S 1701 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEgIT NO. 17 01
BUILDING UI VISION APPLICATIONIPERMIT PLUMBING MECHANICAL
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL OATS
. ,9�i e el 4,- _49
N 'S NAME: ix PHONE: CfOR'S NA LIC NO,
//'/ �� NIC CONTROL
ARCIIITIiCf/IiNGIN .k: LIC NO: ADDRESS: ❑
c e /
CONTACT, -rte -PHONE. BUILllING PERMIT INPO
5���,v AA/ ❑ Consultant Fees Paid by Applicant(Initial) BLI G/ ELECTPLUMB MIiCH
l}�(/ / V lin/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE LQ
I hereby affirm stat I am licensed under powlslam or Chapler 9(ca lateral, JOB DESCRIPTION
Oa'ZwithSmion]fgro)nTDivision3ofine Business end Professions Cale,and my license is RESIDENTIAL'
+„100 PERMIT ISSUANCE
CI• an full farce and IT ❑SFDWL ❑KITCHEN REMODEL
aa.UU Lmense Cl.ss Lic.ppppLIANCIiS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N Q 6 Dam CommcT
Foy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRU URAL.
zONZJ Iandeaammlmy Plan,,hdl be used as publicrcinrd, M ICA'Flo
N
OZ„M UPT0200AMPS ❑INTERIOR IMNEY k1iPA1R
F,4Gm Larrowl Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
�X d OWNER BUILDER DECLARATION OVER lgl(IAMPS ElBATH REMODELREPAIR [:1 DEMOLITION
C 6 1 hereby affirm that I am exempt from the Convince,License Law for the
following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
DJ W O y which requires a permit to conslrvct.alter,iatprnve,demolish,or repair any swcture
pnonoha iksnance,alsorcquires lheappliemn talisuuh permit to lilvoaignedamtanenl SPECIAL CIRCUIT/MISC.
that he is
WHOllcvnsed pursuant provisions of Ilio Conarabor's License luw(Chapter 9
WA:
OO (commencing with Section 7000)of Division 3 ofthe Business and Plafcssinns Code)or TEMR ME 117R OR POLE INST. COMMERCIAL:
6 d of That he is exempt therefrom and the basis for The alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
EMat Section1o3L5 by any applicant far a permit suhject theapplicanno a civil penally of POWEN DEVICES ❑TENANT ❑FOOD SERVICE
1Frrnot mare Chun fve hundred it.][.,($50BIMPROVEMENT
q�6 I.as owner of therocn,or employees with wages their role inn tion, SWIM M I NO POOL ELECTRIC
'ilttd2YY q ❑ and the,,
P Y Yet in Y genus Penna
and dolhowons Cosec: he Com.line istornot's Licenseed owll defarot apply 9O44, wner os. ❑ TflliR
L�� and pmlenainns Cade:The Cnnlmdnrs License law does urn apply In an owner of OUT LIYI'S-SWITCHES-F1 XT(HIES
progeny who builds or impnwea thereon,and who dues such walk himself m through
his own employees,provided That such improvements are not intended or offered for NEW RESIDENTIAL ELECB SQ I.T.
sale.If,however,the building or improvement is sold within one year refrompletion,the SQ,FT.FLOOR AREA S1SQ.FT.
owner-bui lder will have the harden of pmving that he did not build or improve for pur-
pose of sided.
❑ I,as owner of the properly,am exclusively mnnucting with licensed emnmoeTors In 1(YIAL'
onsuoa The project(Sec,7ID4,Business and Professions Code:)the Catharines U-
selawdoesnotapplytoanownerofpropenywhobuildsorimprovestheram,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a conTmemds)licensed pursuant o the Conexchar'u
License Law. PERMIT ISSUANCE d
❑ ImexacmptunJer Seo. ,H&PCbnthe,mawn
Owner Data ACfEN-IlNA1N&VENT-WATI.R(EA) VAI.UA'FION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• Ihereh,.M.umler scraltyaf Perjuryounuf The following dedications:
❑I have and will maintain a Certificate ofComem to self-insure for Worker's Compen- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONS'MUCf1ON
sation,as provided for by Section 37M of the[.shot Gude,for the Performance of the
work far which this permit is issued. RXTUR17S-PER TRAP
❑I have and will maintain Worker's Compensation Insumbee,to regnircd by Section
3700 ofthe lnMtr Code.for The performance ofthu work for which This pemtit is issued GAS-FA.SYSTEM-]INC.401JTLETS OCC GROUP APST
My Wor�f+6 Compenw4bn Insurance earner and I'nlicy
Carie• l(f/L�/�'JH Policy No4 GAS-EA.SYSTEM-OVLR4(GA7
C[RTIFIC O PENSA ION I N FROM WORKERS' GRGSEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEE.'
