S1471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CIV'OF CUPERTINO BUH,DIN'G-BLnCI'RIC]. Ell: ITNo
L PIAiMBIN'G-MCCINNICAL /� 1
'1:i I3UILDING DR'ISION APPI,ICATION/PERMPI' 14 1
BUILDING PROJECT IDF,NI'IF'ICNHON
HUILDINGADDRI!SS: SANITARY NO. APPLICATION SU13NIIIIAL DATE
;20 D S
OWNF 'SNAMF,: YHO :: C N RAC"OR:S NA.1F.: LICNOy�-
Q 2hhC Q 01ji NIC C(1V'1'ROLp
CHITECDFNGINEGR: LIC NO: A D FSS: _ ❑
d
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 1: PLU❑MR ME❑CH
LICI NSI )CONTRACTORS UI CLMtATTON QTY ELECTRIC PERMIT' PI38
1 hereby arrrn d t 1 licensed d p ,of Chapter l(coin ing _ J013 DESCRIPTION
C5Z x;msection]aNRnm J one Bu. dl f„io Cyd ten-lie :e RESIDENTIAL:
til O PERM]F ISSUANCE
i-,=O in full force and effect —/ ❑SFDWL ❑KITCHEN REMODEL
QVV Licenu Com APPLIANCf•_S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y Q G Uam Contreno
nRCHfrECTS .A UN 1 ❑MULTI-UNIT ❑STRUCTURAL
F,=tn PANELS _ MODIFICATION
y Z 1 undemui t Ions t1,' u c p tints
OZ=� UPTU 2fN1AMP5 ❑INTERIOR ❑CHIMNI3Y REPAIR
Licenced nm O{ 201-IIXNIAMI'S IMPROVIiMIiN'I' SWIMMING 1'0019
CkLj WNLABUILDF,R D11'LARA'f[ON OVI2R 1000 AMPS
El BATH RP,M 'JR 11 IR DF,MOIANO
C C Q I her :"EO t 1hm 1 am exempt from the Comecon,License I.aw Rm OK
X O a U following reason.IS cion]031,5,Business and Profnsbns Code:Any city or count, SIGNS F:LFC1'RICAL ❑OTHER
til�+LL i- which require,a permit no consumer,alter,improve,demolish,or repair any drunure % G
prior to its issuance,also requires the applicant for such pmmit to file a signed statement SPECIAL CIRCUITMISC. O
that he is Formed..tuna to the provrsionz of the Contruau',License Law(Chapter 9
�a�C (comntceeing with Stttion70(X)of Division 3 ofthe Business and Professions Cndclor TEMP.MIi T[!ft OR POLE INS'1'. MM 1 1'� ���s.
L d C that hen exempt Iheretioni i I the basis fur the idlegcd exemption.Any v;olmlon of ❑NF,W BLDG/ADDITION ❑DE OLITION
0
kroW Setif on]fUlS by any npplirnmfry permit xuhjcaz the uppliconlmucivll punully of POW[It DHVICES ❑'TENANT ❑FOOD SHRVICE
.mare than five hundreddollurs($500).
FZQ las owner me n employees with wages their sole cam tion. SW I M M INO POOL CLEC TRIC OTHER IiM1iNT
SSG Q these y,structure
) Fera, ,Business,
si ❑OTHER
F. will domewmk.and the he Cour is not,Licenstended e
Law doe for sale(,[,noan lou sine ss
RYI�m and Pm(essinns Cale:The Coimm�ors License Low does not apply to an owner.1 OIfII.EIS-SN'ITCHIS Fl%TURES
a 3 po"my no builds or improves thereon,and who doe.,suchcork himself or through
his own employees,prmided that such Improvemnts are nut intended or offered for NEW Re6.SIDEN"I'1 ECTR SQ PT.
sale.IL however,the building or improvement is sold within one year of completion.the SQ.FT.FLUOR AREA SSQ.PT.
er-builder will have the bnnlen of ,pro ing the he AIA nm build of improve for pnr-
Iwsrof,ulc). v v
0 I,as owner in the looped,,con exdusivJy[anu'ucting with IicumWmb "I
earaca, TOTAL'.
