S 0008 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
29098
BUIi.DING DIVISION IIUII,DINGPROJECTII)b1NTIFICA'f10N '
BUILDING.ADDHH55'. SANITARYNEAPPLICATION SUBMITTAL DATE
�,aa/OWNER'S N;LkAMIr A� �� II��� �� CO RA�ff1HS I`y�ME: v �LIC N 57/,`t N/CONI HOLp
HIT11=1NGINEER: LIC NO: DRESS: C/ ❑
��� S "/ �•
CONTACT: PunNl: ".ht 1. .:HIJILDING PERMIT.INFO:,}
�Y1PXi�•s.a- /q gL ( j(/ it)7� ❑ Consultant Fees Paid by Applicant(Initial) h CLIiCT PLUMB MECH
7V0 01 1 I' I '9,
3 LICENSED COME RACIORS DECLARATION - QTY�,. I I' ELECTRICPLRMIV "�, FEE„F
I hereby ffrn tit t I I I oder prove em of Chuprer 9(wmnsncing , r 1 JOB DESCRIPTION
f „O,1XO nhS Io 70001u1D 3ftheB .ness and Profess ons Cale and any license RESIDENTIAL
�� PERM]I ISSUANCE
n fill f I ffcct PUWL ❑KITCIILN REMODf.I,
t
E-UV lice CI : 1' N APPLIANCIiS-RESIDIiN'flAh COITION El PLUMBING RE-PIPE
F-Z n1 Dmc C nwemr
'DiA - MU TI-UNIT El STRUCTURAL
ARCHITEC'1 S DF.CLARAl10N
L.,ntn PANELS - MODIFICATION
Z Z 1 understand nJ my plans shall used as public records
OZ—
UP TO 2M AMPS
[I INTERIOR [I CHIMNEY REPAIR
iF.y.F"W Licensed Pmfecuranl 201-1(XX)AMPS IMPROVEMENT SWIMMING POOLS
f a yl i-? - OWNER-BUILDER DECLARATION OVER 000 AMPS ElRATH REMODEL/REPAIR El DEMOLITION
R C=, l barely affirm that i sun exempt fm,n the Cnmrnemrx Larose Lnw rnr dm
1Ta'C)ei�W O Telles ing reason.(Seen,,.9031 5,13noness and Professions Code:Any city sur unmty SIGNS 1?LI?GTRICAL ❑OTHER
iW W which.,arm,n permit m crmsuuct,.]let,improve,demuh,h,nr repair any thereto
!: prior to its issuance.also requires the applicant for such pent to rile a signed statement SPECIAL CIRCUUDMISC.
'En} that he is licensed ptnuenrto the provisions of,he Contnemea Licenw,Law(Chapter 9 ER
+=i Cl (commencing with Section 00001 of Division 3 ofthe Business and professions Cale)or TEMP.MITER ORPOLE INST.
d a c Y that he is exempt Ihertfrom add the basis for the alleged exemption.Any violroon of _ - ❑NEW BLDG/ADDITIO
e�N ❑I OhITION
Section]0315 by any applicant for u permit subjects the uppliwm m a civil penalty of MW13R DEVICES ❑TENANT 2 ' D S17RVICE
not mom dam five hundred dollars($51X1). IMPROI�' 1+
'. X56 I,as owner nflhc - rt,nrm In acs wiN wa lhcinnlc cam tion, SWIMMINGPOOL ELIiC'1'RIC
C ❑ PrWe Y Yrn1P Y hes ns penca ❑OTHER
will do the work,and the swnure is not intended or oRereJ for sale IScc.90M,Bminess t�u
Wand Professions Cole:The Contractor's license law does me apply 10 ea owner of OUTLET'S-SWITCHES-FIXTURES V /IF 1 LI EEK
4"3— Pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offend for NEW RESIDENTIAL ELECTR SQ lel'.
sale If,reverse,Ih budding.,emp 1 14 Iti tic yearefcompleto the -� - ,. SO FIT.IlO HAHLA SISQ.t1'.
