S 4358 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF DUPE RTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
' i'Ln1pltlJILDIN(;I•RWF.C'1'IDFNTIFICATIONti I; #Dili{'11L
PERMITNO.
S 4358
BUILDING ADDRESS: -
SANITARY NO.
APPLICATION SUBMITTALDATH
r
O 1 s1,�ce S \\)eYNnP_ tan c� r o 1 `)
L� Z - S F
OWNER'SNAME:1 ` PHONE:
V I'Va�N u�•
CO RACTOR'S NAh1F: LIC NO,
-7 (�'
N/C
❑
CONTROL#
AItCHIFEC'I'/IINGINEHIy; LIC NO:
ADDRESS
c) s�rawlle N.
CONTACT: ptiONe:
;jjl,'1 BUILDING PERMIT INFO, ;p,'_
❑ Consultant Fees Paid by Applicant (Initial)BLDG
ELECT PLUMB MECH
❑ P❑ ❑
JOB DESCRIPTION
LICENSED COM RACIOHS DECLARATION
I heehy onrn Wet lam mixed ad pv,i nrchapter9(emnnenitg.„,l
QTY.' �) 1 ELECTRIC PERMITtit I,/ l yli FEE(�'1,1�+
xftu)r r121r,. /r!�,. ..r .l�?��I, i..,t, 4317en¢fL2u
YERMI'1'ISSUANCF; (SO
,injAcclimn](MMI)afl000ion Sof WC Bminemond Professions Code, and by, Rest
•� 5Z
i all force and cR e7
'ons Clsa Q Lie#
Uma!' z N4 Cuntreemr
ARCHITECTS DECLARATION -
I understand my plans shall be used as public recordsMODIFICATION
RESIDENTIAL'
OSFDWL O KITCHEN REMODEL.
❑ADDITION ❑PLUMBING RE -PIPE.
❑MULTI -UNIT ❑STRUCTURAL
0INTERIOR OCHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
APPLIANCES -RES I DF.NTI A I.
PANFIS
UP TO 20(1AMPS 201
LicmrveJ l'mfcasinnul
201 -loon AMPS
OWNER-HUILDER DECLARATION
1 hereby affirm thin 1 am exempt from the Contractor's License Law far the
billowing reason. (Section 7031.5, Business and lom essiorm Code, Any city or county
0BATH REMOD EPAIR 0I 1OLITION
OOTHER
OVER IWMI AMPS
SIGNS ELECT RICA.
which tcquims n permit to comonm, alm,, improve, demallsh, m repair any offset
SPECIAL COUCH 17MISC.
prior to it, issuance, alsorrqum, the applicant baoich per it m file asignedombalenl
iF--
that he is licensed pursuant to the provisions of the Conlaaols License law, (Chapter Y
'TEMP. MEITR OR POLE INST.
_TS
(cnmmeneing with Section 7000)of Division 3 ofthe Business and Professions Code)or
t hal he is esnnpt them Quin aad Ileo basis fur the ulle,d exemption. Any vi mlani i of
0 NEW HI.DG/ADDITION 0 DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjccE the applicant to a civil penally of
not marc than Eve hundred dollars (I500).
❑I, as owner of the progeny, or my employees with wages us their sole camperismim.
will do the work, and the slmcmm is not intmW W or offered Iia sole (Sec. 7044, Business
and Professions Code :'I'Te Contractor's Limtuc Law docs brn apply m an owner of
0 TENANT FOOD SERVICE
IMPROVEMENT
[]OTHER
SWIMMING POOL ELECTRIC
OUT LEIS -SWII CHIS -FIXTURES
LIP—
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvemanlc am not intended nr offered for
NEW RESIDENTIAL HLECIR SQ FT
SQ. FI'. FLOOR AREA
SRQ. FT,
side. If, nowcve9We IF din,aimPnn'cmenlhenld wLbinuncycandcnntpletloq lha
er-builder will have the burden n1 proving Wal he did not M1ulld or improve for pur-
po¢oLwle.).
0 I, m r of the property, am exclusively contracting with licensed contractors to
TO
rtabuct Wa prnjeer (Se 9(948' ,, dl r.! xCo.-, Ito Cnntmetor I
wae Law does not apply t fp parhhild a improve. thereon dQTY
ho contracts for such pts Jects with a conructims)Icensed parsuant In the Contractors
- t_ p -t if"- "'turf i:' g 1' f!, of
H'11PI,1JMB'ING PERMTT'��'it '�It'PEEII F:�
I -.rl �._ i ,f H. )�- l.ih•n.nt
PERMIT ISSUANCE
Loeme Law.
O lam excntpl under Sac. ,B& PC for this reason
Owner Dae
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
WORKER'S COMPENSA'T'ION DECLARATION
BACK FLOW PROTECT. DEVICE
1 Tombs alliin coder #coolly of pujoi, ono of the, following det lenttium:
DRAINS -FLOOR, ROOF. AREA, COND.