onstmd the project(Scc.7044,Business and Pndcs,lons Cooled The C^me:ce,s Li- w
.e Law does not apply to an owner of Picini so ho builds or improves thereon.and QTY. PLU PER I°I3E
who contracts for such politics x id a contrmtoContractor'sns)licensed purmano the Contractor's
License Law. PF.RMIT'ISSUANCG 6
❑ I am exempt under See. .B R P C for this reason -
AMFR-DRAIN&VENT-Wt IN&VENT-WteA) VALUATION
maer Datewirs/1
WOR KIR'SCOM 0 ijor10N DH CI,ARA TION RACK PLOW PROTECT DHVICI! /Y//V/
1 hereby nl'fnn undur penalty of perjury oia:nl the i...rw;ng dttlitmtinn (/�/
I..as solo will ntuinmi Sectim ricnmof he Lot lCoad inzur the Wnrke2a Cumpcn- DRAIN$-IsLOOR,ROOF,ARIIA,CUNII. SI'1 !S 'I'YPB CONSTRUCTION
scion, r olich i far by Section 3"!00 of me Lubar Cada for perhmnuncc of the
work for which this prem is issued. FIXTURES-PGN'1'kAP
F1 I have and will maintain Worker's C^mpenemion Insurance,as required by Section
J]W of the lahnrCN fort eperformana of the worA l.r which this .it I,issued. GAS-liA.SYS'I"FM-I INC.J(lUl' :CS OCC GROU' AI'.N
My WoA,,,C t�umnce carrier and Policy. GAS-EA.SYSTEM-OVERd1/1 I
Carrier: Policy No.:
ERI IFIG41i OF EXEMI'I'IONI'ROM WORKERS GR/SYSIEN�REATING
IV TF;IN'1'IikCEITOR
COMPENSATION INSURANCE, BU1.DING DIVISION FUHS _
CTei,sc,1 aced sun bn cme,loed ifn:c,crif is I tine hundneddalbu�".100) GR
nr les,.) PLANCHHCK Ila:
Icnnifyteaallbe rbouninm^fore work lbr whohteis,[mama,issued.Is had ,GSA -STORM HA.^_fMI F'P.
not employ any person in any manner so as to leanme subject to the Workers'Comport- ENERGY FFE
O z satin.Laws of Califomia.Dam WAENT/GLECfR GRADING 'EZ o ApplicantN0110E TO APPLICANT':If,afmr making thi,Cenificme of Exemption,you should WAEATING
("' h East, a salient to the Workers Com tion f the Labor Cale, t SQII S FEE
r j tensa provisions Y^n most
{)-I svixinnzorthispcrmit,hallbed[nnWrevsded, (RSERVICL' A ,�
a I do,ith enmply with mdt pro
0.
Q the work for which this far,is
z CONST RUCTION LCNDING AGENCY NIIW RVSIDEN'I'IAL PLMB. SQ.1ol'. PAI D;.0 Redipt#
U O conmm"mn lendingtg[ncy for me p t ounce of
��sFned(se[.San,Co.c.> UYGPIidN '
U Lender,Name s OTAL:
Lenders Address TOTAL:
y 1 certify that 1 have mad this application and pate that the aMme infommtion is BUILDING Fla! .
Ftell cot l agree to comply with all city and county ordinances and ,are laws relating to QTY. MECHANICAL TERM IT FEF:
f..l z building construction,and hereby amhorim representatives of this city to enter upon the . ISMIC ME. �
ahnvo-mentioned property I inspection pulp 11. PBRMH ISSUANCE a 4O
(We)'agu m save,Indemnify and keep hormion,ten City of Cupenlnu aEdn,1 ELECTRIC R!I!
Iinbifine,,Judgmm..te.ced,and expenses whichmuy in may way acerae igunm said Ci ty ALT I;R OR ADD TOMECI I.
VIAM11BINC FI!li
in nce ofthe ' thsprmt.
APPLICANT UNDIiRSIANDS
AND WILL COMPLY WI'T'H ALL NON-POINT Alk HANDLING UNIT(TO 111.0i CIlM)
MECHANICAL ITai
SOURCE REGUhA'i'IONS
AIR HANDLING UNIT(OVER WOOD CFM CONSTRUCTION TAX
Signature of ApplicunUContrecmr Date EXHAUST HOOD(WIDUCID HOUSING MI'I IGAI'ION FBR
I IAZARDOUS MATERIALS DISCLOSURE
Will the upplicom ur Pomre build...nect..antsmreor handle haraNau,nmte,ial I IEAHNGUNI'I'(TOI0),000B .I
as defined by Ilia Gapoallo MO c,pal Code,Chap ler 9.12,a t the Hemet mrd Sufcty
Code,Section 255J2(a)] HEATING UNIT(OVER I( .%X)11'1'11)
0 Ycs ❑No Pq[1)
VENTILATIONPAN NGI.BRE,SID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which
unit hanarJuus air comm�tinentx as defined by the Buy Area Air Quality Stawgemem NOILC:R-COI, l3HP0R IIXI,INX)B'IUI
District, TOTAL
El Yes ❑Na BOILER- >MP(OVER IOO.aN)B'ILI
AIR NDI'I IONER
Ih 'dm 1 N 't 'I I 1' J Chapter 6.95 10 CI'- ISSUANCE DATE
Fame Boston as,S,bdy C I Section,25505,25533; 55141 a I a' if111'fthe HW R FSIDI_N'I'I AL MECII. SQ.]it
'. -
befdringd contend,htr vatrnom,m t t non,re,iEsmanday no Ou'lly'h pun
fit he requirements which must be met prior in issuance of a Certificate of Occupancy.
TOTAL:
Owner or aum.rized agent Date ISSUED BY:
OFFICE