work
or eo.ns required by Section
3900 of the LpMa Code,for the perfortnvna mf the work lice which this permit is is,mey OAS-IiA.SYSTEM-1 INC.4011'I'LETS OCG GROUP APN
My Wmkcr's empe99,,mm,,pp,,Insl1ggora carrier and Policy nymJ+�S �OI ILL GAS-IiA.SYSTEM.OVI:R 4(EA)
Camcv �=j Polity FROM
`al l l L l .
C: ❑+ICATF.OF F.%EMPPolic FROM WONKERS'
COMPENSATION INSURANCE GRIA51'IINDUSTRL WASTE INTERCEF'lOk
I1I111.U1NG DIVISION PBfS
phis section need not be compincJ if the permit is for ono hundreddnllurs(SIIX)) GREASE TRAP
err less.) GREASE FIiE
I ourrythnl in the Performance ofthe work for which thlspwmitiaissued.I shall SEWER-SAN]'T'ARY-S'IORM EA,201 FP. '
not employ any person in any runner so as to become subject o the Workers'Cmnpcn- IiNERGY hl[li
OZ section Laws NCufontia.Date WATER 11PI'ER WNENTIELECTR GRADING ItlJi
Z Applicant
y
NOTICE TO APPLICANT:If,after making this Cer ifiatn of Exemption,you should WATER SYSTEMG`P EATING SOILS FEE become subject m the Worker's Compensation provisions of the Labor Cede,you must
{eJ forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW NIiSIDP.NTIAL PhMII. SQ,I+I'. PAID
UO 'l hemby affirm that here is acnnstrumionlending agency for the performance of Dam pth
W f" the work for which this permit is issued(Sec.3097,Civ.C.)
l Lames Name TOIAL:
O U Lcndels Address VITAL
W I certify that I have read this application and Stam that the above information is RUILDIN F
v0. emneet.l agree m comply with all city and county mrdhrmces and state laws relating m QTY. MECHANICAL PERMIT FEE
Z
)
U G building corrnclum.and hereby anlhirire represcnmtives"it",his city tauncr upon the SEISMIC FL'
abmve-mentioned property for inspection purposes. PERMITISSUANCP.
(We)agree et save,indemnify and keep harmless the City of Cupeninn again.a ELECTRIC Illi
liabilities,judgmenks,costs and expenses which may in any way recm,ii,mmtsaid City AMER OR ADDTO MECII.
consequence of the granting of this permit. PLUMBING Fli.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'('1'O 10.(W CFM)
SOURCE.R ULATIONS 1 / ( MECITANIC .14]i
_/1L-111,/�111�� AIR I IANULINGUNI'r(OVER 10,000CFM) CONSTRUC'111.411
'IA%
SlgnamreofA,licvntVaraceir Date EXHAUST HOOD(W/DUCT) HOUSINGMITIGA INIT+E
HAZARDOUS MATERIALS DISCLOSURE
WiIItheappliant or fumes building mcupain suacnr handle bamrdous material HEATI NO UNIT CFO I(X1.0X1 It'1'U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 75532(x)? HEAT INO UNIT(OVER I(N AR)BTU)
Ye No
VIiN'I'RATION FAN(SINGLE RBSID) PAID Dlaa ,_,vu -Will the applicant or future building a repast use equipment or devices which
\�erit hozaNnus air mataminars as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP Oil I0L000 BTU)
TOTAL:
District?
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AL R CONDI'I'IONER ISSUANCE DATE
fornia Health&Safcty Cordo,Sections 25505,25533 and 25534.1 nnderxumd that if the NEW RESIDENTIAL MECH. SQ.IT,
huildingJoexnot cunon0y havuaten�nt,ih:n it is my mspaftelality to notify the rrcnpunt
ofther rirements which must helmet prior to icwance oft Certificate of Occupancy. LM1%
Owner it amhnrxed agent Dam TOTAL: ISSUED BY:
OFFICE