I have and will maintain a Cenifivam of Consent to self -insure for Worker's Conger-
cation, as provided for by Section 37M of the Iatnr Code, for We performance of the
STORIES
TYPE CONS 'IRUCS]ON
work for which this permit is word,
FIXTURES -PER MAP
0 1 frost I will Twin oin Warker'n Compensation Inaanmna, as rugti red by Section
31(M)ofthe Labor Code. (or the Performance ofthe work for which this permit is issued.
GAS - ITA. SYS'I FM -I INC. 4 OUTLETS
OCC. GROUT'
APN
My Workers Compensation Insurance artier and Policy number arc:
Came,: Policy No.:
GAS - EA. SYSTEM OVER (En)
CERTIIICATE OF Ie%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASIANDUS9'III. WAST Ii INTERCBPIOR
-g B1IILDING DIVISI(YN IY.dS
(Thissution need not berompleled if the pe,mit is Lx one hundrod dollars (SIDE
or less)
GREASE '1'RAP
PI.ANCHECK FEE
SEWER - SANI'I'AITY- S' I' ORM EA. 2W 17.
I certify that In the pertormamecufine work for which this permit islssued l shall
nm employ ens person In any ,anter sops' hn tppexasceUDthe Workers'Contpen-
Wu- Ca f /b
FN EROY FEI?
WATER HEATER WNENT/EIXC` t
cation Tr `l
Applicant 2— 7 /��
GRADING FEE
NO I, , I 'r: IG a0cr .en a of Ex npt� �t� Lin, you should
Manures )re, mthe Workels Compensation .... isionsof the LuMa Code. yoantmt
WATER SYSTFMIIAHATING
SOILS P'E'
Gmhwi comply with such provisions or this permit shallMdeemed rtvoked.
WATCH SERVICE
CONSTRUCTION LENDING AGENCY
I hcrebynffini there tan constriction kolimg agency for the perfatmmre„f
NEW RESIDENTIAL TIME. SQ. FT
PAID
Dat Receipt#
the work for which this parrnil is issued (sec. 30R, civ. C.)
Lender's Name
TOTAL:
I.cnders Addrtxs
TOTAL:
BUILDING iE
Iceftfy that l ha' duh' tipplictili i ad.tat but he M1 -f f correct.
Iagree to comply with all its d N . county a ce t a I I i gt
building construction, and hereby tuthoriu representativesof tti. city m enter upon the
t I:Rn•'.b
QTY. It. 1 "MECIJANICAI PERMIT 14+, i4 £ '
suds .I�ftfiT ert.
SEISMIC :E
PERM I'I' ISSUANCE(We)
ELECTRIC i' -716
nhovo-mcndotied pm,ny for um,..lar purposes.
agree m xme, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgtnertH, emu and experues which may irony vayaccrucagoinst slid City
I. consequence of the granting alibis permit.
AUIF,RORADDTONIECH.
PLUMBING Fz
AIR HANDLING UNIT(T010,008 CFM)
MIiCI{gNICAh ITE i
APPLICANT UNDI STANDS AND WILISCO . WITH AL1, NON -POINT
SOURCE HEGULA NS.
HANDLING UNIT(OVRR 10,000CFM)
CONSTRULTIONTAX
ri,AIR
urea GcaniA aroolicati
EXHAUST HOOT) W/DUCT)
HOUSING MITIGATION FEE ”
I IAZARDOUS MATERIALS DISCLORE
HEATING UNIT (TO RX0, 03111'U)
Will the applicant or future building wcupam store nr anJlc h' a,dous anmenal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health anti Safety
Coda Scetion 25532(10'!
HEA'T'ING UNIT (OVER 100,000 BTU)
❑Yes []No
PAID -
nae Receipt #
VENTILATION FAN (SINGLE RESID)
BOILER- COMP CLIP OR 1NEWIU BTU)
Will the applicmdinm,ihefinvg by fine H useoquipr Qunrdeviceswhich
emit hvnnlons air ennumtinenta us JcOnuf by the Btry Arun Alt Quality Management
Disaica^
❑Yes No
O
- AL:
BOILER -COMP (OVER 100.000 BTU)
Alk CONDITIONER
I hove read the bamNomntmerinlxregnlrement. undo e, 695of the Cali-
Hama a Health & Safely Code, Sections 255115, 255�and 255 undemtand Ilett if the
building AmvtoI cu tlyhmeomnan vt it ismy ins litytonntifyth.11pard
ISSUANCE. DATE
A
/
NEW RESIDENTIAL MECIL SQ.
lie mqui mems ch must be p' Ce - tey1 y
O tl ge I v Dat f
TOTAL:
ISSUED BY.
/ / OFFICE