t hlJ lllmcth h Ic, fraising thlhed'd Ilald inimprove h 1 %
pow f:1 )
1 ..rr older property.am a ly cont i g lh licensed centaur rt l
construct h project(Sec 9014 Business and Ps ref o corm)The Cat
onerem I'
ase Law does tot apply to an owner tritest wbobuilds(it improves throe and QTY(',, ,'+ • PI HING PERMIT-t - ' FEE eI
who contacts for such projects wpursuant ith a contractors)licensed pursuano the Contenemis +' UM
;'cert u , a ”, •
License law. 911AR
ANCE
❑ I am exempt under Sec. .B&P C for this reason
IN& 'I'-WAT' (HA) VALUATION
Owner Date
WORKER'SCOMPENSATION DHCLARA'I'ION PROTF,C 1a1hereby affirm under Penalty of perjury one of the following declarations: OR, OE iA. ND. STORIES I'YPIi CONSTRUCT ION
cation,as provided for by Section 3900 of the Labor Code.for the performance of theweek for which this permit is issted. ER B'R❑I have and will mninumn Worker's Compensation Incumna,lax required by Sumiun3900 all he Labor CI yyf�r thepc�Ir�1r f No work forwhich title permit lx ivs,md. STEM-I INC. S OCC.GROUP APN
My Worke' t<y''�t ins,fgf(ed Policy natter arc:
/) �'� 'J1• GAS-IiA.SYSTEM-OVER4(IIA
/ Cartier: lel in FROM
'
CERT IFlC O PENSAi ON INN FROM WORKERS' GREASMISDUSTRL WASTE INTERC )R
COMPENSATION INSURANCE BUILDING DIVISION 19:Eti
(This seetidn need not he completed lithe Permit is for enc hundred dollen($Hot GREASE TRAP -
nrlessJ PLANCHECK PEI?
I renify thin in mo parformuncenfthc workfor which tots permit ix issuaA,l xhnll SEWER-SANITARY-S'IONM IEA.200FT.
r not employ troy pcann in any mnnncr so usmtacome mAiem to the Workea'Camper- ENIBUYFEIi �(
Z 'mime Laws til Cnlifomis.Date WATER HEATER W/VENT/ELECTR
Z O Applicant I GRADING PE
NOTICE TO APPLICANT.If,after making this Cer ificme of Exemption,you should WATER SYSTEM/fRFATING SOILS FEE
F '--' become mbicid In the Worker's Compensation pmvinuna of the Labor Code,you must
forthwith comply with such provisionsaphis serail,hall hcdeemedat rkcd: WATER SERVICE
Q
r
�D _ CONSTRUCTION LENDING AGENCY NIiW RE DENTIAL PLB, SQ,Irl', 1 A ate real''Z E1tmrehy nffrin that there is a nmstmetion lending agency for the yerformancc of
the work for which this permit is issued Ser.3097.Civ.C.)
Q V Lendeek Name l'OTAL:
Lenders AJJress TOTAL:
C 1 certify that I have read this application and some that the above information is BUILDING
h cease t.I a,me comply all fi ay nform,ordinance,.rod some tows rel.tins v' QTY. . MECHANICAL.PERMIT. FF.,E
V huild g a fon, dh by 0 ' ,representatves of his city m enter 1po,the • 1' SEISMIC :E
move-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to sCirririve,indemnify and keep hued...the City of Cupagainst 13LIiCT CPEE
liabilities judgments,cons and eapcmes which may in any way accrue against said City ALTER OR ADD TO MGCII.
'PLUM INC,FEE
in consequence mf the granting of this pemtif
APPLICANTJ/,'�'(',y)RSTANDS AND .L COMPLY WITH ALL N N-POI T AIR HANDLING UNIT(TO 10.000 CUM) MEC ANICAL FEE;
5 BEER 1CU1 fI IONS. '
f / G AIR HANDLING UNR(OVER 10,000CFM) CO :TRTCTv Rs'I'AX -
Si reefSi reef
2, an
.Lor ¢�O te . EXHAUST HOOD(WIDUCf7 ILO SING MITIGATION FF.F.
f{AZ DOGS MATERIALS DIS CLOSURE
w5llthcapplirms r fume builmoloire nt nom,,lmndle havrdous mmedal HEATING UNIT(TO 1011,1X)1 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.;,a the HeaIN and Se&ry
Code Seenon 25532m)p HEATING UNIT(OVGR 100,000 BTU)
❑Yee El No V17N'I'I LATION FAN(SINGLT RCSID) PAID
Date
Will the applicant or fwurc hu'dding ardepe m use cquipm•1In des lde,which ROILCR-COME'(HI'(1R 11111,(N O RTU)
nit haxum is our contaminants as defined by the Bay Arca Air Quality Management 'ID AL:
into^ BOILER-COMP(OVER 100,000 BTU)
❑Yes FINE.
I have read the hurardmusm:neduls requirements tinder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE.DATE
forms He 1A,&Su f Iy Code Se vions 25505,25533 and 2.5534.1 undo land tit d if the NLW RESIDENTIAL MIS CII. SQ.PL -
randimgder,ral lariall,lave u mato,Art It all m1porldefitl In notify theoll"I'm
of he aa,mm at,which mit hemu are to issuance ora C,onfiride of occuPmry,
Ot,mr.a.mla riuN egcm Dam 4 ISSUED BY:
OFFICE