B 0163 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY S�Q�1 mom'
CITY OF CUPERTINO BUILDING-ELECTRICAL. PER f1,Nf)1,10 16 3
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL JJ
BUILDING PROJECT IDEN'TIF'ICATION
HOIIDINGADDRISS: SANITARY NO. APPLICA'1'IONSUBSUITALDAI'E
03-75' �/�Il �lonJ 1��, �673lz� -3 yZ-cr
OWNER'S NAME: ( PHONE-Z_
^.vO CONTRACT'OR'S NAME: LIC NO: NIC CON'TNOLp
;7T at
ARCHIT'ECTENGINIEER: LC?IICC(%No: f/N ADDRESS: ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
/ ����,` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB RCH
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
nn'but hereby mffiut 1 an,licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aaZ 'th Sectim700(fol Divisinn3nlThc Business and Professions Gde,and mylicutc is
�.m 00 to I'EIiMIT ISSUANCE RESIDENTIAL:
rmI force one eneWW,,
�UU License has `��^ Lick ❑SFDWL [I KITCHEN RIEMODIEI.
E W DateLIIII e_Contra c c• .kc. APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RH-PIPH
IN,pp�'j ARCHITECT'S DECLARATION PANELS ❑MULTI-UN[T ❑STRUCTURAL
ZOOZ I understand my plans shall bo used as public records MODIFICATION
OZ4p fav D0200AMPS El INTERIOR El CHIMNEY REPAIR
F�.F'.W Licensed Proclaimed 201-I01IBAMPS IMPROVEMENT
❑SWIMMING POOLS
Oat I am BUILDER m CL Caudel N OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
^� Q I hereby M.that 1 am BUILDER
from
the RA ION License Law for the
nil: F following ami(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHE
H which requires u permit ar mnswct,slmq improve,demolish,or repair any structure �,
OQJ
ph.,1. l.¢uancemso requires the applicant for suchpeunino file.signed sentence SPF;CIAL CIRCUIT/MISC.
that he is licensed pursuant the provisions of the Commences License Law(Chapter 9
t�r1�000 (commencing with Section 70CM&Division 3of the Businessind Professions Code)ar TEMP.METER OR POLE INST COMMERCIAL:
a K n
that he is exempt therefrom and me basis for the alleged exemption.Any violation oR [1NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 byany applicant fora pernd,libjects rheapplicantto ri,rol pximh,of POWER DEVICES []TENANT ❑Fool)SERVICEFZ} not more than five hundred dollars($500). IMPRD MENT
Q ❑1,as owner of the propery,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
Sat 19.0 will do the work,and the structure is nm ime idedmufTered include(Set.7aW,Business ❑ R
W"m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pai tubo huims nr imnprove,thenen.,and who dues such work himself or through
his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL ELECIR SQ I4.
sale.If.howevcp the building or impmvemenr is sold within one year nfrnmpIe SQ,FT FL66R AREA $/SQ FE
r-builder haw the hathe hurdon of proving the,he did not broad
poanr improve for par `�
eofaalt.) TOTAL: IV•,
❑ I,ns ower,of Ibe property,ant exclusively contracting will licensed conwmnrs to
mslruct the motor, Stec.70,14,B-mals and Professions CWe.,The Cnntruceo's..a-
cause Law doesnot apply toanowner of property who builds or improves thereon,and Q'py. PLUMBING PERMIT FEE
who contracts for such pmlect with a conwnm(x)licensed putuan to the Contractor's
License Law. PERMITISSUANCE
❑I am exempt ander Sec. ,B&P C for this reason
Owner
ALTER-DRAIN&VENT-WATER DEA) VALUATION
Dnte
WORKER'S COMPENSATION DECLARATION HACK ROW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declacto as:
FII have and will maintain a Cenificate of Consent an self-insure for Workers Compere DRAINS-FLOOR,ROOF.AREA,COND.
union,®provided for by Section 37M of me Labor Code,for the performance of the STORIES 'TYPE CONSTRUCTION
work for which this permit is issued. FIXITJRES-PER TRAP
❑1 have and will maintain workers Compensation Insurance.as required by Section
3700of the labor Code,for an,perfn..mal the work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Cympen�m insurunce cancer and Policy namhesa�, .;q -I CAS-
Carrier: ll ))
Policy No.: ''7" I J EA.SYSTEM-OVF.R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR _ BUILDING DIVISION FENS
(This section need not led completed Hall,permit is torous,hvndreldollum l$100 GREASETRAP
or less) PLANC K E s
I cenilyth:n in the Particulate(if work fnrwhich this Permit is ixmeJ,leM1nll SEWER-SANITARY-STORM FA.2W F'I'.
not employ.,pc.min ytnunna.a) pp rep�yhjRI to the Worker,Cnn:pem —it
E
z aaBnn hawa of Cal troy a 4s 1 l`T L WRI'IiR HCA'TRR W/VHNT/BLBCTR
yOyO Applicant I/:r ig. 5 v1111INGrE y..,
G ti NOTICE TO APPLICAN'D IL alter making This Cenifi of IExemponn,you should WAFTER SYSTEMITRE VHNG
f"t , bcmme slmot,to[)in Worker's Compensation provisions nr the Labor Code,you maul SOILS FEE
Qforthwith comply with such provisinm.,his permit shall be deemed revmked. WATER SERVICE
CONSIBUC`HON LENDING AGENCY NEWRESIDENTIALPLMB. SQ,FT. PAID
U O Ihereb,fi item thsnhem is a common.lendingegency for the performance of Date Recei M
w+ the work for which this Fell H Issued(Sec.3WO.Civ.G)
O HLerma'a Name v T AL:
ULenders Address TOI'A
H1 1 certify that I have mad this application and scare that the above information is BUILDING FEE
y concert.I agree to comply with all city and county ordinances and state laws mining it, QTY, MECHANICAL PERMIT FEL?
V Z building construction.and hereby authorise representatives of this city to enter upon the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE F.LECI'RIC FEE
(We)agree m save,indemnify amt keep hamth
lless e City of Cupertino against
ITabilities.judgmems.costs and expenses which may in any way sector against said City ALTER ORADDTO MECH. /-1
in rimequencc ufthc gmming ofthis permit. PLUMBING FEE yC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL PEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0010 CFM) CONSTRUC'UONTAX
Signnure,of A,hicar/Comracmr Dura HXHAUS'I HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL 4 DISCLOSURE
WIII theupplaeanlnT Fannie hvildingocenpant snore or handle he....lonsnwtvrinl ABATING UNIT 070 lW,1%IB BTU)
a definel by Ibe Cnpcnino Manicipm Code,Chapter 9.12,and the Health and Safety
Grote,Sectio 25532(x)? HEAPING UNIT(OVER 100.00)BTU1
❑Yes r7 No VENTILATION PAN(SINGLE RFSID) PAID
Dam Receipt M
Will the it co sm or furore defining by the rn Bose equipment or Marta which BOILER-COMP(3HPOR 100,00 BTU)
mit hamrdnm air cnnraminams as defined by the Bay Area Air Quality Management TOT1
District?
❑Yes No BOILER-COMP(OVER IIX1,gk1 BTU)
I have read the havrdous materials allurement under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
Roman Health&Safety Code,Sections 25505.2.5533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FE
buildingdoes not current) have a tenant,that it is o
y my of a Certtycate of Occupacup.m
of the reyuircrnemx which must be met prionm issuance oRa Certificate of Occupancy.
Ownerorautinrimal ager Date TOTAL: ISSUED BY: e O
OFFICE