S 0092 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU PERTINO BUILDING-ELECTRICAL PERMIT N0.
'BUILDING DI VISION APPLICATIONIPERMIT PLUMBING-MECHANICAL '
' I ( _ BUILDING PRfIJECF IDENTIFICATION
UILDING ADDRESS SANITARY. APPLICATION SUHMITI'AI.DATE.
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NAMIi�L
: PHONIi: CONIRAC'1011'S NAME: NIC NO:
NIC CON1ROhM
zs3 - 806
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�ANCHITECT/IiNG1N1iER: LIC NO: ADDRIiSS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) .n6 EO.IiCT PLUMB MEC if "
LICENSED CONTNAC'I ORS DECLARATION
Vt ' I t I r
TY ( �_I CLECTRICPCRMITtt •" IEEf '
I hereby offirint that I am Scented under provisions of Chapter 9 @norm c g .•, . a ((^r .tw JOB DESCRIPTION
OW d'ZWOO wird Scv,,m7(MMBn1 Dvision 3ofthe Bust . fe
:mud Prossors Cale andmylcnse is RESIDENTIAL
�
Fes,IyF
in full force and chat. PERMIT ISSUANCE
❑SFDWL L�JTCHENREMODEL.
aVU License Class "Ip
Lic.p APPLIANCES-RESIDEN11AL ADDITION �If PLUMBING RE.P[1'E
F-�W DartCmdrlmnr
[]ADDITIONon G - _ - ❑duan-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
F psi z 1 undersand my plans shall he used m public oo...ds PANELS. MODIFICATION
'Oz-O UpiO2MAMPS 0INTERIOR C1 CHIMNEY REPAIR
F%4`L til gLicensed Professional201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
' WadOWNER-BUILDL'N DECLARATION - OVER I(MM)AMPS ❑BATH REMODEURITAIR ❑DEMOL.ITION
IY C d 1 hereby efum that I am enempt from IM1e Contractor's License Law far the
O cal U IoHowing reason.(Section 9031.5.Business and Professions CNe:Any city or only SIGNS ELECTRICAI. OTHER
LLl�+t y which require.aµrout to consaua,alter,impure,demolish,or repair any onshore ff
y.x.04' pro t t :. L 9 th ppll If suchpe it to filcad,ra,dstatement 11�'I:CIAL CIRCUf1/MISC. .w
dint lie licensed p tt the provisionsal tl Contractors,Li,ou.se Law(Chader9
(cn nmeneinyw0 Sw11 h]IM1U)nf D'vlin h Sof Ilan Rhomeand 11 mfni,h sCnde)., II:MR MC'THR OR POLE I NST. COMMERCIAL,
„
1.p�,o a Thad he is exempt Therefrom and the basis Gu the alleged exemption.Any violmim of -
iC la, ❑NIiW N1.DG/AIJDI'I'I(lN ❑DBM01.1'I'I(lN
Q of Sceiion 7031.5 by any applicant for. chand,abjems Neap,hem looi,ml penaltynf I'Ov.9iN DEVICES, IENANT ❑FOOD SEI2VICIi
FZanot more than Eve hundred dollars S5WL IMPROVEMENT
❑Los owner of be proµny.or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC
fFC will do the work.ond the screw.is not in¢ndedoro(fared for sale(See](Ff4,Business OTHER
W 3�' and Professions Codt,. he Contractor's License Law doer not apply to an owner of OUR LFOS-SWI'TCHES-FIXTURES
progeny who builds or improve,thereon,and who does such work himself or through -
his own employees,Prwidod that such mraoscmcn6 are hot intmWcd of olfered for NEW RESIDENTIAL FLEC'TR SQ PI'.
sale.IL however,the building or improvetncnllmold withinane you of annp.e.ion,the - - SQ.ITAfl;tR jlRHA $SQ.I`U
owner-builder will have the burden of proving that he did not build or intpmve for poo- r //��
poo f I )
❑I f th pmpen) am exclus ly e t eef g hh licensed contract 1.
f �!
construct tb project(Sec 7614 Business dl f .Code')Ifie Corona L ,-- - - p,• u�"V
ten. La does not apply to an owner of prpeny h builds or Improves themo add QTY. ' - '!iI PLUMBING PERM / 'FEES,ai
inn concocts torsuch projects with a contractor(s)Icensed pursuant the Comrdemrs I
License Law. PERMIT ISSUANCE. �f LVr
❑ l am exemnl ander s B&P c her this a,nn tVALUNIty(}
AIXER-DRAIN&VENT'-WATER WA) VALUA'T'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE?