IThis.,cctionneednoThecnnipletedifthelnrntiliafnrnnehundreddnllnrs(51(X)1 GREASE'I'RAP
or less) ,. ANCIIIiCK ITS
Icenify that in the performance of the work fix which this pennih ix i.csued,lshall (� ° t
SEWER-SANITARY-S'IDRM EA.200IT. \\ �FNFRGY ITE
not employ any person in any manner so v m iecnmc wbject To the Workers Compere 1 ,_
Oz cation Laws of California.Date WATER HEATER W/VENILELECTR l `\
z Applicant NG FEE
h NOT RTO APPLICANT:If,ufmr making This Certificate of Exemption,you should WATER SYS'1'EM/TREATING tli
become subject To the Worker's Conupenmtion powi s of the Iaher Code,you must
LiO� forthwith comply with such provision,orthis pennitshelf hdeemed ravaged. WATER SERVICE PH(L�)
� z CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT" Dam Haciptp
V Ihereby am=thin mm
em is esdoaian lending agency for e performance of the work for which this Mrmit is issued(ger 31191,Civ.CJ
Lender's Name I TOTAL:
L) Lando,Address IOIA O
I molly that 1 have read this application and state that the above information is BURDEN 'EE
To
F h correct.l agree To comply with all city and county ordinances and slam laws relating to QTY. MECHANICAL FERN FEF,
(�z building construction,and hereby authorize representatives adiis city To enter upon the SEISMIC
above mentioned propeny for inspection purposes. PERMITISSUANCE
(We)agree m save,indemnify and keep hordes,the Cay of Cutenin.against ELECTRIC F tE
liabilities,troll an.,c cured as peones whichnmy in any way acemeugainst said City ALTER Olt A DO TO MF.CR
in consequence of the granting of This permit. PLOMBING I :P.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NONPOINTAIR HANDLING UNIT(TO H0.0I10CFM)
SOURCh REGULATIONS. ../ MECHANICAL FEE
�I _ p / f- Oy AIR HANDLING UNIT(OVER TO."CFM) CONSTRUCTION TAX
Signature of Applicaral(/ tar (-(J— vllam0 EXHAUST 1 I00D(WMUCT) HOUSING MITIGATION FEE!
HA RO(1UBMATERIN,S DISCLOSURE
WilltheClita Mum bpal Codes Capt r 9.12,boodle h eaNnandmaterialSafety
HEATING UNIT(T(l IlX1,IXro IfI'U)
as detinet io the Cupertino Municipal Code,Chapter 9.12,and the Health and Sufcty
Code,Section 25512(vE? HEATING UNIT(OVER IIq.IXKI BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID Data Rcccipta
. e Will the vppliatm or future building occupant use equipment or devices whleh ROLLER-COMP(3HP Olt 100,0 XI B'FU)
mit LaevrJou.v air contaminants as defined by The Bay Area Air Quality Management TOTA
Diavlet?(
❑Yes ❑No BOILER-COMP(OVER 100.If10 BTU).
I have real the luxurious materials regaiparri under Chapter 6.95 of ds,Cali AIR CONDITIONER ISSUANCE QDATE
fomia Health&Safety Cale,Sections 25505,25533 arta 25534.1 andefnartl mat if the NEW RESIDENTIAL MECIL SQ.IT.
building tires but currently have u mnanl,That it is at,re,wasihility In notify the nccupmn
ofthe cament,which all
sofa Cenit3emeofO euDwifiFFor /W�T
e TOTAL: BY:
authonzcJ agent am ISSUED
OFFICE