S 1458 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
WARCHITF.�/ENGINEER
C'RTINO BUILDING.ELECTRICAL P('RLHI I SAY 1458
VISION APPLICATIONIFERMIT PING RING. TBYRNNIFIC l\.T
BUILDING
PROJECT lDRR1'IFICATION
BUILDING ADORE SANITARY NO, APPLICATION SUBMITTAL DATE
SCL
GlZ Jam/
'HONE'. CON' A OI NAME LIC NO'. WC CO1/�ff
McC l�� cJrnacR OB7st>sLc°I
EER: LICNO: ADDRESS: ^[� 'h�1^� ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ COnsDltant Pees Paid by Applicant(Initial) IdLDG HLECp PLUMB MFC
HH
❑ ❑ LJ
LICENSED CONTRACTORS DECLARATION ION QTY ELECTRIC PERMIT FEE, JOB DESCRIPTION
I hereby affr n bad I a licensed d p ns of Chapter 9 our arre ng
aa'ZHN t WI(NIofD' l ftheBu de fission,Code and toylcensois RESIDENTIAL
I+10p w1 PERMIT ISSUANCE,
aF k4., r f II f r - / ❑SFDWL - ❑KITCHEN REMODEL
6UV Lio.rec CP"� LI,I APPLIANCES-RESIDENTIAL ❑ADDITION E]PLUMBING RF-PIPE
F V W Date Gmlmemr
w C. ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
F y m I understand my plans shall be used as public records PANELS MODIFICATION
O Z UP TO 200 AMPS
L1 INTERIOR El CHIMNEY REPAIR
WW Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
rid
OWNER BUILDER DECLARATION OVER I(IfH1AM1'S ❑BATH REM DEf1RFEAIR El DE OLITION
C 1 herehy ullien that I am e.,alpa routine Contractor's License Law for the .T
C y C) following acus....(Nation"1101.5,Business and 1'mfev.un,Code:Any city or umnly SIGNS ELECfRICAI. t OTHER
W y which redone,a permit to construct,alter,improve,demolish,of repair any tmclure
Fe,q I$Oy� prior In its issuance,also raryiecv the oppliclmt dn,uelt petmin..0leasigned stletnert SPECIAL CIRCUITIMISC. IF
2hy that he is licensed pmaultnl In lLC provisions of the Cmnttor(,beers,Law Chapler9
Q� (commencing withSmlion 90W)nfDivision3 oElhc Business and Professions Code)or TEMP.MIGLER OR POLE INS'I COMMERCIAL
t1 y o Ihut he is exempuhemrmm and the h.sis for the lilkged exurei er,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W
' Ireton 70315 by y applicant for o permit vubjcds the nppiicunl m o civil penally of POWER DEVICES ❑TENANT El FOOD SERVICE
�� anansate than five hundred dolbm($500), IMPROVEMENT
�. d0Lasawa,,ul the property,It it,employees.,In wages as their- none compensation, SWIMMING POOL ELECTRIC
F�
I'll dothe work,and the structure is not intended offered for sale(See.7044,Business L3 OTHER
j C m and Profession,Code:The Contractor,License Low dam non apply to ua owner of OUTLETS-SW ITCHES-FIXTURES
4'6 property who huilds or Improves thereon,and who does such work himselr er through
his own employees,provided that such improvements are not intended or of',,Id fur NEW RESIDENTIAL ELECTR SOFT. -
sale,ll,howevca the huildmgor improvement i,sold within uneyearof mmpltion,the SQ.FT.PLOORARHA $ISQ.FT.
wria builder will have the harden of proving but he did not fall or improve for par- -
pose of role.). -
❑ [,as owner of[lie property.Inn exclusively I( bur ing with licensed contract x r0 TOTA
mrhuct the Enpet(Sec.71,14,Business and Prnfir—on,CMcJ'nc,Conductors Li-
nsel.ewuse,not apply to at Owner or property who builds or bnproves thereon,and QTY. PLUMBINQ PERMIT E.
who eonbans foramh pI Jets with x cortmcmgs)licensed pursuant m theCenlmt..r's
License Law. PERMIT ISSUANCP.
❑lam examnpt under Sec. ,B Se P C for this reason
ALTER-BRAIN&VENT-WAI ER GCO VALUATION
Owns Date
O q
WORKERS COMPENSATION DECLARATION BACK Id,flW PROTECT.D13VICE. / 3��
Ihereby
andvaltiinnunder Penalty ofp Juryoneo theself Endowing Work, aCo LG
❑ I have on,a,a,,,will main by SeclerniTIMof da,Lahr Cod i,for the Workersy,of th- DRAINS-FLOOR,BOOP.AILHA,COND. S'T'ORIES 'fYPH CONSTRUCTION
worn,as provided for by I,issued.
