B 0662 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICA1 PIiRMIT NO.
PPLICA ON/PF. M T PLUMBING-MECHANICAL pn�o
UI IN ' 'ION _ ��'� V (�Z L l/QJ sJ`T
BUILDING PROJECT IDE N'I IFICATION
IiUiLDING ADDRESS: SANI'IARYNO. APPLICATION SUBMI I-1'AL DAT
188-7) HRFITH WAY'
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
<$D,v YT G�C NIC CONTROL.p
1RCHI1 EC`fd NGIN EILLGN2.I�T4 ADDRESS: ❑ ��
lc1 t h
CON'I'AC'P T PHONE: BUILDING PERMIT INTO
;� h ^�^� ❑ Consultant Fecs Paid by Applicant(Initial)
J BLDG ELECT PLUMB h1ECH
K C C`f
LICENSED CONTR (TORS DECLARATION QTY ELECTRIC PERMIT FEE
m
1 hereby affirthat I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
Ci4Z with Section]1XIo)afuivieion 3oftne Husines—ird Pratessforc Code.andmy license is RESIDENTIAL:
woo PERMIT ISSUANCE
1-ty— in full force and effect. �UW'1- ❑KITCHEN REMODEL.
=U F- License Class Lic,b
Q ❑ADDITION [I PLUMBING RE PIPE
ya W Date Contractor
F>Q.y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL'
Z O noZ I understand my plans.hail he used as public records MODIFICATION
AMPS 200 TO
oz—`O UP HIGPER[OR ❑CHIMNEY REPAIR
FNFW Licensed Professional 201-Ig1U AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOIX)AMPS El HALF REMOI]GUREI'AIR DEMOLITION
C C Q I herchy affirm that I am exempt tram the Contractor'.License Law for the
xd O i U following reason.(Section 7031.5,Business and Professions Code:Any city nr county SIGNS ELECTRICAL C3 OTHER
which acquires a permit m amamn,aper,improve,demolish,or repmr any swcwrc
FLLO� priors is ,mance.also the ptran1 file datntemem SPECIAL CIRCUIT/MISC.
9 tf uch g e
t y tooth licensed p rsua I to the prevision,of the Cormaturs,and
lse (Chars)
66Q1' thmhaisexenmihtheen,,.7=dthebasi., 3 (Ihe B . ens dPrf ':'on.GMe)na TEM('.METER OR I'(ILE INS'1'. COMMERCIAL'
W-,❑O is tar the allc6ed exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0
iG^W
Section]U31.5 by any subjects the applicant macivii penalty of POWER DEVICES
W..y ❑TENANT ❑FOOD SERVICE
t more owner
Eve hundred dollars y amp.
IMPROVEMENT
_Q wiLothewrk.the the stuy,mmyemntended with wageastheir sole carpe urines, SWIMMING I' OL ELECTRIC
WFO will dothework,and,The not offereddo ford,appm]Ba4,9ucarol DOTTER
13 w and Professions Cade:lTc eves theater.
License Law sacs nm applyor ll owner of OUTLIffS -SW FIXTURES
t1.
his own who builds or improves thereon,and who does such work
te intended
or offered
red For
his own employeese building that such improvements are not iyear of or offered far NEN R IAL ELECTR SQ IT.
sale.If.however,lne building or improvement is sold within one year of complaint.the SQ.FT Iq,00R AREA b/SQ.ITT
nowner-builder aEd have the burden of proving that he did not build or improve for prer-
1.u smcdale. 11937
❑ 1,if owner of the pmpeny,am exclusively contracting with licensed commemms m TOT
msvun the project(Sec.]044,Basines and Pal Worcs Cede:)'fhe Contrvnmr's Lh
cense Law does not apply to an owner ofpropery who builds or improves thermm and QTY PLUMBING MIT FEE
n
who contents for such projects with a contraer(s)licensed pursuantto the Contractors '% —7 / 6 7 /9
Licen.w Law. PERMIT ISSUANCE T L (/ e'_f
Qcxem tun Sec. __ .B&PCfor thisre -on
dl ALTER-BRA"
- TF.R IIiA) ^VALUATION
�
WORKER'S CO, 'NSATION DECLARATION�P BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury,one of the following dedurations: ( V CJ SJ
I have and will maintain.a Certificateaf Cmsentt—ell'-in,tre for Worker's Compen- DRAINS-FLOOR,ROOF,ARIA,COND. STORIES TYPECONSTRUCTE
cation,as provided for by Section 37W of the Labor Code,for the perfarnonce of the
work for which this permit is issued. FIXTURES-E'ER TRAP
I hive and will maintain Workers Compensminn lasmmnce,as required by Section
3700 of the Labra Code,for the performance offle work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My W'orke's Compensation Insurance carrier and Policy rougher sure:
Caviar. Policy No: GAS-EA.SYSTEM-OVER 4 EA)
r CERTIFICATE OF:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INTERCEPTOR
(Tbie,venat need and he rvmplried if the permit is fin ane hundred dollars IS FIJI) BUILDING Ill V ISI(1:J�PEI1S
or less.) GREASE TRAP PLANC I IE
I verify that in the performance office work forwhich this Want is issued,I%hall SEWER-SANITARY-STORM F.A.2X1 FI'.
