S 1067 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 111111rvG-ELECT RICA I. Pli UT NO.
BUILDING DIVISION APPLICATION/PERMIT I'LUhfl{ING-MF.CDANICAL 1.i 067
BGILDINII PROJECT IDEN'TIF'ICATION V
SANITARY NO. APPLICAHON SUBMITTAL DATE:
BUILDING ADDRESS:
/ O33 G
OWNER'S NAME: /� PHONE: CO RA 1' SN AMIi: LIC NO. — NEC CON"I Rot.N
CA SOS S
ARC[I'I'ECDENGINEER: LIC NO ADDRESS: ❑
S. J.
C'ONTACI': PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CUM"FACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE JOB DESCRIPTION
1 he„by affirm that I am licensed under provisions o'Chapter si mummudem,
DccZ with Sections of Division 3 of the Ursine.,%and Profev%mrs,Cale.and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
F O in full line,and cRectt,� �/� / ❑SPDWL ❑Kit CHEN R1:MODEL.
<U~ hiccme Class V`r� 'tics, �yo APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'LOMHING RISPIPF,
,Z al Date Contmetor
6CC ARCHI I'IiCI':S DECLARATION PANELS ❑MUI:I'I-UNIT ❑S'ENUC'1
~m X, lunderstand my,lura,hall heumd a,puNlerecords MOUIIICAlA'IION
OZ14.p- UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
I-�FIiI I.me^sed Proc Tonal 201-10(a)AMPS IMPROVEMENT SWIMMING POOLS
�•.Ef� OWNER-BUILDER DECLARATION OVER I0MAMPS ❑BATT{REMODEIIREPAIR ❑DEMOLITION
C ad Q 1 hereby aRrm that I am exempt from the Contract.,'.,License Law far the
XO a V following mason.(Seeman 1031.5.Business and Proas fesamCade:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 a F which requites a permit to consumer.altar,improve,demolish,or relvo any%fracture
FSO prior to as issuance,also requites the applicant for such permit o file a signed statement SPECIAL CIRCU IT/M ISC.
flythat he is licensed pursuant to the rm.ision.of Commnafs License Law(Chapter 9 COMMERCIAL:
WG0 (commencing with Section1(XXp of Division 3,Rare Business and Professions Cmlc)or TI3MI'.MHI'IRORPOLE[NST.
a R o y tM1m nc it exempt thercfmm and the M1usis fns Nc alleged cncmptinn.any violminn of ❑NEW I LOWADDITION ❑DEMOLITION
W..y notnwrc031 five
any
ahundred dollars
appbam fora fsvinit subjects the applicant son elvll Penalty of MWBR DEVICES ❑'I'FNAN'T [II-OODSERVICE
s($300)
ycanp, IMPROVI!MhN'1'
EZG ❑Lm^wncrk.the are
not intended witnwaid for oale(Se .campctnminn, SWIMMING POOL ELECTRIC ❑OTHI?K
F- andwill dothe wons ande: a ContunotimcnJed erraw dofafot apply to an towner of
I�al��
and ProPossiuns Code:The Contractor's License Law does not apply m an owner of OU'I'LEES-SWI"TCI{ES-FIXTURES y
IL 3-. property who builds or improves themou and who does such work himself or through
his own employees.provided that such improvements am not intended m offered for NEN'RESIDENTIAL[LECfR SQ FT.
sale.IL however the bnadingo,improvemem i%rold within one Ycar of nunplain.,rife SQ.FI'.FLOOR AREA LSU.FT.
ser-huildef will have the burden of proving that he did nm Fui1J or intpmve for pur-
pnscaLmlcJ. TOTAL:
h as owner of the progeny,am exclusively contracting with licensed contractors m
em t ct the project(Sec.10,14 1{ ,u and probes l^s Cod ,Tb s- t C :Li-
e t I d tapptyt 'fr pry n brim libracon,and QTY PLUMBING PERMIT FEE P A
tub connotes f hp 1 t. ocontusions)licensedP II tl C . t /u
Cc L' 111RNIII'ISSUANCE
I,m cWmpt under Sum. B&ICT th,% .:m
At, ER-DRAIN&VENT-WATER(EA) �/ A C)�
•Owner Date (�
WORKER'$COMI'13NSATION DECLARATION rC FLOW PROTECT.DEVICE
Ihereby illlinnundertain.Certifyofparryry oune^f the hollowing dorker'lons: f IaUY L
0Ihave and will mammin oCenifcam of C.nscnuosdf-insum fur Workc/%Gtmp,n- DR IsLLI(IH,ROOFARIiA.GOND. STONIES )Tl'I'Ii CONS"TRUCI'ION
cation,us provided for by Section 311X0of the labour Csde,for the pefromance of the
w^rkfnrwhichrhkpmmiti,issued. F OR TRAP
I have and will maintain Waders Cmapeasation Insurance,as required by Section C�
? (X)of the LaMx Cade,!.,rife perfonnuna.!rife work forwhich this permit is inuW. STEX .40U'ELETS OCC.GROUP AI'N
My Work' GC alICCOMPENSAIM cr:md Policy nt�bac vg. ��
sunnm t !JL.
