30855 (2) APPLICANTTO FILL IN INFORMATION WITHINREDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. O H Vr^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI1I17AL DATE
q4 -Sou,,]x-,p( S c-ecl�Jer A-.f -Jlgp
OWNER'S NAME: _ PHONE: p/�(j CON'IRAC'TOR'SN LIC NO:
• N 25-7 qO Y'6 / N/C o
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: � � // (PI7IONf::
GDN 1�` 1 v (4 b) ��6 BUILDING PERMIT INFO
k� Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMP MECH
LICENSED CONTRACTOR'S DECLARATIONQ'fY. ELECTRIC PERMIT FEE ❑
QI hereby affirm that I mm licensed under provisions of Chapter 9(commencing JO DESCRIPTION
FgeZ with Section 7000)ol'Division 3 iOna Brsine'sand Rod..l ons Code andmy llnmisn is RESIDENTIAL'JO
F O PERMIT ISSUANCE
full farce and effect.
�WG to ❑SPDWf. El KITCHEN REMODEL
UO Date CWss - Liak ' APPLIANCES-RESIDENTIAL.
F-�a1 Dam Contractor ADDITION PLUMBING PIPE
z;�p nil ARCHITECTS DECLARATION PANELS MIM-UNIT ❑STRUCNRAL
s rzn Z 1 understand my plans shall he used as public records MODIFICATION
Oz-0 UP TO 200AMPS El INTERIOR El CHIMNEY REPAIR
r4l:w Licensed Pmfesvfomal 201-IWBAMPS I IMPROVEMENT
OWN17R BUILDER DECLARATION
Q 1 hereby affirm that 1 um mp
exet form the Contractor',License Lew fur too, OVER["AMPS ❑BATH REMO[JJMJ p�AtR 0 DEMOLITION
W U following reason.(Section]1111,5,Business and Prafessi...1,Calc:Any oily or wanly SIGNS ELECTRICAL. C1 OTHER YY
which requires a permit to wn.oract,alter,improve,demolish,or repair any snucarm -
priormitsistuance,also nalmoerthe applicant forsuch pconino file a signed statement SPECIAL CIRCUIT/MISC. APR p
Mpppppp vWvW�sI that he is licensed pursuannathe provisions of be Consonant's Lkcnse Law(Chapter9 Rant
x (commencing with Scaion ANX))rf DivisionJof Ne Business and l'mfessions Ctdq or TBMP.MEIER ON i'OLE(NST. / COMMER �IA -
2 p`, oG shut he is exempt therefrom and the hour,for the alleged cxemptirn.Any violation of ❑NE ' ('iuP QDQ9�JfL(� OLITION
LLXl aN•
Section 7031.56yany applicant far.permit subjectstheapplicant m a civil penahy of POWER DEVICES C'�i
tmnre Nan five hundred dollars($50B. ❑TENANT O SERVICE
�Q ❑I,es ownerof the properly.nr my employees with wagesm theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O will do the work.undidammcmm brief intindedn,offned fortune lSce,7044,Business ❑OTHIiR
and Professions Cale:The Contractor's Licence Low cities not apply to an owner of OUTLETS-SWITCHES-FIXTURES
R" property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemcnts are not Intended or offered far NEW RESIDENTIAL F1.13CIf SQI'
sale.If,however,the building or improvement is sold within one year ofcompletier,the - SQ.IT,FLOOR AREA $/SQ.PT.