not cmlloy very pcawnin any manna so nsmhecnn¢xuhjecl unhe WnrkecC Compen FNE IT_E /
O Z xedon law,of Cafi1 G FLEfomia.Ilse WATER HEATER WNENT/ELECTR
Z Applicant I^I
NOTICE TO APPLICANC If,alta maklne this Cmtifi,de of Exemption,You ehoald WATER SYSPI'.M/IR17A'I ING SOI FEE
become subjectto the Workers Compensation provisions of the Labor Code,you must '� -. _
pl Q forthwith comply with such provisions or this penin shall M deemed revoked. WATER SERVICE I r 1 1I'�'�
� Z CONSTRUCTION LENDING AGENCY NEW RESIDEN'T'IAL PL-MB: SQ.ET. IJ 111 PAI
U I thereby alarm that is a construction lending agency for the performance 11 ( Untc Recciptp
the work for which this Permit it issued(Sec 3N7,Civ.C.)
OU Lenders W. I� I I T AL:
Lender's Address )u TOTAL: II
0. 1 really that I have read this application and state that the move information is ) BUILDING ITE
N normi l agree In comply wild all city and countyn firancesund'dorlawsmlutingto QTY. MECHANICAL PERMIT
ru
U Z building construction.and hereby authorse irepresentatives of this city to enter upon the s w SEES MIC ITE J O
mra c runt inciel property for men"inn pmpmex,
(We)agree Io save,indannify and keep namdess the City of Cupertino adman PERMIT ISSUANCE
'--� ELECTRIC PEE
liabilitics,jidgeren¢,coas and expenses which may in any way...ogainasaid City ALTER OR ADD TO MECH. t
in asequence of the granting of this permit. PLUMBING FEE 171
APPLICANT UNDERSTANDS AND 'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM(
SOURCE REGULATIONS.
MECHANICAL FIiIi �7 �. 1
WJ AIRHANDLINGUNL'r(OVER I1T00CPM) CONSTRUCTION TAX
'ignamre of Applic.UC.. Dat EXHAUST HOOD W/DUCT)
HA].A11 US MATERIALS DISCLOSURE HOUSINGMITIGATIONFEE
Will thnapplicant er future building mxerapant store or handle hrstradous material HEAPING UNIT(TO IIXI.00F)BTU)
as defmned by the Calandra Municipal Code.Chapter 9.12,and the Health and Safety
\p� CMc,Section 25532(a)? HEATING ON]'T(OVER I(M,(XXI BTU)
�Yex a
_ VEMILATION PAN(SINGLE BESIDE PAID
W5d the a Ocaa m future h fi c emu nl ace e t or devices which Dam Receipt a
PP B' Pa 4uipmen gO11.liR-COMP(311P OR IW.IXIO BTU)
emit hazardous air contaminants:m.,JefjncJ by the Bay Arca Air Quality Management
Diann:' ��(/ TOTAL:
❑Yes B011.13R-COMP(OVER 100.000 Bill)
1 have read the havMomaterials aterials rcquiremcn6 under Chapter 6.955 of the Cali- AIR CONDITIONER
ISSUANCE A E I
fomia Hcithn&Safety Cate,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Pr
building does not currently have a tenant,that it is my responsibility to notify the txcupant
ohne reyuir mments w nuc be met pa a iUyanne ora Certificate of C/yl i
wnena uuldrazed agent L Dafe TOTAL: ISSUED BY:
OFFICE