S 1444 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pl;tIT NO
Bl]ILIIING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL �J 1444
BUILDING PROJECT 1Diwiri FIcATION
ILI]ING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
105'7(9 SOCAr '76-6 V+ 12 1,�l
OW'NER'S NAME: _ PI10NF.: CONTRACTORS NAME: LIC NO:
� �n��91-^yam L Akto�OIIIJ NIC CONTROL p/t
RCIIITIiCIIENGMF;ER: LIC NO: ADDRESS: ❑ O `
CONTACT: I'HUNF,: BUILDING PERMIT INFO
WG -Tat 376 ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECi
'BQPcD GIJcL�Pst�2 � _o� L4T
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT' FEE
1 berehy affirm that I am licensed made,pbvi,ior,of Chepmr 9(commencing J013 DESCRIPTION
WOO wilt Schon 7000)of Division 3 of.be BnorreS and Processions Coat.and my..cense in
WOO O PERMIT ISSunNCERESIDENTIAL:
C 4'F in full torte an lLe Zj e J v ❑SFDWL [I KITCHEN REMODEL
el-L) Licensee '"' Lica APPLIANCES-RIISIDEN'DAI. [I ADDITION [I PLUMBING BE PIPE
NQDaIC Gmltrucnlr_
111TECI'S
a DECLARATION PANELS ❑ U
MCH[-UNIT' ❑STRUCTURAL
ZOyZ tun r. and In dn. hull be used as public records MODIFICATION
OZ-_0 UPFO200AMI' TERIOR ❑CHIMNEYREPAIR
E'
Fa� w Licensed cd Profln^ul 2UI-1000 AMPS IMPROVfiM ENT ❑SWIMMING POOIS
OWNER BUILDER DECLARATION
C Q F hereby i ffien that I am exempt from the Cemmemd License Law for the OVER IfKK)AMPS ❑13ATl1 RIiMOHEIJRIiI'AIR [IDI?MOLI'I'ION
W3IL F following reason.(Section 7031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
W O y which ec'uner,a'emit m cans..ucl,eller,improve.demolish,or repair any structure
prior its issuance.also malaiieslheapprcant far such Dinnitto file a.signed,ammem SPECIAL CIRCUI'1/h115C.
x�G� [hut hu is licensed pursue...to[lie provisions Orme come and liceme Law(Chapter9
w.5.00 (commencing win Salto.7NXbof LuMono 3ofthc BusingssunJ Prnte.aintu Codd or TEMP.METER OR PD11 IST4 COMMERCIAL'
a iaC es c nm he is exempt nerd....and the basis for me alleged exemption.Any violation of 'W BLDG/ADDITION ❑DEMOLF ION
4• Saceun]113 LS by any applicant lid upennil subjects the applicant toacivil perulty of POWER DF,VICTS
way IENANI' ❑FOODSERVICE
f=� not mare nun Eve hundred dollar.'or s y employees W i.
❑ do[has ewerofthe pm pent',rmyntended croffertal their sole compensation, SWIMMING IKH)LIiLECI'RIC IMPROVIiMIiN'1'
F+ will dume'imv,and me a Cureiwols Lienee aw does
to an.Business ❑ TITER
or
3 m addurn ary who
GWor imp Cnmmerio License Law Joy sol reply m an nwncr of 011'I'LGIS-SW I'TCIIES-PIXTUR65
his
urinary winbuilds arimproves..aeon,and who doessuch work
tededoror.hmugh g4
his own however,
the
pmvidnl that such irlpms sold within arc nal intended or offered for NHW RHSIOf!NTIAI.ELECI'R SQ BT.
vlclLhnweveq vete iltebra int of pemcnt is at heidon Wild
or improve
SV.FI'.FLOOR AREA S15V.FT.