owner builder will have the burden of proving that he did not build or improve for par,
iva.afsale.). 1 C�u"
❑
I.as owner of the properly,um exclusively contracting with licensed comments to
construct he project(Sec.7041,Business and Professions Code:)The Connector's Li- -
censeLawdoesnotapplytounownerofpropenywhobuildsorimprovesdamem,and QTY, PLUMBING PERMIT FEE
who contracts for such projel s with a contractors)licensed pursuant to the Contmctues
Licence Law. PERMITISSUANCE
❑ I um exempt undrz.Srx. z,— / It&P C fonhis reason _
1ACI1iR-DRAIN&VENT-WATER EA)
nw... ( r _^ _ VALUATION
• WORKE S COMPENSATION DECLARATION BACK FLOW PROI'ECI'.DEVICE Z
Iherebyill maintain
ai under penaltyte perjury oneofthe following alonsCon t J
(have and will maintainstion 37M of the Laborourn to self i.for on, nnforro Cnmpem DRAINS-Fl.(>OR,BOOK AREA,GDND, STORM TYPE CONSTRUCTION
.moron,r provided for Section 3]W of the Labor Code.for the performance of the
work far which Nis permit is issued. MIXTURES-PER TRAP
❑ 1 have and La will ode,fon Worker's Compensation Insumnce,a required by Section
My Worker's
Labor Ctde,fnnhsurance performance r and is Poork forwhichthis Permit is issued. GAS-EA.SYSTEM iINC.4OUTLETS - OC ROUP APN
My Wodu's Crmpensmimn Insurance Cartier and Policy number am:
Carrier: Policy Nn: OAS-EA.SYSTEM OVL'H 4(EA)
CERTIFICAI'17 OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANUUS'I'RL WASTE INTERCEPTOR
(This section need not ba completed iOhe permit Is drone hundred dollars(S IM) LDING DIVISION FT?I:S
or Ins.) GREASETRAP PLANCI 'K
I cenlfy that in the performance of the work for which this permit is issued,l shall
SEWER-SANITARY-STORM EA.200 F7.
not employ any person in any manner so u to became subject to the Worker,'CommpeEN L'
z 'urian Laws of California.Dole WATER WATER HEATER WNENT/ELECfR DING :E
y Q Applicant '
F7 h NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
ai became subject to the Worker's Compensation provisions opine Lndn Code,you nmst S F'
[SI forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE _
0
d
CONS
tthem RUC'v[ON LENDING AGIiNCY NEW RESIDENTIAL('LMB. SQ.FT. PAID
LJ 0 kfia,wyaffimillannm is.
..ad Seatirn len ding agency For We perfoomence of _ Dole RettiptM
4 the work for whicM1 Chip pomit is issued(Sec.3097,Civ.CJ
0Lenders Name TOTALo
as I<nderI Address TOTAL.:
FVas) I certify that 1 have mad this y and court and stats that the above information is BU LDING I'IiE �.
wn z>A building construction.
agree roan.and with all chyand represntainanen:md stem lawsrmpor m QTY. MECHANICAL PERMIT FEE
V G buildingconsaudio,mm f macluan zereprcsemmives of this city menrer upon the S ISMICIF.Ii
nMrvwmontioned properly for inspection purposes. I'13RMI'P ISSUANCh
TWe)agreo m save,indemnify arta keep harmless the C'ny of Cupertino against P.CfI<IC FEB
{iabillties,judgmenm,arsu anJ expcnsas which may in any way accrue against said City ALTERORADDTOMUCH.
tv
asequence of the granting of this permit. LUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONI'TITO ID,"CFM) AZI
SOURCE•REG/V'..A��'IONS. T / .CHANICAL FEE
7 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRU ON TAX
Signature off canUConrmcm�---"'~~~ Date / EXHAUST GOOD(W/DUCII HOUSING MITIL TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willmeaplabount or from huilding awpcmmoreor humane hamrdous material HEATING UNIT(In IX;0dfi BTU)
as dolmed by the Cupertino Municipal Coote,Chopmr 9,12,and the Health and Safety
Cak,Seetinn 25532m)! HEATING UNIT(OVER 100.000 BTU)
Fl Yes El No VENTILATION PAN(SINGLE RESID) PAID -
Will Ne applicant or furore building occupollBuse equipment or deices which
Dam pt N
Diumnzallous air conmminanE as defined by the Bay Area Air Quality Management BOILER-COMP(3NPOR 100,(gB BTU)
Ui.mricrt TOTAL:
Yes EINa BOILER-COMP(OVEN IW.(XIU BTL)
I have read the hazardous materials requirements under Chapter 6.95 of fie Cali. AIR CONDITIONER ISSUANCE DATE forma Health&Safety Cale,Sections 2.5505,25533 and 25534.1 understand that if the NEW.RESIDENTIAL MECH, SQ.IT.
building does nm curtently have a mmol,that it is my responsihinkly no notify the occupant
nl'the reyuiremem
h ranthe met Prin ! I Cenificateof Occupancy q
SMOwner or auNon em Date �. ISSUED BY.
OFFICE