Gnricr; P.Ilcy No.: GAS-1 S r' OVER4(13A)
1410N 17ROM WORKERS'
' >N INSURANCE GRI3ASE/INUl15 LWASTE IN"TEHCIi19UR BUILDING DIVISION P131iS
(This wsorm need not be cnmplened How permit is benne hundred killer,($[(as) GREASETRAY
PLANCHECK FEE
or Icas.l
Loy my person
in the p,rfomumcmaw, s ork becmew bjesi to permitsissued,'Comm- SI3WEH-SANITARY-STORM EA.Np IT.
not employ any Peso^^in any manner m as m become subjn't m the Workers'Cnmpcn- ENERGY ItiE
oZ .,,tion lax.of Calimmia.Date WATER HEATER W/VENT/ELECTR GRADING 193E
O Applicant
Z y NOI'ICl3 TO APPLICANT:If,after making this Certificate of Exemption,you should W'ATIiR SYti TI3M/IREATING SOIhs THE
F-' b,mnm subject oo the Worker's Cninpcmatioto provisions of the Lol.n Cade,you 111-11
a
forthwith comply with such provisions^nhic permit shall be deemed revoked. WATER SERVICE
DJ Q
6.
CONS'[RUCTION LENDING AGENCY NEW RESIDI3N'IIAL PLMtl, SQ.IrIL ['AID
])a'. Rccmpl
I hereby affirm that them'isaconstrvmiot lending agency Carol,,peut'nnname of M
WFthe work for wh)chrhis permir is ism.it(Se,.3091.Civ.C.) TUI'A '
U Under's Name IMAL:
} Isndcis Addm%s ARICITI:
1 131i
Q. 1 sonify that I have read this application and mmc that the above inhmnmlon i.,
Fh cancer.l agree m comply with all city and county madames and state laws reining u' QTY. MECHANICAL PERMIT FEF. TE
V Z building construction.and hcmby tountre rePEcenmfives of this city to enter upon the
aMwcmentioned pmpeny for inspection pulpa%es. PERMIT ISSUA NCH 11313(Wc)agree m save,indemnify and keep mardess the Cityul'Cupertino againstliabilities,judgment%,costs and expenses which may in any Is yaccmcaguin.asuidCity ALTI2R OR ADD TO MECIL ".FAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH IIANULING UNIT(TU 10,1X10 CPM) A.-'13SOURCE GUI IONS.is /D/4#7 EIKHAUST LING HODUNIT(OVBR In.IM)CPM) DONIignatureof Ap 'a.'— DmeEXHAUST HOOU(W/DUCT) MI'I'IGATI FEE
AZARUOUS MATERIALS DISCLOSURE
Will rife app mans err fmure huiming cecupant score^r handle h...wims natural
tIEAfING UNIT CTO IOp.tXX)BTU7
as defined by the Cupertino Municipal Ctdc,Chapter 9.12,and the Health and Safety III3ATING UNIT LOVER 100,000 BTU)
Cole,Schon 25532(m^
El yo, n VENT ILA IION FAN(SINGLE REST) PAID
/� Dntc R,,eipt to
Will loc applicwn or future building occupant use equipimmal or devices which BOILER-COMP CIHP OR 100,000 If'IU)
emit harardnus air senutnti tants u.,defined by the Bay Area Air Qualify Management 'TOTAL:
IuIldml HOH,FR-COMP(OVER I W.(NX)B U)
Yes sk,
I have read fee fia�ardmwoto,Se materials255 requirements undo Chapter(?95 of the Call-
AIR CONDITIONER ISSUANCE DATE
RtmiaHealth&$armyCalc Sne..%2fildi is 533 anyandmibili1 In man,the
that ifthe NEW RESIDP.NI'IAI.MECH. SQ.17.
buildingdoes not is have,cnanuhoto isanyof a ibilitym notify the rwapam
of the uw ' mut me1pnamissuance nfa'e�fic�sf Oecu
�)me TOTAL: ISSUED BY:
Own rot auNone F o
OFFICE