B 0274 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 PERMIT NO.
BUILDING DIVISION APPLICATION/1'F.RMIT PLUMBING-MECHANICAL SOOOI /S.,(J�IIIL 4
BUILDING PROJECT'IDENTIFICATION
BUILI'ING AUDRLSS: SANITARY NO, APPLICATIyN:IJ ITTA DATE
U�1 ,Be /'h ,q-✓e �y o 7 /874
OWNER'SNAME: PHONE:
' `^ CONTRCNAMSe� f B
LIC NO:
ARCITEC/fNG N❑IC �xVj JVryC�ONT
ROLpJo L ' NO Akge
ff
CONTACT. PHONE
BUILDING PERMIT INFO
t ❑ Consultant Fees Paid by Applicant(Initial) BLDG Ii PLUMB MIT/I
LICENSED CONTN R'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby uRm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
=14r O RTZ Ih S.d..7O0a Division 3oftha Businessund Professions Code,ondmy license is RESIDENTIAL
00 nt full binaural effect. PERMIT'ISSUANCE
O
RUZU License Class Lie.a \NC. SFDWI. EI KITCHEN REMODEL
RQL Date-Contractor APPLIANCES-RESIDENTIAL. �
D we ARCHITECTS DECIARATIONDDITION ❑PLUMBING RE-PIPE
Z O rue 1 understand my plans shall be used as public exemrds PANELS C MULTI-UNIT C STRUCTURAL.
024-O UI'TO 21N1 AMPS MODIFICATION
W 4censad Pmfesshonal ❑INTENIOR C Cl IIMNI7Y REPAIR
6 ..t 201-IWBAMPS IMPROVEMENT
yyaa..I OWNER-BUILDER DECLARATION OVERIMIAMPS [DEEM MING DEMOLITION
W OIL 6 1 herehy.Sa Thal 11. exempt Tann the Contractors Cw a License Low for the C BATH RCMODEIIREPAIR (]DEMOLITION
3 d FUF.. following rears is ISecliom construct,
Business and Professions h,oe:Any city or roomy SIGNS ELECTRICAL. C OTHER
W Oo N which requires a permit ro roms the aper,impose,demolish,or repair any structure
m� priomni¢issuance.also requires the applicant lnr.,uch permit n OlcosigneJ smtumem SPECIAL.CIRCUIT/MISC.
�} that he is licensed pursurm to the provivions of the Contractor's License Law(Chapter9
X00 (cancommng with Section 7000)of Division 3 ofthe Businessund Professions Code)or TEMP.MICf[R OR I'OLEI COMMERCIAL:
t1�j caof that he Is nwalu therefrom and the basis for the alleged exemp tan.Any violation of C NEW BLDG/ADDITION C DEMOLITION
{+• Section]031.5 by any applicant for a pemdt subjects the I
y pp item roacivil penally of POWER DEVICES
F`aoat more Than file hundred dollars($Stgl. ❑TENANT ❑FWD SERVICE
F1I „awnerof the mo,ofi,ar my employees with wage.,as Nch,cle compensmlon, SWIMM ING POOL ELECTRICIMPROVEMENT
qty' O will Jo the walk,unit'he smrcmm is not intended oroffercd far.11(See.9(x4.Rotor. , El OTHER
al32 and Professions Care:The Contractors License Law does not apply In on owner of OIITLGI'S-SWITCHES-pl%TURFS
pmpeny who builds or improves thereon,and who does snch walk himself nr through
his own employees,provideal Nal such improvements am not imendad or offered for NEW RESIDENTIAL ELECTR SQ rm
sok.IL howeverthe building or improvement is sold within one year ofermpledon,the SQ.FT FLOOR AREA SJSQ.FT.
owner-builder will have the burden of moving Thal he did not build or improve for pur-
poseofmlcJ.
C 1,as owner of the propcny,and exclusively contracting with licensed contractors to 3T : f
construct the project(See.9W4,Busne.,s and Pmfesslmu Cadc:)'me Conoaclor's li-
censeLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthemon,and QTY PLUMBING PERMIT FEE
who Common for such pntcas with a conrmrtorfsl licensed pursuant to the Contractor's
License Law.
C lamesemplundcr Sec. ,11&PCfnr this rcuson PHRMINSSUANCE
Owner Data AUfER-DRAIN&VENT-WAT17R TEAT VAL(lAT1ON
thWORKER:SCOMPero ENSATION DECLARATION BACK FLOW PROTECT.DEVICE / OOl1V
Ihereby aunder penalty of perjury one of the follmving declarations: !
