S 0107 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELV.C,TRICAL PHRMTT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-A ECHAN'ICAL
BUILDING PROJECT'IDEM'IFICATION
BUILDINGADDRESS: SANITARY NO. AI'1'LICATION SUBMITTAL.DAII7
O W 5 Cr{o•�
OWNER'S NAME 1 COM�Cjgi' N LICNO'.
`�?/ ^ NIC CONTROL a
1W1RCHITECT/EN6 iER: LIC NO. ADDRESS: ❑
S - deco Ga 1 30 7kGGY ,td 4J q z
CONTACT: PHONE: BU ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI(%l ELF PLUMB 4E 1
tom.
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
/Cad/\ r��••\
I hemhy.form that I ata licensed under provision,of Chaplet 9(commencing JOB DESCRIPTION
O=Z with ScOon)00)nf Division Jof the Ruaincosvnd Pm(csinm CoJc.andmybeenseis RESIDENTIAL:
mph PERMIT ISSUANCE
In
CUE• full force and effect. ❑SFDWL ❑KITCHEN REMODEL.
QUU License Class Lica APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIT'S
F Z W Dam Conm mun
yQy ❑MULTLUNIT El STRUCTURAL
ARCHITF(TS DECLARATIONPANELS
OZNZ IundcmanJ my plain shallbeuscd vs public me III UP TO 200 AMPS MODIFICATION
[]INTERIOR ❑CHIMNEYREPAIR
E.=FO Licensed Penfes,ion.1 201-1000AMPS - IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVERT Ah S ❑BATH1J�tODEL'REPAIR ❑DEMOLITION
lY C 6 I hereby affirm that I am exempt from the Con ore License Law for the �t � R q
kL U following reason.(Section 7031.5.Business sad 1'ndesOme,Cale:Any city or county SIGN. L ❑OTIiEW
1+13¢h
which requires a Permit to construct.aIt p dearcolch,or repairnY:finewre
F�Oe pro t I - also y the l hpe 'lt fl 8 J:t temcnl SPECIAL CI 'UIT/M1 .C.
� Y
that he ficens,ajipursuant ithe p Ith Cnit I I Lioca,LawChopterc,
Ofy'�p (cm g 'tin Sccl ]I%%)) fD nil H N . JProfession,Code)a, TEMP.METER OR POLE INST.
mpl nn Any viol
d iaC es c that he Is exempt henchman ad the buss far the.]lege]cne . as on of TION C1 DEMOLITION
4. f)V BI
HLUG/ADDI
Section]031.5 by any.applicant for a permit subjects the applicant m a civil penalty Of POWER DEVICES �NNNILUr[HI�IN�f❑FOOD SERVICE
til mom than from hundred dollars(Still). IMPROVEMFN'1'
ESG ❑1,us owncnd the property,arnry employees wish wage,as lhebsolc com'—don, SWIMMING POOL ELEC]'BIC
will do Ihewnrk,omA the xvucmrc Ix ern omm�Jcd or offered f r sale(Sec.7144.Iaamesa OTHLR
��'m
C3 aad Profic,iom Cnk I he C t IIS^I I Ie, ' hr: owner n! OUTLETS-SWITCHES I'IX"1 TIRES
property 'h h ]kao p [hereon, J 1 suchkin Il orthmu(,h
his(own employisco,provided t t such i t: m NEW RtlS1UENTIN.HLhCT2 SV Pf.
SR PFLOOR AREA SISQ.P.
soneIL however.the building or hoprove cna sold withinohe
coster-builder will have the hanhn of Proving l hon he did not build or improve for put-
Ce
se;;f salon of the property,a exclusively c waling with I—sed mnuamors h; 'I'OTA L: 1`/✓-j/V���
construct the project(See.7(44.In sinexs and P rolurnions Ccani The Conlravoos Li-
cense Law dmsnotapply to an owner of property who builds or improves Thereon,and QTY. PLUMBING PERMIT FEE
who commas hsr such projects with a conImcmn,)licensed pursuant to the Contractor's
Limine Law. B&P C for this rtaxov PERMIT ISSUANCE
❑ 1 oro exempt codon Sc .
