S 1684 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESITNO. 1684
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL
z'� BUILDING PROJECT' DENTIFICATION
BUILDING ADDRESS `4� 1 /� rA C,a MyVo � �p9)QrINO O�O ' SANITARY NO. API'LICAI'ION SUHMII"I'Ah UAI'F:
L l 7 /� /(J fir' 'V [
OW ER' 14:4 VV C L_I,1'IDg,Z4g.OVaag7 CONTRACIT)R'S NAME: LIC NO:
NIC /�k CON'fROl.p
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ 88Zy
CON'T'ACT: PHONE: 6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant Onilial) BLDG ELECT PLUMB MECH ,
LICENSLD CONTRACTOR S DECI ARADON QTY. ELECTRIC PI7RMIT FEE
I he chy find that 1 nm hisca rad p '- I Chapter 9(uo n nem.ing JOB DESCRIPTION
O�Z with Section 7000lof Division 3 of the Business and l rofns o s Code,and my l ce oce s ` RESIDENTIAL:
WOO PERMIT ISSl1ANCF. SJ .Sv
FW. in toll tweezed effect. ❑SIU I. CKI'TGHIEN REMODEL.
LUVLmcnm Class Iic.M APPLIANCES-RIESIDIENTIAL DDITION ❑PLUMBING RE.PIPE
h64 Dare Contractor
ARCHITECT'S DECLARATION ❑MULTIUNIT ❑STRUCTURAL
Fvz Iunderslvndm I hall be used public records PANELS MODIFICATION
o�yQ my as
IIP T02(1t1AMP5 LJ INTERIOR [I CHIMNEY REPAIR
f-r3Fu] Licensed professional 201-100DAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER wernaId fr DIi he ConTION OVER IOq)AMI'S C BXrU REMODF.IJREPAIR [I DEMOLITION
I hereby affirm that 11. exempt from the Contrnctor'x e:Any c Law for the
50=u 4sllowin (Section]031.5,Business:mJ Professions Cale:An n T ❑at HER
g reams. ri city rs,coon y SIGNS ELECTRICAL
3 a-h which rcyvircs n permit m mnawet,aafter.pplicant
nt for such
demolish,oru s sig nay statare
ement
,F]�O� patheisscensed e.also
uanttowades he prevision of for Commeminnicense ned Law(Chapter
SPECLAI.CIRCUITIMISC.
RmannumeI., it pursuant to the of Division
of the Coria s, License LawsCadv)r9
�..Q� that he is ixempth Sectirom700sh
and of Diaiiionsdthceged exempt Professions CnacO or 'rEMI'.ME'I'F.R OR POLE INST. COMMERCIAL,
that Section
is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION
'b- not o mtD n five any hundred
liana for subjects the applicant vo a civil gennlry of I'OWIER DL'VICIS C'IMPRO I' El FOOD SIiRVICE
XQnot more then five hundred Dollars(f 51X)).
❑ hoz owner Df the progeny,or my employees with wages as their sole compensation. SWIMMING POU,ELECT RIC IMPROVEMENT'
F- will do the work.and the structure is not intended orottend forrJe(See.7W4,Business Of
[]OTHER
WW :"2 and I'mfeasiom Cale:The Contractor's License Lips,does not apply to an owner of OVTLE'IS-SWI'rClih:S-FIXTURES
IL 3., Ino'"Y who builds or improves Thereon,and who does such work bim.mlf or through
his awn employees,provided that such improvements am not intended in uttered far NEW RESIDENTIAL IELECIR SQ Fr..
sale.lit,however,the building or improvement is sold within one year of completion.the SQ.17.FLOOR AREA $/SQ.FE
ownechudder will have the burden of proving that he did not build or improve for puT-
.ovv). / O ,� TDrnL: 4
Wm awnet m'me pmpertr,am exdaamely cammcting withlicensedeamtrarmt,m
annnct the project(Sec.70Wl,Business dad Pmfcesions Count.,The—aaa—t is Li- •�j
m Law does not apply to an owner of property who b .