❑I have and w 11 maintain a Ceti if Consent to sol l'-insum for Workers Campen- DRAINS-FLOOR.ROOF,AREA,COND.
sation,os provided for by Section DW of the Labor Cale,for the performance of The '1k STORIES TYPE CONSTRUCTION
work for which this permit is issued. FI%TURES-PER'IRAP < {A / 1
V
I have and will painter.Workers Campernution Insurance,as required by Section V-
3
7M of the Labor Cale,for for performance of the work for which this permit is faced. GAS-FA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Cimmerian..Insurance Cartier and Policy number.:
Carrier: Pnlicy Na: GAS-EXEA.SYS'I IIM-0VER 4(EA) ��
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(Thal welon need nal be completed ifthe Iarmlt is for one
hundred dollars(gl(k) BUILDING DIVISION PEES
at less.) GREASE'TRAP PLANCHECK FEE
I certify Ratio the any e manceof the work lar which This permit is issued,'Car shall
not I-.Layanypersoranany manner so as to henune subject to Wmrken.'Cmm n- SEWER-SANITARY-STORM EA.200<T.
R ENfiRGY Ill?
mppli int of Califnmia.Data V y
z O Applicant 1 WATER HEATER W/VENT/ELECTR GRADING FEE
LN. NOTICE]0 APPLICANT:If,i fpr cooking This Certifladd of Exemption,you should WATER SYSTEM(FREATING
became subject to the Workers Compensation Provisions of the Labor Code,you must SOILS FEE
� 0 forthwith romply wish such provisions nr this permit shall he deemed revnkal.
WATER SERVICE �J9
5zCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O l hereby office that them is a conswction lending agency for The Performance of Date Rccciptk
LLFthe work for which lhis permh is issued(See 3099,Civ.C.)
O U Lenders Name TOTAL:
4 Lender's Address T f O
1 cenlfy that 1 have real This application unit slate that the above information is BUILDING PEE g Q
N conscr.I agree to comply wish all city and county mrdimhnces and smte laws mimingm QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby moll-lim representatives of le,vityl.emerup,m the SEISMICmf
ahave-menrioned proPcny for inspection purposes.
PIiRMIT ISSUANCE O
(We)agree to save,indemnify and keep hay in
the City of,agmina against ( ELECTRI
liemair,jurn ofthec don and expenof fix pswhich may in anyway acerae against said City Iry ALTER OR ADD TO MECI I. O
in consquence of the granOng of Nis permit -2-C) PLUM ING
APPLICANT UNDERSTANDS AND WILT COMPLY WITH ALL NONPOINTAIR HANDLING UNIT CFO ITOW CFM?
SOURCE.REG ULATIONS. p MEC( FEE
�j A AIR HANDLING UNIT(OVER 10,003 CFM) CONS ION TAX
Signature MApplican A.rmrpr Date V EXHAUST DOW(W/DUCT) HOU 1 MI'NGATIONFEE
I IAlEARDO RIMS DISCLOSURE
Will the uPPlicam or(more building rccupam stoat or handle harardous mamdal HEATING UNIT(TO 1013,0001 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heald and Safely
Code,Section 25532(.)? HI?ATING UNIT(OVER 11X1,000 BTU)
E]yes CNo
VENTILATION FAN(SINGLE RES ID) PAID
Will the applicant or future bolding occupant use equipment or devices which Date Neceipt M
air havzrdaus air imagination a,defined by the Bay Acta Air Quality Ni.agemenl BOILER-COMP(3HP OR I00,000 BTU)
Dietrim? 'TOTAL:
E]yes El No BOILER-COMI'(OVER 1(kk0(NI BTU) 0
1 have read Ne hazmdoua maerial,requirements under Chapter 6.9.5 of the Culi- AIR CONDITIONER ISSUANCE DATE
fomiu Hired&Safety Code,Sections 25505,25533 and 25534.1 understand for if Ne NEW RESIDENTIAL MECIL SQ.FT.
building does ned currently have a meant,that it is my re,Ponxibility to notify the owe"part
ouirc
f the reqmcnts which must fares prior to issuance nfa Ce
obtain,ofOccupancy,
Ow mrmindionsedageat Date TOT 1' ISSUED BY:
OFFICE