S 0273 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nuu.DING.ELECTRICAL PERMIT NO.
nUI1.DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0273 Ln 7 3
BUILDING PROJRCf IDENTIFICATION
J
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTAL ONE
Ioi4-ro AMBFUA cT-
OWNER:SNAME: r� - PHONE': CON)'RACTOR'S NAME: LIC NO�,
MRw
x OT/r i , l e�,p]NA s� NIC CONTROL p
� RCHITECP.NGINEER: I,ICcon ADDRESS: ❑ 50
tD VtD MM4 C213T�c
CONTACT: /� PHONE; _ BUILDING PHRMIT INFO
(�V tD Pr=" 1408)9"6-384 ❑ Consultant Fees Paid 111'AP111iCaa[(Ialllal) BLDG ELECT PLUMB MIiCH
LICENSED CON'FRACPOR'S DECLARATIONQ'PY. 'ELECTRIC PERMIT FEE
1 hereby affair that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
OZ with See..7gNpofnivisinn Jofthe Br,mr,sand l'mfosmm Cde,ond my licence i. RESIDENTIAL:
woo O Pf?RMI"I'ISSUANCE
F LL O n full farce and e1Ted. SPDNI. ❑KI'I'CHIiN REMODEL%UF License Class Llc.g APPLIANCES-RESIDENTIAL LI ADDITION ❑PLUMBING RE-PIPH
ha� Dme � Contractor
Orn ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCNRAI.
Z O m z 1 understand my plans shall he used as public records MODIFICATION
OZ`30 up TO 2N)AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licemed Professional 201-I00DAMPS IMPROVEMENT - SSW IMM ING POOLS
4MM :J OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑HATH REMODEL/RHPAIR ❑DFMOLI'rION
r�CC 6 I hereby IT,.that I am exempt from the Comd
reor'c License Law for the
O Wy U following reason,(Soria.7031S.Bnsineas and Iknfosdors Code:Any city or county SIGNS ELECTRICAL El OTHER
3 LL which requires a permit to contract,alter,improve,demolish,or repair any eracwre
prior to its issuance,also requires the opplicunt for such pewit to file a tignednatentont SIECIA L CIRCUIT/M I SC.
that he is licensed pursmmt to the provisions of the Comrumors License Law(Chapter
U�00 (commencing with Sedinn]m)of Division loOhe Business and Profaom siGde)nr TEMP MLTER OR PoLF;INS'f. '
C.m 2�1 thin he it c.empt the Brom and ma tussis fit the allegwl scroprion.Any va,hhim al' is
EW B.D I]➢IT}L1N El DEMOLITION
Section 7031.5 by any applicant for a gml
cit subjects the applicant to a civil penalty of POWER DEVICES (J
} nm more than five hundred dolla¢155110).. V/NTggg
❑ ❑FOOD SERVICE
=6 hat owner of me progeny,or my employees with wagcsmthei...lecompensatlon, SWIMMING POOLELECFRIC Mf'NT
FFC will doth work,and thettmcmrei.s not inandedorm0ered for sale(See7044,Business TF Of R nH
3 and Notesimuv Code 'Be Contractors License Law does oat apply m un owner of 011'fLE'I'S-SWITCHI?S-FIX'rDRI?S yat
pmpeny whobuildsm improvesthereon,andwhodocs such work himselforthrough (�` 6�
his own employees,provided that such improvements am not intended nr ofiired for NEW RESIDENTIAL I?LEC'I'R SQ Fr.
sale.IL however.the building or improvement is sold within one you of complmirathe SQ. iiiiZE {iSREA S/SQ.PL
neora,milder will have the burden of proving that he did not Wild or improve for pur- —j U
T 21
ndthe progeny.um exclusively contracting with IicemeJcontramo1 m
nmci ihaepmicet(sec.9044,Business and Profusions CoJdl'ITc Cnntramor's le.
