S 0947 APPL16ANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMI INO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0947-
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: Q� � SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PNONE'� C R'['`�O�'S NBAji�-//J �.^`!^d�NO NIC CONTROL#
ARCHITECT/ENGIN "�LIC30: AD S J/-C!F lel t��(�P�/ YQ��
CONTACT: PHONI3: OC+`/7 I ILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG IAJ'.CT PLUMB MECH
❑ ❑
LICENSED CONI RACTOR S DECLARATIONQTY, ELECTRIC PERMIT,` FEE,
1 hereby affirmm i l m licensed under p rChapter 9¢nmme 'ng JOBILIESCRIqTION
OW�Z wim Sectlon]IIf10)ofD sen 3ellh'e ear. sand Profcaslo Ce,e,a nyl cense is - RESIDENTIAL:
WOO PERMII'ISSUANCB
aFWt Licene Cls and effec� ❑SFDWI. El KITCHEN RNMODEI.
UU License Class ID Lich APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
y stIlnta Conrtaemr
ARCHITECTS DECLARA'T'ION - ❑MULTI-UNIT El STRUCTURAL
zonz I understand my plans shall be used as public records PANELS MODIFICATION
UP 10200 AMPS ❑IN'TF;RIOR ❑CHIMNEY REPAIR
�l Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMINGPOOLS
k� OWNER-BUILDER DECLARATION
f% Q L hereby affirm t,t I an,exempt from the CnnOacdn's Licence Law fnr the - OVER 1000AMPS El BATH REMODEUREPAIR 71 DEMOLITION
3 O y U following reason.(Section 7031.5,Business and Professions Calle:Any city of County SIGNS ELECTRICAL El OTHER
G F which requires u permit m.nswa,alter.improve,demolish,or repair any structure
.W+0 prior to its issuance,alsorcquices the npp)icamforsuch permit m fileasigneA statement SPECIAL CT RCUIT/MISC.
y that he is licensed pursuant in the Prnvisionsof the Comments Livens.Law(C,pm,9 -
W GAO (commenting with Seelton Will ofDivisiun3art,Business and Professions Cede)or TEMP METER OR POLE INST. COMMERCIAL:
d q o C that he is exempt therefrom and the basis for the alleged exemption Any suoution of - ❑NEW BLDG/ADDITION [I DEMOLITION
0 Sectlen 91131.5 by any applicant fora permit subjects the appllcantIli a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
or mora man five hundred dollars(55110). IMPROVEMENT
7l.as nwnernl'the prnpeny,mmy employees with wages as their solecompensmien, 1 SWIMMING POOL ELECTRIC
will do the work and the antcune is not intended oroffercil fnrsale(Sec.9044,Business OTHER
and Professions Code The Commerce's License Law does not apply to on owner of )OUTLETS-SWITCHES-FIXTURES -
r property who builds or improves thereon,and who does such work himself or through Ic
his own employees,provided that such improvements are not intended or offered for NEW RESTDEN'HAL ELECT SQ FF. 10
sale.If,however the building or improvement is sold within one yearofu,mpletion.the / 'Q.JJy//I.FLOORARHA $/SQ.I,l'.
owcav
r-builder will he the burden of proving that he did not build(it improve for par-
poseorsalc.).
1,4s owner of the property,am exclusively contracting with licensee camnrnors to
cnnstmcr the project(Sea 7044,Business and Pretenders Code:)The Commerce's Li- -
c L d t apply In an owner ofp perry who bonds to , h oo d Q,TY' 'PLUM131NOPERMIT FEE (�
Li-
came
comparesf h projects with a Coro t Oliensedp s n tt Contractor. '. NOV B 4444ffff
Lice ' Law. PERMIT ISSUANCE. RECID
❑Ire empt under Sec B&P C for bisection -
'ALTER-DRAIN&VENT-WATER RA) gl,pp 1 ,
Owner Dam uUryGMfy(V
- WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
T hereby vBirm under penalty of perjury one of the following deolamlionsu
❑I have and will maintain a Ceailicnte of Conscnnoself-insure for Worker's Coupon- DRAINS-FLOOR,ROOF,AREA.COND.
