S 0229 AYYLIUAN1 10 FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMPP - PLUMBING-MECHANICAL Q O n
BUILDING PROJECT IDENTIFICATION SJ L
BUILDING ADDRESS: SANI LARY NO. APPLICATION SUBMITTAL.DATE
1023b 13oNvr r� r c �f� 2r ,so c-�x
OWNERS NAME: �2PBoA .7 f974rCONTRACfOR'SC@ NISIGV�L /
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R: IC NO: ADDRF_ ❑
9 CSU 1 MG rO 6 . v a
CONTACT: �s PHONE: BUILDING PERMIT INFO
❑ C(nSulteut FceS Paid by Applicant(Initial) 131 DO„ EL?— PLUMB/ MEC
LICENSED CONTRACTOR'S DECLARATION \ QTY, ELECTRIC PERMIT F lrJI/ CJ ICJa/
1 hereby arum that 1 am licensed under provisions of chapter 9 poli mencins JOB DESCRIPTION
"Z with Section 7200)of Division 3 of the Businessand Pmfesdans Code.and my licensei.c RESIDENTIAL
�'UO^ in full force and effect ^ PERMIT ISSUANCE
U�j Licenu Class 1 Lic.x zA ❑S WI. ❑KITCHEN REMODEL
HZW Ilam Contractor APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
an
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p v�Z I understand my plans shell W used as public rcnmrmPANELS a MODIFICATION
OZ^q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4�J Licensed Prate 201-IIX0)AMPS IMPROVEMENT ❑SWIMMING POOLS
y f..I OWNER-BUILDER DECLARATION
Ie W a I hereby affirm met 1 nm exempt from the Connector's License Law for the OVER IWk AMPS ❑BATH REMODEIAEPAIR ❑DEMOLITION
3 d U fn icasmg rcasoa(Section 7031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL which mquims a permit to rorewn,aper.improve.demolish,or repair any mncmre
prm
ion.its issuco.ramaquires theipplicanmi
t forsuch pert m fileasiloeJmm
meem SPECLALCIRCUIT/MISC.
vvWW11� thom isaing with
Business License Won;CWCer9
W 6^•0� (commencingwithScmion]qq7 of DivisionJnfthe Business and Professions Cale)nr TE ET'll INST.
0. o y that he is exempt therefrom uad the basis for the alleged exemption.Any violation of C3 NEW BLDG/ADDITION ❑UUMOUTION
'^
Section 7031.5 byuny applicant for a permit subjects the applicant tea civil penalty of 1'OW 1 ES'
^v) ❑ ti FOODSERVICE
F Z i• not more than five hundred dollars y amp. 'i REC'
E=C ❑Lo th,work,the pmpeny,structure
yemntended with wage as their role compensation. SWIM I .ELECTRIC
y will dothework,and CNIC: he Cont is tors Liceed.L aweredforot apply to m, ose,or ❑OTHER
and erofesh.h Cale:The oyes tacmr's License Law Juts not apply m on mvner of Ol1TLE'TS- HES-FIXTURES CITY m It
D' property who builder or improves tWrsmn,and wM1.Das such work himsdf or through ��s'�-t.-aTr'Iie
his own employees,provided that such improvements arc ant intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ Fes. ljUR VS(y FT.
owner-builder will have the Norman of proving that he did not Wild an improve for par-
ose
pofsale.). LAC A�.(J`` \{.
❑1,as owner of the property,am exclusively contacting with licensed cmamcmrt to
Constcerwo uctLa the project(Sec.70X4,Business and my who bui Code)noCommutersuarean. Li- T V
cense Lawdoes nnchapply eun owner ofpropcny whosedp.r improves Cortmeand TY BIND PERMIT FEE
who comrcts for such pmjecn with o ttmtrcmds)licensed pursunm m the Cnmmnnr'x
License Law. PERMIT IS UANC
C,I am exempt under Sm. .B&P C for this reason
ALTER-DRAINVENT IiN( ) VALUATION
Owner Date /
WORKER'S COMPENSATION DECLARATION BACK FLOW PR . EVICE
ulTJ C7 O 0
jc
1 hereby rm under penalty of perjury one of the Indicating declartiore
❑ I have and will maintain o Certificate of Concalto self-insure for Worker's Cnmpem DRAINS-FLOOR,ROP, .GOND. S'IOR GS TYPE CONSTRUC TION
,anon.as provided for by Section 3700 of me LWr Cede,for the performance of the
work for which this permit ix issued. FDORES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Cale.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 LITTLE TS
OCC.GROUP ANN
My Worker' n n Insurance eyrie end Policy number ore:
Carrier: at L �/� .Iiey No.:_ GAS-EA.SYSTEM-OVRR4(EA) ri
CERTIFICATE OF EXGMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSJ'RL WASTE INTF.RCEP IDR UI G VISION FEES
This section need not hecompleted Bill.permit is far one hundred dollars 1$1OBI GREASIi TRAP
.r less.) PLANCHEC
I.,any that inthe performance a.MC, .Oo to bec fnewhichthis perthe it WActor sued,I SEWER-SANITARY-STORM FA.2UU PT.
no,employ any perstm in any manner sn ss m become subjan.the Wakeri Co.,..Compc- ENERGYIli O
Oz mti.ol.awsof ate' ^la. WATER HEATER W/VEN VELECTR
Z 2 Applicant Z.' GRADIN F.'
,A NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMOREATING
a ' become&object to the Workers Compensation provisions of the labor Code,you must SOILS FE
{iI forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ,PT. PAID
V 0 I hereby affirm that is.emoulction lendingugcney for theperrmmlmceof I to "'Up,
U. the work for which this permit is issued(See.3097,Co.C.)
0 U Lenders Name OTA.:
Lender's Address L:
1 certify that I have read this application and state that the move inf.rmmion is BUILDING FE
IIn correct.I agree m comply with all city and county ordinantts and slate laws alming to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to cater upon the SEISMIC
ahove-mentionedproperty1'orinsp tionpurposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino again ELECTRIC
liabilities,judgments.mals and expenus which may inany way accre alumm,Mid City' ALTER OR ADD TO SUCH.ine nmlanowe of the graining of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IBM)CFM) Mr:CHANICAL
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER lo.mx)CFM) CONSTRULTIO TAX
Signore mApplicant/Contractor Dam EXHAUST HOOD DVMUCr) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or home building occupant store or handle hazardous material HEATING UNIT(TO 1000.000 BTU)
as defined by the Cupertino Municipal Cade,Chape,9.12,middle Health and Safety
Cede,Section 25532m)? HEATING UNIT(OVER 100.0011 BTU)
❑Ycc ON. VENTILATIONFAN(SINGLERESID) PAID
Will thea applicant or furore building am use t or devices which
Dae ftcceiLu p
1 pp dby the e,Air
BOILER-COMPOHP OR 100,000 BTU)
reit hazardous tar wnmminanw as dcOneJ by the Buy Arcu Air Quolily Management TOTAL:
on It❑Yes ON. BOILER-COMP(OVER 100UII0 BTU)
I Wve real the hazmdous materials requimn¢nts under Chapter 6.95 of the Cali- AIRCONIIITIONER ISSUANCE DATE
moria Health&Safety Code.Sections 25505.25533 and 25534.I utwe smad twit if the NEW RESIDENTIAL MECH. SQ.Im
building does not currently have v tenant.that it is my responsibility ht notify me occupant
III the requirements which must W mel prim to ixsoance of it CCnificme of Occuponcy.
Owner or authorized agent Date v ISSUEDBY:
OFFICE