c ase Law does not apply to an owner ofpmpeny who builds or improves thereon,and QTY..' PLUMBING ERMIT'I FEE
who contracts fonuch projecu with a contmdor(s)licensed punuunuo the Contracmra
License Law. PERMIT'ISSUANCE
❑lam exempt under Sec. ,B&P C for this mma)n IL
AIJ 17R-GRAIN&VENT-WATER(EA) VALUATION
caner �' - Dom
'S COMPENSATION DECLARATION HACK FLOW PItOTEC'I OF VICE Z
T 1 hereby oflirm under Penalty ol'per my ode of the indicators declaraxors:
,jl have and will maintain a CeniOcam of Conseniin self-insum,for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND' S'1'ORlli, TYPE CONSTRUCT ION
talion,as provided for by Seeli or 391X1 of the tabor Code,for the performance of the `1'��
work for which this petit is mmod. FIXTURES-PER TRAP Y
1 have and will maintain Workers Compensation Insurance,ns requirul by Section
371X1 of the Labor Cade,far the permanence of the work for which this gr oat is issued. GAS-EA.SYSTHM-I INC.40UTLETS OCC GROUP AI'N
My Workers Compensation Insurance carrier and Policy number um: , q
Carrier Palmy No,: GAS-EA,SYSTEM-OVER 4(EA) �-3
CERTIFICATE OF EXEMPTION MOM WOR KIEtS' GRI?ASFAINIIDSTRD WASTIiIM'1?I1CF.PIOR 1
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Guisectionneed not be completed ifthe Permit isfonmehundmddollaa(SIBO) GREASETRAP
or PLANCHECK FER
I cenify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 F'.
soan
not employ any person in y manner so as m become subject m the Workery Contain- ENERGY FI?I?
,� ,,tion Lows of Cut homia.Date '
z O Applicant WATL'R HCAIER W ENT ELECTR GRADING ITE
NOTICE TO APPLICANT.If,after ranking this Certificate of Exemption,yon should WA'1'I?R SYSTP.Mn REAPING.
became subject or the Worker',Compensation provisions of he Labor Code.you most
SOILS FEE
forthwith comply with such provisioreor this permit shall be demand revoked. WATER SERVICE
0. Q
z CONSTRUCTION LENDING tionled AGENCY NEW RF,SIDENTIAL PhMR. SQ,FT. PATO 1
UO kfV
torwhicaffirm that diti iaimed(ee30landln, agency fartheperfnmtllnecof g
Le work for which mit permit i,issued(Sec.JPA],Civ.C.)
Q U
Lender's Name TOTAh:
Londono Address
U1 certify that 1 have read this application end,rote thin me aboveammonium ammium is BUILDIN y?E
�L V0.] correct.lagluem comply with all city and county nrninanswv and suttee htws mimingm 'QTY. MF,CHANICAL'PERMIT PEE
U Z building construction.and hereby auborirue representatives ofthis city to enter upon the SEISMIC .F:
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE ,
(We)agree to auve,indemnify and keep harmless the City of Cupertino against VL 'FEZ
liabilities,judgments,costs and expenses which may in any way accrue againsisaid City pLTI?R OR ADD'IYl MI3CH, PLUMBING LE
in ndihence of the graining of this permit.
rl
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.004CF10) MECHANIC L FEL?
SOURCEREGULATIO
/J AIR HANDLING UNIT(OVER IO,"CFM) CONSTRUC ION TAX
SI roof Applicah trm:m Date 7 EXHAUST HOOD(W/DUCT) HOUSING N ITIGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building occupam stir,or handle huinNou,material I IEA'I'INC.UNIT(TO I(X),ll(W if ED)
as defined by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)R HEA'L'ING UNIT(OVER I W,gXI B'FU)
❑Yes ON. VENHLA'1'ION FAN(SINGLERESIU) PAID
IAta RCs a p
Will the applicant orfutum building occupant use equipment or devices whier BOILER-COMP(3HPOR 10X,(100 BTU)
iJ hava
Naus air conminantx as defined by the Buy Arca Air Quality Management
/ i da, BOILER-COMP(OVER 100.000I11TU)
❑Yes 0 N
I have rend the haeadnus tmatedals reyuiremems under Chapter 695 of the Cnli AIR CONDITIONER ISSUANCE DATE
fomia Health&Safery Gdc,Sections25505,25533 and255Ji.l understand mat Bite NEW RESIDF.N'TIALMECH, SQ.PT.
building does not currently have tenon,shut it is my responsibility hs unify the acupam
of the osairearamu which must be and prior m issuance of a Certificate of Occupancy. l
Owner or amhodual agent Date \ _ ISSUED BY:
OFFIC111E—