ALTF,R-DRAIN&VENT-WATER PA) VALUATION
Dae
ORKERS PI'NSATION DI; IARAT]ON RACK PLOW PROTECT.D VICE cli
Iherchyafimtunact, ally ofperjury,neoffhcfellnwingdeclarations
1]I have and will maintain v Ccnilicam of Consent toself-inm¢Int Worker's Compcn- DRAINS-FLOOR. .AREA.GOND, STHRILS TYPE CONSTRUCTION
cation,as provided for by Section 3]01 of the IaMn Code,for the performance of the
wool which this permit i.i...ed. FIXTURES-PIE AP
❑1 have and will maintain Waders Compensation Insurance,as required by Section
3700 of the labor Code,mine,perasrmance of the weak for which this permit is i.awed. GAS-EA.SYSTEM-1 INCA EIS OCC.GROUP APN
My Workers Confer tion Insurance cmdaand Policy mmarberere: GAS-EA.SYSTEM ]IEA
Carica. Policy No.:
CERTIFICATHOF EXEMPTION FROM WORKERSGREASEBNDUSTRLW CIRC
COMPENSATION INSURANCE BUIL -D IMON SEES
(Tbissaalso neednm he completed n ohe pemtitn foreme hundrtddnllas($1W) GREASETRAP
1'LANCHECK EEE
or less.)
I certify that in the performance of the work for which this permit is issued.l shall SEWER-SANITARY-STORM FAA
not employ any person in any nommi so as as hecome subjecOo the Work,,,'Compcn- ENERGYFEE
O Z nation Law.of California.Dae WATER HEATER WNIiNT/[LECfR GRADING I':
Z Q Applicant
lied. NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYSTENU BEATING SLIM F]
1••' become%objectto the Worker x Compensation provisions of the Labor Code,you must
forthwith comply with such provision or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMtl. SU fT' PAID pore RcmiptN
Z Thereby affirm that there ixuconstruction lending agency for the perlimwncc of •
U 2 the work for which this permit is issued(Sec.7097.Civ.C.) TOTAL:
O U Lenders,Name
Lcmolo,,Address IGUAL.
> 6Wi 1 eerily Thal I hone mai this application and eine thin Ibe above mosmutinn Is HUILDIN<i
.H.x V) coned.)agree mc(Ioldy with all city and county ord'munces and state laws relating or QTY. MECHANICAL.PERMIT FET: SEISMIC IT710
U laddiegemrclmcdonand herchy I horizc rcpmscnlativcs of This city it)enter upon the
sho,O.Oac ioncd clonally lit inymction pnrryncs. PERMIT ISSUANCE FI.FC'I'R1C Il
(We)all,,,loon,acdcnmlfy and keep harnllery the City of Cnpeninn against
liuhilifics,Judgments,casxomA expmrsexwhich luny roomy wnyuccom almil"saidCity ACfERORADDTO_MECH. PLUMBING q]i sci
in consequence of the gnmting of this perinjt.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10141MA)CI M) MIiCIIANI(Al.11ili
SOURCE REGOLATION
16 AIR HANDLING UNIT(OVER 10.IXNI CFM) C(INS'TRIJC'I' 'I'A%
Signature of app co,Cnman
n Date EXHAUST HOOD(W/DUCT) HOUSING MITLGAT NPFF
HA].ARD S MAT'13RIAL3 DISCLOSURE
Will the vpplicarnorfuturchui]ding occupant"amorhanJle hazardous ar ial HEATING UNIT(TO H0.0N)BTU)
av defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00.I00 BTU)
Case,St 25532(v)'!
�Ye, ❑No VENTILATION FAN(SINGLE RESID) / PAID
pone Receipt#
Will Ne applicant or future building occupant use equipment or devices which BOILER—COMP UHPOR 1E0.01)(
mit hezardnus sir amlaminams as Jcfincd by the Hay Arca Air Quality Management 1BTO)
TOTAL:
Dinrinl BOILER—COMP(OVER 100.00IITU)
OYes 11 No
I have read the hairvdcan materials ager 6.95 of fine Cali- ALR CONDITIONER ISSUANCE DATE
rcyuortmenu umler Ch
ford.Health&Safety QWe,hosenom 25505,25533 and 25571.I a dincomod that if the NEW RESIDENTIAL MECIL SQ.del'.
building does not cmmndy have v match,that it is my msponibilit m edify the Occupant
of the mearemnnx which mus be met prim in issuance of Cenifcae of Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED Ely
OFFICE