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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUII,DINGDIVINIO P LICA�]flN/PERMIT PLUMBING-M1IF.CHANICAI.
BUILDING PROJECT' IDENTIFICATION'.
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BUILDING ADDRIiSS:
RoAD ea--R�o
SANITA
MILE Ai'ION SUBMITTAL DA'Z'E
6-�'8-9�
U NER'S NAME: PHONE:
tL I PP6 NNE Z$7 $080
CONTRACTOR'S NAME: LIC NO:
u)N 352 64Z
NIG
❑
/COONTROL#
CCC
ECTn , EH: LIC NO:
3 SC H'S�L--4 �E
A DRESS: s
QZ-`5o Sc�-NIc 3L CUP 1O
3NTACf: PHONE:
BUILDING PERMIT INFO _
i �� 6aof,vN z s z -1-7 C? 7
❑ Consultant Fees Paid by Applicant (Initial)
BrL-U�E/ ¢ERCT I'LUMH ME^CII /
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LICENSED CONTRACTOR'S DECLARATION
I harem afnrm that I am licensed under pmviaion. of Chapter 9 memouradng
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCC j-0
stairs ection l(IWpd DivisinnJof me Business and Pmfessions Cale. and mylicenu is
in full forceand ofce. (�Z6
RESIDENTIAL;
WL ❑KITCHEN REMODEL
APPLIANCES - RESIDENTIAL
License Cann
Data Cnmmctnr
[]ADDITION ❑ PLUMBING RE PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION'
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT DSWIMMING POOLS
ARCHITECT'SDECLARATION
I understood my plans shall be used as public records
'
PANELS
UP T0200AMP5
LicensW Pmfosumal
201-I"AMPS
OWNFR-BUILDER DECLARATION.
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 9031.5, Business marl Pn,fasaime Code: Any city or county
❑ RATA REVBn EUREPAIR [I DEMOLITION
❑ OTHER
OVER 1000AMPS
SIGNS ELECTRICAL
which rryuircs a permit m conmum, afar, improve, demolish, or repair, any structure
SPECIAL CIRCUIT/MISC.
prior to it issuance. also requires the applicant for such cannot to file a signed statement
that he is licensed pursuem to the provisions of the Commences License].me(Chupmr9
(commencing with Section 7000) of Division 3 of the Business and Pmfessions Code)or
dual he is exempt therefrom and the basis for the allopm exemption. Any vlalation'of
_
',EMI'. M=..R OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Sation 1031.56yanyapplicrm for. permll subjects m inifiicanuo. civil penallynf
not mare than five hundred delta,, ($50(h. -
Dl, as owner of the pmpemy.mmyemployees with wages as theiroArompemaion,
will do the work, and the srnamr0 isnot intended or oEercd for sole (Sec. ]044, Business,
POWER DEVICES
❑TENANT ❑FOOD SFRVICH
IMPROVEMENT
❑ OTHI?R
- -
SWIMMING 11001, ELEC'T'RIC
and Pmfessions Case: The Comractofs License Law does not apply to an owner of
OUTLETS - SWITCHES - FIX'I GRES
property who builds or improves themor, and who does such work himself or through
veents am not intended or offered for
his own employeesprovideds,providedthat such improm
sale. If, however, the building or improvement is sold within one year ofcompletion. the
poser-builder will have the handle. of proving that he did not build or Improve for put-
enfsale,.
❑ L, as owner of the Pori an, exclusively contracting with licamed canoammx m
- --
NEW RESIDENTIALELGCTR /
FL )R AREA
p
SISQ, FT
Q / Q
TO
omouct the pmjml (See. 70,W. Business and Professions Code:) The Contmcmes Li-
courseLawdoesnotapplymtotownerofpropertywhobuildsorimprovesthemon,and
[�� y
QTY; ' PLUMBING PERMIT FEE
'�''`
onound licensedpumme Contrannrs
whormancLs forsuch project with amntarsuum
License Law.
J v
PERMIT ISSUANCE
1 am exempt under Sec: . B & P C for This reason
Clamor ' Data
WORKER'S COMPENSATION DECLARATION
ALTER - DRAIN & VENT -WATE )
BACK FLOW PROTECT. DE
ypl. ATI /
5 8
IherebyafMnunder penaltyofofC ryoneoTthefollowing
L
orkeesCo
will maimm Sectio Certificate of the Li to acorn. for for Workees Comp the
ay.: provided forac Section 39011 of the Labor Cala, [Doha perfnrminme of the
n, r hick this
work for Nis smell is issued.