I hereby short under Penalty of perjury one of the following declarations:
Fl Ihave and%ill maintain a Ccnificam of Co®enuoself-insure for Workers Comped- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided fur by Section 37W more Labor Code,for the perfonmmce of the
work for which thisµrout is issued. FIXTURES-PER TRAP
n 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Lahor Cole,for IM1e performance Oil the work for which This permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROVE' AI'N
My Worker's Conmensatinn Insurance carrier and Policy number arc:
Carrion I'nficy No, GAS-HA.SYSTEM-OVIIR 4(EA)
CERTIFICATE OF FAEM17ION FROM WORKERS' GRCASI%INDUSTRL WASTE INIERCF,ITOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(This section need not be completed adsµomit is for one hundred dollars(SIM) soolilGRIiASF.TRAP
or lass.) 'LANCHECK HE
I codify that in the perfommnccofthe work for which this penitis issued.[,hall SEWER-SANITARY-STORM EA.200 FT.
nal ample,any puna in hey masher,to a,to theeoml subject m the Wnrkan'Comped- ENERGY PEE
oz ,.lath Laws of Calif orriu.Dam WAfBR HEA'THR W/VIiMT/EI,ECfR '
G O Applicant l GRADING HE
G fry NOTICE TO APPLICANT,IL after making(ON Ccnifirde of Mirthful r,you should WATER SYSTEM[]BEATING
F become subject to the Workers Copensation provisions of the Labor Code,you mus SOILS PER
forthwith comply with such provisions.,,his permit shall her deemed revoked, WATER SERVICE
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAI,PLM. SQ.IT. PAID
LJ 0 I hereby affirm lin mere is.construction boding al,r cy fish oo perf chromOe of Dae
H the work for which thin permit Is issued(Sea 309],Civ.C.)
Q oir
U Lerdcds Not X(-AL:
61Lender's Address
0. cenify Ilam i have reed this application and slate that the above information isBUILDING FE
In correel l agree to comply with all city and county ordinances and state laws felting to QTY. MECHANICAL PERMIT '. FEE ip
LJ Z building coretmroon,and hereby amhutre rnpresemraves of this city to enter upon die SEISMIC FEE
It
above-mentioned proµny for inspection purposes. I'it ISSUANCL
(We)agree toom e,indemnify and keep harmless Me City of Cupertino against PLUMBING FEE
C FEF.
liabilities,judgmems.cost,undexpense,which may inmy sly.ccouet,mmisditiCity ANTER OR ADD TO MECIi. -
at asequence film
DERoaming this permit
.p
- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'('1014000 CPM) MRCIIANICAI.PH9 "
SOU� E,ULATI(n
.Wt`E L �q�11 AIR IIANDLING UNIT(OVIiR 0.0WCFM) CONS'I'RUCfION TA%
SimdtrreofAPphcanVCommaor 4 1Datee EXHAUST HOOD(W/DUCT) HOUSING MH'IGATDN IEE
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle haenrdms material HEATING ON[*[(TO 100.0013TU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Cade,Section 2553260/ HEATING UNIT(OVER 1110,000 BTU)
E]YO, E]No VEN'HLATION PAN(SINGLE RES1D) VAHO —
Date Rc,Oipi# -
Will me applicant or future building oecupont use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hierarchies m
s air conmimems as defined by the Bay Area Air Quality Management TOTAL:
d� Dislrict'
❑Yes ❑No MOILER-COMPfOVER IMMOBTII) - -
s
I have readthc hazani materials rgoimmems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Hedm&SaRTy Coda,Sectiom 255(15,25533 and25534.1 untinsmnd Inas if the N17W RP.SIDENTIAl.MECH. .SQ.Fr.
building Aces nal cunendy hnvca lennnto Ihod it i,my m,So smility In toothy dm occupant -
oftherequirementwhichmussbeme,Imi t,atamoo of o Cenif,sto of Occupancy.
Owner or mhnur red ugem Done ISSUED BY:
OFFICE