crbodeer will have the M1UNen of proving that he did not build or improve for put-
Poe
ef
❑I,a other ofthepee.7(9,[ cine s and eommcuns with i)The
enntcto"%i- 1' I'n1
,Il,mct the project(sec.7(ui,[rosiness and Prore%aims abe:)'me camracalr.u-
nwLaw does noutpplyloan owner ofprapertywhomdlmnrimp raxi,mereon.and QI'Y. PLUMBING PERMIT FEE
who contracts for such project%w ith a contractor(s)licensed pureuann to the Contractors
Liccnne Law. PERMIT ISSUANCE
Imo exempt under Sec. .BP PC for.hi....an
act
ALTER-DRAIN k VIiNT-WATER(EA) VA LUA'I'ION
,Ile
WOR KERS COMPENSATION DECLARATION BACK FLOW PROI'EC'L DEVICE ' h
I hereby affirm under penalty nl perjury one of the following declarations: V
❑Ihavc:md will mointuinuCanircalu of Ganser..mselFlrovre for W..lark Camped- DRAS'-FLOOR.ROOF.AREA,COND. ;T'(IRIIr 'TYPE ClNS'IRUCI'l11
canon,as provided his by Section 370(1 of the Labe.Code,for the performance of nc
work Ila which this permit is issued. 19XTU PER TR
❑I have and will nerimain Workers Compensation Insarao c,as arimed by Section
3700ol'the LxM,r Code,Bothe perfamlancerefnc work for which this permit is issued GAS- i STESI! INC. )UH I.E '
/ My Wmk Con penf�lim hI' .Ice i Policy no r - OCC.GROUP APN
X Cmnoi 'i; J .DaintyNo: GAS- YS H I- I
CERTIFICA'1'li OP B%I,MPTION FROM WORKERS'
COMPENSATION INSURANCE GRE INIXJ9F WA9HE 1 'E R
(This semiem neednot be r editell if the permit is forone hundluldoll...($pd) BUILDING DIVISION LE
,it less.) GRE fSTRAP ES Q
PLANCHECK PEE
I certify that in the perlormanm of[lie work for which this pul'mi.isiswcJ.Lshall SEW � IiA.219 PI'.
not employ any proon in any manner so as to become subject to the Workers Cnmpen- ENERG Y °EE /
Z cation Luw,of California.Date
Z O Applicant WATIiR HEATER 0.'/VENT/EI.I:M R GRAD F
p) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shoal) WATIiR SYS'l1iM/I RIiAI'IRG
a ?
become sehj,a to the W..ke,L Campensmiun provisions of the labor,Code,you mmt SO .. EE
[JJ forthwith comply with such provisions orchis pernel shall he deemed revoked. WATIiR SERVICE
Z) z CONST RUC'I ION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.IT. 0)
UO I herahyafrrmmm,twac .rmsbuatsn lendirgagcncyfm 11w,ifi,rmuneenr v Date Receipts
IL P the work for which Itis permit its issued(See.3197.Cir.C.)
OU LmdcdName AL:
Lenders Addre,as 10TAI_
F0. 1 e,,dily that I have read this application and ,an Nat We,hove inform anion its Il11LDING FEE 2
V) correct.I agree m comply with all city and county nrdlnaamea and state haws minting to QTY. MECHANICAL PERMIT FEE
U z building mnsWtlinn.and hereby amM1orian mpmsentaires of this city menNr upon the SEISMIC FEE it
ULner mentioned Property lot impaction puHxasea.
(We)agree to sova,indmnaify and keep harmle,,I[,a City of Cupertino.gains. PERMIT ISSUANCE O 17M RIC PTE
Iiabilibe,juJgmem,men and enpensn which may in any way acture against said City ^
ualnamvoflhegmn.ingnl.hispermi.. ALTER OR ADDIO MUCH. Z_V P 1MRING BYI3
APPLICANT UNDERSTANDS AND WILL COMPLY WINIALLNON-POINT' AIR HANDLING UNIT(TO IO.gp CFM)
SOU ATIUNS. ME'HANICAL VEE
AIR HANDLING IJNIT(OVER 10.000 CITD CONSTRUCfION TAX
nature of Appl " ntracki Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MNIERIAL,S DISCLOSURE:
Willthe applicvm or future building examend store nr handle hamrdons Tmcrlal H EATI NO UNI'IG 0100.(NsI B'IU)
m defined by me C'uperuna Municipal Cale.Chapter 9.12,and the Health and Safety
Calc,Smlion 25532D)7HEATING UNIT(OVER 100.000 ROD)
E]Yes ❑No
VF.NTILAI'ION FAN(SINGLE RPSID) PAID pate Recei Ie.
Will the applicant or future building acre p re,use a,."win or Acvicu.which gO1LF.R-CONY iHP OR Ifp.lAp PTU p
•[nil htcardom air eamandimntn us defined by the Bay Aura Air Quality Managancut ( )
Disnimp 'I IAL
E]Vex E]No BOILER-COMP(OVER 100,00)B'1'0)
I M1nvc rend the h:v:mloun....coals reyuircnmms under Cbapmr GJS of the Culi� AIR GONDI'ITDNER
ISSUANCE IJAI'li
holding
Health s o Safety Coda.e.gems 255(15.SSD and 25534.1 to notify h that it.he NEW RESIDEII'IAL MECH. SQ.IT.
hndmngea<anmcarendr have he met prior
israno,of
a Ce Ptycie,of notify he cecupun. �O
of the quire con which moa he met prinnu Ivsuun cola Cenilica.c uf(),-cupanry.
Owner or authorized:Igcm [)are TOT L: ISSUBDBY:
OFFICE