cation,as provided for by Section 39(10 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this parmh Is Issued. FIXTURES-PER'I'RAP
❑ 1 have one will maintain Worker's Compensation Insurance,as required by Saloon
37f0mfam Labor Code,for the perfonnancenfthe work fnr which this permit is issued. 4 GAS-EA.SVSTEM-I INC.I OUTLETS OCC.GROUP APN
My Worker's Compensation Insurer.carrier and Policy number ore:
Carrier. Policy No.: GAS-FA.SYSTEM OVER 4(EAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
'
(Thisaratineed act be completed ifinepenn,is for nae lmndred dollars IS I IID) r,^ .BUILDING DIVISION FFFS
on
unless. GREASE TRAP PLANCHLCK PEE
Ic Ifyt,tintheperformaneo 'thownrkfor whichlhisparmitlsissued,Iehall SEWER-SANITARY+STORM EA.2W FT.
notemploy yperson' eymannerc vmb. un
become the Wnars'Compar- ENERGY LET
O Z cation Laws CTYfo ia.Dal- WATER HEATER WNENT/ELECTR
IAP plic:m GRADING FEE
r... ti NOTICE PPLTCANT:If,aftermakingt rs Cartifareor Exemption,yen should WATER SVSTBM(fREATING
a ; become su t m the Worker's Compensation provisions of the Label Cade,you most SOILS FEE
forthwith comply with such provisions or this permit s,ll be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ,Fr. PAID
UO 1Faulty affirm that there is a construction lending agency for the performance of etc Receipt#
GLH the work for which this permit is issued(Sec.3097,Cie C)
O `� Leaders Name TOTAL:
UL.I Landre,Address. TOTAL:
LW I certify that i have re l this appl motion and state that the b f i - i BUILDING FF.F.
i.a V71 correct Iagree t comply II all city and countyordinancesand stat .lar min. gt QTY., MECHANICAL PERMIT .. FEE -
U G building construction,and h by stainsaria,representatives ofthistty to eructation the SEISMIC FEE .
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree.snug indemnify and keep hvrmless rhe Ciry of Cupertino against FLECTRIC PEE
liahi'tics,.ludgmena,costs and expanses which may in any way spectra against said City' ALTER OR ADD TO MECH.
in cliequena of the grnnlm fill i1 PLUMBINGFEE
APPL 'ANTUNDP ANDS Abe WELL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR !P�DUE ' IONS. MECHANICAL EFF.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA
Sign tare Applieav ntxnemr Date EXHAUST HOOD(W/DUCT) HOUSING MTTIGATI FEB
HAZARDOUS MATERIALS DISCLOSURE
I the applirnnl or future building oceupam score rr hurdle baronies malarial HEATING UNIT ff0100.000 BTU)
as define by the Cupertino Municipal Cnde,Chapter 9.12,ane the Health anti Safety
Code,See0ov 25532(a)'f T HEAIINGUNIT'(OVER100.000B'IG)
[-]yes C]No VENTILATION PAN(SINGER RBSID) PAID
Dma Receipt#
Will the appli.ntnrruwre building occupant use ea Air Qullit Marta which BOILER-COMP(3HP OR 100,003 BTU)
k emit District?
s air contaminants as defined by the Bay Area Air Quality Management TOTAL
Dievict^
E]Yes 0N BOILER-COMP(MER II0,080 BTU)
I have read thehemdaos materials requirement,under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Lomas Health AtSafety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nm currently have a tenant,that it is my responsibility,.notify the occupant
of the requirements which mus,,tact prior,.issuanco ofd CertlEcam of Occupancy.
Ownerorauthorized agent - Date TOTAL: ISSUED BY:
OFFICE