❑ I have and will maintain Worker's Cance df arm w Insurance. h required by Semina
3700.fare hbor Code, for the perfomtance of the work for which mispamit is issued.
DRAINS -I1.00N. ROOF, EEA, CO
STORIES
Z
OCC GROUP
TYPECDNSTIiUCT10N
SLGL(�.
//
AIN
FIXTURES -PER 3RAN -
GAS-PA.SYSTIiM-I INC.40UTLe
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
2
jy Z^fig-0%
GAS- EA. SYSTEM-OVER4 LA)
GREASFANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
it COnviSION
JU
PEES
(This season had nmbecompleted ifthe permit is farone huMred dollvs(Sllq)
,a less.)
GREASETRAP
NCH K FE .
[�GRADIN5
Icenify Nmin the perfomtanceaf the work for which this permit is issuW.l shall
sol cmploy try lemon In any int t/f�cpmayyjcgto the Workers' Compan-
SEW. EA. 200 FT.
RG 8. O
WATER HEATER WNENTIIeLCCTR-
1-1-1
t Applicant
Arson Lawaas iT
t NO3'ICG At LICA T. i, after making this Certificate of Exemption, you should
became Infirm to the Workers Compensation provisions of Ne Labor Cale, you must
WATER SYSTEMNREA'I INC,
SOILS Flo
forthwith comply with such provisions onhis permit shall be deemed rcvokcd.
WAI ER S17KVICEI
CONSTRUCTION LENDING AGENCY
e performae of
I hereby anion thanherc is a connotation lending agency forthnc
t the work for which that sI tood(Sm. 3W7, Civ. C.)
' Lenders Name��
Leaders Address -
l I comity that I have read this application and shite that the above information is
NEW RESIDENTIAL PLMB. SQ. FL
PAID
Itne Itecciptg
0
fAL A O
TO rAL:
t
UILU NG'C:E Q Q
jf
QTY. MECHANICAL PER
Fe:E
P
SEISMIC j a
1 torten. l agree to comply with all city and county ordinances and state laws relating 10
huilJing cnnaructinn, and hereby uuthnriae represcmetivcs of this city mentor upmthe
PERMIT ISSUANCE,L
above-memioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupertino against
CI'RIY m 3 /
PLUMNIN `LE
liabilities,judgments, costs and expenses which may in any way, arcme against said City
in comarpcnecofthe...... ir,ofthkpermf,
ALTERORADDTOMECIL
AIR HANDLING UNI' I' p'010.0g)C
MECHANIC I. PET
CONSTRUC'TIONT 7
ONIT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS, /
V
-
AIR HANDLING UNI 'I'IOVIiR 10,lI1N �
Si stare of ppl ca�nV� wcmr ])ate
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WI)UCII
HOUSING MI'fIGA'1'1 FEE
HEATING UNIT (TO 10,001 BTU) I
Will the applicant orfuure building oceupunt wooer htmdle humorous notarial
as defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Code, Section 25532(a)'r
❑Yex Nn
I HEATING UNIT (OVER 100,010 BTU)
,'AID Date Recciptp
VENTILATION PAN (SINGLE RESID)
BOILERCOMP(3IIP OR100.000 BTU)
- ,
Will me applicant Nmre building occupant use equipment or devices which
Area Air Quality Management
monikers air contaminant as defined by the Bay Arc
OL ,
BOILER-COMP(OVIiR IW,"ITTU)
of,
3, ❑Yes �No
L/ p '�
AIN CONDITIONER
the harmdous materials t under Chapter 6.95 of the Cali-
I have readrequire
156614NCE P=r
NEW RESIUEN'1'IAi. MEC 11. SQ. Pf.
D s a 7
fomiu Health & Scurry Cade Seasons 25505, is an, esp 25534.11. mats y b that if the
building dies nal currently have a mnant, mol it is my responsibility m notify the occupant
f Oecupan y.
ems which m I he met prior m Lssucmca of a Candice?`
7a vO qs
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ISSUED BY:
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caneror uuthatred agef Uja
OFFICE