S1381 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY.OS'CUPER'1'INO xu MBING-%'fElH MICA Pe H'No
i`
BUILDINGDIVISIONAPPLICA'1'IONIPERMIT RIHIjMNG-alECf RICAL 1381
BUILDING PROJECT IDI?NfIFICATION
LDING ADDRESS: SANT"I'ARYNO. APPLICATION SUBMIT IAL DA'r1r.
' E • PHONE CONTRACTOR'S NAME. LIC NO NIC �CON�ROL
M�o I / »i,-CIA
:1411'EC'fIENGINEEK: hIC NO'. ADDRESS: ❑
��-2ss- a E
CONTACT. PHONE.: BUILDING PERMIT INTO
,1 , '�I( s ❑ Consultant Fees Paid by Applicant(Initial) BhD ELECT PLUMB MFCFi
❑ �rY�yINNI
LICENSED CONTRACT OR'S DECLARA'T'ION QTY ELEC'I'R IC PERMIT FEE
I humby affirm Inas 1 as ficen.ed under pawkims of chapter 9(comnre tem, JOB DL'CRIPTION
,O p C0 wiih Seninn]1xp)ofDivision 3nOhe Busines%anJ Profe.siun.Cale.andmyliccn.e is
¢: PERMITISSUANCE RESIUF.NTIAL'
-lU in full force and eEect. S- I. ❑KITCHEN REMODELW
�V F Licence Cl;u. I. #
d V APPLIANCES-ItIJIUENTIAI, IJI'IION ❑PLUMBING RE PIPE
NQ L UJIe Cnl+lraelnr
ARCHITECTS DECLARATION 'OM UNIT ❑MODIFI RAL
MODIFICATION
Z O vt Z 1 undersand my plan%%hall be used as public records PANELS MODIFICATION
UP TO 200 AMPS OZ-G, [I INTERIOR ❑CHIMNIiY REPAIR
F�F"m Licemud Pmfir,ocoil 2111-1 TWAM I'S
IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER )ECLARRHON (TVI?IIW,AMPS ❑BATIIR ( + I DEMOLITION
C d I hereby affirm that I am exempt Tars]the CmddcfoT%License Law NF the K32V follosvinbfeaaon.(Section]0315,Businessamd Prefeuinm Code:Any ciryoccomIy SIGNS ELECTRICAL El OTHER
Q pooh ts issuance, I. r requires
applicantf such l,der,improve. ilt f1 �& J:tt<mcen S PECIAL CIRCU ITIM INC.
bot he n: i mr,dant the pro,iotm,otth L t t I L 1Chapmr9
[ails Q�0 (u mm. eg with SSelr 7110(porDiv:vin+3 of the East a s.od lnfe:rn'(ole)or 'TEMP.METER OR POLE INSI COMMERCIAL'
d d e a that h,,,exempt thcreflont and the latus lin the alleged cxcniptioa.Any violation of ❑NE
P0TEOODSERVIC
ESectinn]0?LS by ay applicant Oapcmitsuhjecls he aplrm macvl pcwof POWER DEVICES N 2
11 //% HM01.'1'ION
nor mon:than five hundred dollar.($500E OVEMENT
eS ❑1 fih p pony PI Y lh g: th I pe t SWIMMING FORM.ELECTRIC
/o
ill do to k dd T t t J J E df -1 S ]014 H - 'IdJk-l1L e,pTng�—
� 'm andl Code:91 C t I L J I Iplyt er of IUrI FTS-SWITCHES-FIX'TIIRESP '-
pmlwody I b'Id:or ilrpoorsfl [who da,,such walk h .. the ugh
his own emplo,,rp J d thtr t Wehommocannem, t ina,vided Ta offered for NEW RESIDINI IAL ELECiR SQ PT. ggg���yyy���������
sats If however.ill h ve building ip 'cm t Id Chino ) f PI t ice Nc S/Q�"M r. OO $15Q.hT.