3'lOU..f Ibc Labor Code,for the performanu of the
work e,whichthispermit Is issued. FIXTl1RES-PFR'I'RAP
❑I have and Li will maintain Wn info Compel us, Ireurrwhi h fin,
by Section
3]110 of the Lith Code for the perfnnnwmc of We work l'nrwbich this permit is ix,uel. OAS-EA.SYSTEM-1 INC.40U'I'LETS OCG GROUP APED
MYMWorker Cur tpenemian I wrana,urian and Policy num er arc:
Carrier�� 'la" PoIICY Na.: J11/Ola4 CAS-EA.SYSTEM.OVP.R4(EA)
CERT 'I ATF. F EXEMPTION FROM WORKERS' GRF,ASFIINDUS'1'RL WASTE INTERCEFIOR
COMPENSATION INSURANCE BUILDING;DIVISION FIiRS.
(Thi,,ddhdncedr,ebecmnplt,d lfdmpermit'n Enron,handfed dollars($into GREASETRAP
nr In,,.) YLARCHLCK FEE
I certify Olt in lheperfnrmunm oflbe work for wloul lhis permit is I...W,]shop SEWER-SANITARY-STORM EA.200 FIL
not employ any person many manner.m as to become subject to the Workers'Camper- 1'
Z cation Laws of California Dale WATER HEATER WIVENT/ELECfH
O 1 C GRADING PtlE
Applicant
fn+ NOTICE TO APPLICANT:If,after making this Certifiwle of Exemption,you should WATER SYSTEMIPREATING
SOILS ..ill
F hemmembjctto the Wacker'.Campuxahis court shelf
of e del.uhor coda you must VU
W � forthwith comply with such pmvlsionS or this permit shell M1e deemed resulted. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY YF.W RESIDENT IAL PLMP, SQ.FT. PAID
z II...byatfirm thu0here ie oconstmctian lending agency for the FIT houneoof Dom ReeeiplN
the work for which at,perm,,is issued(Ser.3 Wl,Civ.CJ
OLender',Nene 'IGIAL
U Lcndcr',.Address TOTAL:
�.n a BUILDING FF:F,
1 certify That 1 have mad this appllcadnn and stmt that On,uhove'mforminion is
pj correct.I agrco m comply with all city and count,ofducart,trod nIn(.laws relating m QTY. MECHANICAL PERMIT' PEE
U IF dingem,ruione,and herebyautherize represcmutives ofmi,chym enter upon me SEISMICp'
above-menToned largely for ilepecTml articles. PERMI"f ISSUANCE
lh
(We)agree m nave,Indemnify and keep harmless the Ci(,of Caper ina against tlhECT ..
liabilities,judgments costs and expenses which may to any way lame against said City AMERORADDTOMECH.
PLUMHING hli
n e
msCANTc Nthe gSTAN of this peWIL
APPLICANT UNDERSTANDS AND WILL COMPLY Wll'H ALL NON-POIM' AIR HANDLING UNIT(TO IgOIId CPM)
MECHANIC IJ'HN.
SOURCE REGULATIONS.
AIR LING
NIT
to, I EXHAUS HOOD
W/DUCER Ifl,(lOfI CFM) CONST CTIONMITIGATION
TAX
Signature ofApplicenVConun o t EXHAUST HOOD(WIUUCD HODS OMITIGATION PE6
HAZARD ITS MATERIALS DISCLOSURE
,1111 thenpplirvnt or[umac huilding ownpanl,tnrc nt handle haanNnue mnmrial HEATING UNIT 00 100,00U BTU)
I,def e1 by the Cupertino Municipal Code,Chapter 9,12,and the IBeall h and Safety
Code,Sermon 25532(a)7 IMAL ING UNIT(OVER 1(10,0011 BTU)
❑Yes FIN. VENTILATION RAN(SINGLE RESID) PAID
Ism, Receipt 4
Will the air cord m future building occupant use equipment hr devices enwat
emit hazardous air emtmninuts as defined by the Buy Area Air Quality Monngenmm BOILER-COMP(314P OR 100,000 BTU) TOTAL:
District? BOILER-COMP(OVER 100,000 RTU)
❑Ye. El No
I have mqwm
ad the hazardous materials is under Chaplet 6,95 o1'the Cul l- AIR CONDITIONER ISSUANCE DATE
fmnio Health&Safety Cade,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL.MFCH. SQ.PT.
building dats not currently huvm mart,that it is my reaponelbility mortify the o¢upanl `
..f
in eon whi h loom be met prior m issuance of a Cenifiane of kcuaap cy
.
win,rear,
rl a agent / e TOTAL: ISSUED BY:
OFFICE