30943 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY'
'
BUILDING C N' REkmlr rvoCITY OF CUPERTINO PLUMBING'.
LUMB '.MIHICA.BUILDING DIVISION APPLICATIONIPERMIT BUILDING IROJECI'IDENTIFICARION . 30943
CAL
BUILDING ADUkF.SS: SANITARY NO. AI'I'LICATI(INSUBMITTALDATI
22 to STr=VEQS
OWNER'S NAME: '�-l�w PHONE 14 F(lN TOR'S NAME LIQ NO "
�"- N/C - CONTROL#
RCHITECT/ENGINEER: LIC NO: gUURF.SS �� ❑ ^!`1'e ��
DA i� C
CONTACT. PHONE: /.�,�qV_v� � BUILDING PERMIT INFO
D�v�o P��N¢ ta�)�+�6-iB9�2 ❑ ConsultuntFeeaPeidbyApplicant(Initial) "� R- LDp ELECT PBMECH
sill al
LICENS-ED CONI RAC'IOR'S DECLARAq'ION' QTY „ELECTRIC PERMIT
1 heathy of rid the,1 am licensed under tanskinn.of Chapter 9lcnmmemnig `',JOB DESCRIPTION
"Z NSatian 7gXR of Divisinn3nfthe Business end Professions C<de.rA my license is t
f�00 wt PERMIT ISSUANCE
tY W 'in full force and effect. FDWh ❑KITCHEN REMODEL
aVV License Class Lid. APPLIANCiElLRESIDENTIAL. A ITION [I PLUMBING RE-PH,E
�ZWW Dare Contracmr
ARCIR rEC'S DIiCLARNPON _ []MULTI-UNIT El STRUCTURAL
F,inz Iand...land my plushall hmm
eed as pilihe ands PANELSMODIFICATION
O Zm=Q Oil In 200 AMPS ' ❑INTERIOR - L3 CHIMNEY REPAIR
lir N., LL1 Licensed Prafesninnul 201-IBIXIAMPS IMPROVEMENT
[[[ppp��••1
OWNER-BUILDER DECLARATION OVER IgX1AMPS ❑BATH RIiMODIiUREPAIR 0DHMOLI'f10N
Q I herehy of and that 1 am exempt from the Contranorx License Law for the
ipy,O0.V following mason.(Section 7031.5.Business unit Professions Code:Any city or county SIGNS ELECTRICAL [I OTHER
which requires a permit m wnsmm6 dter,'hnprovn,dor mlmb,rid repair any....canoe 19 _
F"�des pdom..itsiss...ce,also requires the epplicum fur such pertniuo Eleasigned stmemem SPECIAL'CIRCUIT/MISC. F '-
•E that he is licensed pursuant to the poisbrous ofthe Contmoor'x License Law(Chipter9
(eonunrniug with See i7l1M)orDivision J oftha Businemerd Professions Code)or 'TEMP.METER OR POLE INST. COMMERCIAL:
6 c pG ohm he is exempt therefrom and 0¢basis for the alleged exemption.Ali,violation of L']NEW BLDG/ADDITION [I DEMOLITION
�m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT . " C3 1700D SERVICE
not more than five hundred dollars($500). h MPAMBOIENT
E]Las ownerofthe property,army employees with wages astheirsole comperation, SWIMMING POOL ELECTRIC ((�� 11JJ
G will do the work,and ibedruduic is not intended mroffered formle(Sec.70n,Business T R
to a and Professions Gale:Thu Commnors License Law them not apply to an owner of OUT-EfS-SWITCHES-FIXTURES
1 property who bui its or Improves thereon,and who does such work himself or though
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECIR SQ IT.
sale.if.however,the building or improvement is sold within one yearofaompletinn,the . .Q.FT. RAREA 5/SQ.lei.
erro
buddef will have the harden of poising that hu did not huild or improve for pur-
prseafmle.). ! Ur WrLONO
❑1.a%owner of the pmpery,am exclusively contracting with licensed contractors to
eonstmet the Pmjua(Sol.7N4,Bmmd,,and Plarmion.Cadet)The Contactors LI- -
c se,Law dons not apply to an owner of porpeny who InAhN nr minuses there...,ant QTY. PLUMBING PERMIT FEE '
who contacts for such projects with a comeacmKs)licensed pursuant to the CommnnR E3_7
Lkranw .Luw. PIiItM11'ISSUANCI? -
❑Icon exempt ander Sem,11&P C for this reason -
/J-� AT TER-DRAIN&VENT-WATER( /�VALUATION
W LARATION BACKFLOWP O tCT.DEVICH /t\
ll
1 hereby affirm under pertly of perjury one of the following declaration
•'�Ihnve soil will mainminaCcnificam of Cnmenuosdhinsurc lin Worker's Compen- DRAINS-FL rL OND.