owner builder 'ill have h burden f proving that h did not build -improvefor par / / a
pose L TOl n1iq
1,.'owvar of the pmledy,um exclusively commding with Ice teed c+nmuo..m
cocoanut,(be pmjeot(Sec.]0.M,Business and Prof...ions Code. Tne Ccon emr's Li-
.w Law dons not apply in an owner ofpropeny who builds or improves thereon,and QTY. PLUNIBING PERMIT
Who contracts for such projects with a contdktorlU licensed pursuant to the Contractor's
Liccnx Law. PERMIT ISSUANCE
❑Ism cxcmpt order See. B&P C for this rosnn
AdJFR-
BACK
TEN
D
Wer ordrPCaltyof SATION DECLARATION HACK FLOW PRO("ECT.DEVICE
I hereby affirm under penalty of Iwrjury one of the following dedamtion.:
0i l have and will maintain a Cenifieate of Consent to self-insure for Worker s Compcit- URA INS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
s t on,os powidol for by Section 37011 of the Labor Calc,for the perform:mcu of the
work for which thiv permit is Insimd. FIX'I'DRES-PER TRAP
❑ 1 have and will maintain Worker's Cmnpen%ation Invumnac,a.required by Section
37W of the labor Cite,for the performance mfthe work for which this permit is ismed. GAS-EA.SYS'I EM I INC.Y OUTLE'T'S OCC.GROUT' AIN
M)Workers Compensation Inmiance earner and Policy number are:
Carrier: Policy No: GAS-EA.SYS rEM-OV ER 4(EA)
CERHFICAI'1:OF EXEMPTION FROM WORKERS' GRIiASFIINI]USTRh WASTE INTERCLPI OR
COI PBNSAI'ION'INSURANCEU GI' ISIONIT
flhia,vection n.d bccmnpino-lifdo,permit ix for one landred Jol lam 15100) GREASETRAP
orlesv.) JPA.D
ANCHI?'
I certify that in the performance ofthe work forwhlch this permit i.issued,I dial SEWER-SANITARY-STORM EA.200 FT
not employ any person in any mann..Iowa,hecome.hget to the Workers'Copan- ERG P li
OZ vaiom Lows ofcalifnmia.Data WATER HBATHE WNENTATLECl'RADING ITE
.Z O Appllc:ut
NOTICE PO APPLICANT:Il,after making dol Ceameme of Exempunr,you Ah Id WATER SYS ENVI ELATING
beeon¢subjeat m Ne Workers Cumpen.aion provisions of the Labor Calc You must SOILS 11313
forthwith an uply with such provisions or this pennit,hal be deemed revoked WATER SERVICE
2 C(INSTRUCI'ION LENDING AGENCY NEW R[SIDf:N'I'NI.PLMR. SO FI'. ID
Q O Ih..If,affirm mance,.uamsmatiunlcndlngugerey for the performance of D: c ka1ciplk
�+ the work far Which this Imnnit Is issued(See 3097,Cl,.C)
CLU Lenders Nae 'FODAL:
lenders Addi..ss TOTAL
>' Ill 1 certify that I have mad this application and.tam that the above information is BUILDING FIT
Gra
l;GZ toolbars agree nrromply hrmby city mri county ordinances es and ea,vtum
to ca.rdming he QTY. MECHANICAL PIiRMIT . .
UZ huildingumatnmuon.endhcrehyuudmriurcpresentativeeul thixcitymemm�lpnithc SEISMIC FEE
ahuvensnti.aad property lis ino,,lTmr purposes. PERMIT ISSUANCE
(We)agree to a,c,indemnify and keep harmless the City of Cmctrina again,q ECTRIC hili
Iiabilitics.judgmentc,cr,t%and expenses Which mayinany way actiom against said City ALT ER OR ADD TO MECH.
PLUMBING FE[
in mCANT UNDERSTANDS
Sthisp WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ifl.lxq CFM
MECHANICAL ��E
SOU 2CIT REGULATIONS.
r
AIR HANDLING UNIT(OVER 10,000CPM) NSTRUC'IION 'AX
ef
nature ofApp mant/ Dam EXHAUS"I'HOOD(WMUCT) USINGMITIGA IONFEEHASMATHRIAIS DISCL OSURE
Will the eppheanbuilding occupurt.torcorhandle hararam%material HEATING UNI'r(TO 100,000 BTU)
us dIrned fly the Cupertino Municipal Colic.Chapter 0.12,and the Health and Safety
Ccdq Satin.2553260! I HEATING UNIT(()Vi?R Im)lxxl 11111)
❑Ycs ❑No
VENTILATION FAN(SINGLE RIlS1O) Dae Recciptp
Will the applicant or future building occupant use equipment or devices which BOILER-COMPL!HPOR 100.000 BTU)
mit heaard0us air contaminant%as defined by the Bay Area Air Quality Management TOTAL:
Jlsuicfl iRALER-LIMP(OVER 100.0d)BTU)
C]yd, ❑No
Lave nand the harurdims ntaerials requireatil under Chapter 6,95 of the Cali- AIR CONDI'I ONER ISSUANCE DATE
forma health&Sdery Cale.Section,25505.25533 and 3534.1 understand neat aNc NEW RESIDENTIAL MECH. SQ.14.
building does no¢urently have a tenl that it is my responsibility to notify the occuNm
of the requirement,which Inca be met prior to issuance of a Cerd Gcam of Occupancy.
Owner n.authodmd agent Date TOTAL: ISSUED BY:
OFFICE