build.or improves duca and QTY PLUMBING PERMIT FEE
whcontracts Our such possums with a contmctorid licensed pursuant to the Contmnors
License l.aw. PERM]'T '3UANCIE �•,�'O
❑ I am exempt under Sec. .B&P C for this reason
Owner Dam ALTER ALN&VENT-WATER(EA) VALUATION
WORKER COMPENSATION DECLARATION BACK FLO (]T° ' DEVICE �,^1
I hereby affirm under penal,of perjury one of the fallow :fallowing declandi... VV
❑ I have and will maintain a Cerd iese of Consent to self-insum fm W'orker's ComPet- DRAINS-FLO( ,AREA,COND. STORIES TYPE CONST RUCTION
cation,as provided for by Section 3710 of the Diner Code,far the performance of Tbc
work for which do,ti-mil is issued. FIXTURES-PIER TRA
C L have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the Tabor Cotte.for the performance of the work for which thi s permit is issued. GAS-IEA.SYS'IE NC. UTLETS OCC.GROAT' APN
My Wod.er's Compensation Lnmemse artier and Palicy mummer ran:
Carrier Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CIRU IFLCATE OF EXEMPFION FROM WORKERS'
COMPENSATION INSURANCE GREASR/INDUSTRL WASTE.INTERCEPTOR
II1111.U1N(i DIVISION PEES
IlLis seninn need not be completed ifthe permit is Forane modestp$RX0 GREASIETRAP
or less.) I'LANCHIECK FF.Ii 209Ps95-
1 certify that in rite pefi'ommance of the work for which this permit is issued,l shall
not employ any person in any manner so asset subject s became subjeco The WorkerCnmpem SEWER-SANITARY-STORM IEA.2001T. ENERGY FEE X
4 0
,Z. plaws of C.II(otos Dom WATER HEA'T'ER WNEMf/ELECFR
Applicant
O Applicant GRADING FEF
y NCH ICE 10 APPLICANT:If.after making this Certificate of Exemption,you should mWAFDR SYS'IM/IR EATING
al^ hcuune subject 1. he Worker's Compensation provisions of the Indan Code,you oot SOILS FEE
f� �yy fcift,tit eonply with such provisions or his permits hall be deemed waked. WAFER SERVICE
CON num is.'10Nmnima]NO AGENCY NEW RESIDENTIAL I'LMB. SQ,FC PAID
V I herebyich thi lhmtnti ieaed(See len]coding agency forThe performance of
Date Receipnp
the work for which this pump is irsucd IScc.3097.Civ.CJ
0 F" Lndcr's Name TOTAL:
V lundee'v AJJrtsa 'TOTAL: y'O-
�z curif,end 1 have read this ii I t d store That the above imfoann= is BUILDING FEE ay 00
Ft IY Y PP ice ion an ��
UzH comply and with all city and comnynraimansof and cont Hwtrc tisain to Q'ry, MIiGHANIGAI.PERMIT FEE
buildingamsuueinn,unJhereby authorize reprtsenmtivesofthis city toemcrupmThe SEISMIC FEE .2 o0
above-mentioned property for inspection purposes, FERMI r ISSUANCIi
(We)agree m savde
e,inmnify gad keep harmless The City of Caper inn against ELECTRIC 197E y0. 4
Habil mics,judgments,costs and expenses which may in any way amre against said City AIJ ER OR ADD1'0 MIECIL
PLUMBING PBIi
APPLIin CANT
Nthe granting Sthispermit. RNAV 02Sr U•
AI'I'LICAN'T UNDEHfI)1NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(011 CT
SOMI .E R.GUI. HO M17CIIANICAL PER
t1 C/I Q��0Y AIR HANDLING UNI'TGvER Iq(XX1 'MI CONSTRUCTION TAX
Signor rent pplicupmd(C a' r ✓ Intra S f llAUS]'IIOOD(W/DUCT) CIII UC `P s'osn n•
BAZAR 5 MATERIALS DISCLOSURE
HOUSING MITIGA'f10N FEE
Will nM1e upplleanmrlh,a ouilJing occupant sorcar handle hazardous material HI?ATING UNIT(T01001,IN10119'U) `J
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Henhb unit Safety q4
Cade,See)r(+"25532(.)! III iATINGUNI'1'(OVER I10.00IB'IU)
k.I ❑Nd VENTILATION FAN(SINGLERSID) 'PAID/
Uamc RecctptM / 1
Will the applicant or furore building by the BT use equipment m devices which BOILER-COMP LIMP OR 100,(00 BTU)
emit hnzurdnm all nmuminmts as fined by rite Bay Arca Air Quality'Management 'TOI'AI:
Disnict l BOILER-COMP(OVER 100.0000 B'115)
❑Yea No
I have owes the hazardous mamrials reyuimnm
ses under Chapter 0.95 of site Cali AIR CONDITIONER ISSUANCE DATE, �\
humin,Health&Safety Cale.Seetionx 25505,25533 and 25534.I understand then if The NEW RESIDENTIAL MECIL SQ.
buildlmgdoes not current,have mount,that it lz my re,varrohilitym notify the accupmn C
of the q 'nnmm Ich mustMmet to issu.ncc ata Cenificat of(kc trymcy. _^''ITfa'� �f
Owner r oozed age t Ude TOTAL: ISSUED BY:G DP— Hct-7.�rX.$.eoi
OFFICE