mama,as provided for by Section 3700 of the Labor Codd an the performance of the _ STORIES T PE CONSTRUCOON
work fnr which this permit is toured. FIXTURES-PER TRAP /
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37Mofthe Labor Code,fnr the pinormmncol'the work for which this permit ii l.sued. GAS-EA.SYSI EM-II 4011TkS OCC.GROUP -APN
My Wader C m nsation lnsuan ecartier ant Policy.ulna arc
Cartier. Policy No.:� GAS-EA.SYSTEM-OVF.R4(FA
^• CERTIII qT 1 EXEMPTION FROM WORKLRS'
COMPENSATION INSURANCE GREASEIINDUSTRL WAS TE INTERCEPTOR -
EU .0 VlSI(lN EELS
(This semina aced nrnbe completed if the permit is for one hundred dollars(SIM) GREASE TRAP
or
le".) PLANCHI!CK .
Toy any that in the any
of the becomork e subjecch t
is pinthe W rkerm'edlshall SIiWEN-SANIq'ANY-STORM F.A.2q)FT.
not employ any person in ry manner so is to become subjen w the Workers Cnmpen- - ENERGY PEE �
z ,Z ...am Lmosaf Culifoaiu,Date WATER'HCATF.R W/VENT/ELECTR
Applicant - GRADINGI7E
y NOTICE TO APPLICANT:If,of s,making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE.
forthwith comply with such provisions dnhi,.permit shall be doomed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW NESIDENTIAI.PLMB. - �SQ.PC PAID
UQ Thereby affirm that there i.ucmrulnstmn lenJi.g agency for the perfurm:nne mf DateMe #
the work for which this pemdt Is Issued(SCC.307,Civ.C.)
QU Lender's Name - - - gnTAL:
U Lender's Admit, -
H1 cenify that I have read this applirnio.and.acute that the lissome information is - - " BUILDING F
IA correct.I agree to comply with all city and county ordinances and state laws relatingto, QTY, MECHANICAL PERMIT FEE
V �.. building wnxtmatian.anal hereM1y nuthodzC rcpresennnivcs mflhis city ranter upmnhe SEISM[
above-,mentionedpropenyfarinspectimnpurpsses, ' PERMIT ISSUANCE •'
(Vie)agree to save.indemnify and keep heatless the Caymf C.Penin.agaimt ELEC RI EE
dabilame,judgmcros;aab and eapenseswInch may in anyway accrue against said City ALTERORADDTOMECIL
In camequence of the granting of this pennitf I 1 1.U M Bill G :B *-2LDLL it-I� -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO WSM CFM) -
- SOURCE REC '.. IONS. MIiCHANI AL FRE
AI R HANDLING[IN IT(OVER 100b)CFM[ CONSTR ION TAX
of ApAWaim EXHAUST HOOD(W/DUCO HOl1SING MI ATION FIiIi
' HAZARDOUS MATE ❑ISCLOSU � - - 1~
Wil the applicant or imam buildin6..capons store man dk heca rale vin HEATING UNIT(To IMXXX BTU) - -as defined by the CuPetimo Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 2553200 I[RATING UNIT(OVER 100.000 BTU)
❑Van F1 No VENTILATION FAN(SINGLE RFSID) PAID '
Date Nccipt#
Wilt the applmminror ma a building necupu[try Amb ipment or uality anagement li0[LER-COMP(3HPORIN),M)Ilri'U) -
mit hemNnus air conmrninants am define)by the limy Arca Air Quality Management TOTAL:
'�Distrie@ No
[3y. BOILER-COMP(OVER I(to"BTU)
��
[have read Ne haallous materials mquimmenu udder Chalxer h95MNe Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if tat NEW RGSIBENTIAI.MECH. .$U.FT.
building does not currently have a.nam,that It is my responsibility to notify the occupant
of the requirements which coon be met prionoissuance nfu Ccnifcen of Occupancy. .. -
Owner authorized.,car Dan - J ' ISSUED BY, -
OFFICE