00010105 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 00 U/ V /
[CITY,OF CUPERTINO BUILDING-ELECTRICAL . f PERMITNO.
BUILDING DIVISION APPLICATIONIPBRMIT PLUMBING-MECHANICAL VBUILDING PROJECT'IDENTIFICATION' ..A.h:8{UILDING ADDRESS � _� _3LD
SANITARY NO, APPLICATION
NSSUBMITTAL DATTE
VNER' A PHONE: CO. 'RACTORS NAME: LIC NO',
N/C ,CO/NLROLN
., CHI ,NEER. LIC NO: ADDkESS: ❑ �'1! / `y 13
CONTACT PHONE: Q;�srL; .//'gUil,Dli)NG(PERMIIIIT INFO''i,:
❑ Consultant Fees Paid by Applicant(Initial) RLgG ELECT PLU99e MSE—CAHH
LICEN97D CONTRACTOR S DICIARATION QTY ' CI'EG7 RIUPERMI P/e rl �l t+PEE j^ull
1 here(y m@ ruI a t I licensed and 1 fChapter 9 ba moue c g . , .' t _ Y'1 - JOB DESCRIPTION
Q 04 with S.ri un]WO 10 nJof tM1a Ht si ..- ire r cssn vCnle ane lise ',
FOOTIAL
fullforcevtd effect I'IiRM111SSIlANCF;
tY m F t" / :FUWL ❑KITCHIiN REMODEL
aUU LicenaCas Lic.M APPLIANCES-RESIDIiNT1AL ❑ADDFUON ❑PLUMBINGRE-PIPF.
yQ Dvm Commcmr
F7rn ARC III rECT'S DECL PANELS
[]MULTI-UNIT ❑$TkUCfURAI.
ZOV,Z, lt'ner.wiJ my plans shall neanal as public records MODIFICATION
O Z..O UP'IOZ00 AMPS [I INTERIOR ❑CHIMNEY REPAIR
aoal❑�; Licensed W fcssional 201-IWOAMPS IMPROVEMENT SWIMMING POOLS
2 OWNER BUILDER DECLARATION
a Q 1 hereby affirm that 1 am exempt from the Cnntxactor's License Law for tM1c OVER 11000 AMPS El RATA REMODFIJREPAIR [I DEMOLITION
O a U following reason.(Sectlan]031.5,Business and Nnfcssimts Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
which w,mmx s permit m can.,wa.:alar,improv,demolish.no,repair any smucwro,
Prior to its issuance,also requires the aWlieant for such permit to file a signed statement SPECIAL CIRCE IVMISC.
Cfthat he is licensed pursuant to the pm i,mm,of the Contra umr'x Lirense low l Chapter9
f+I`+p0 (commencing with Scrumn 70M)(it Division S of the eusinessand Professions Code)or TEMP.MR CER OR POLE INS . COMMERCIAL
a a e W thin he is cocain dmrefrrn,and the basis for the alleged collatioon.Any vielaion of ❑NEW BLDG/AUDITION ❑DEMOLITION
Section 7031,56,aaya,heant ueapermhnunieets mimeappbrent to a rant pencil,.f POWER DEVICES te El TENANT ❑FOOD SERVICE
not more than five hundred dollars(SSo0). IMPROVEMENT
ZO ❑ l,avrwveroflbeproFeny.mmy cmntended with cared I aleidue.compensation, SWIMMING POOL ELECTRIC
L.`
will Jo the work.and thvswnum is nunimanJnl.,,offered rnr sale due.7044,Puniness ❑OTHER
3 and Professions Code.The Cnmructnr's License Law does not apply m an owner of OUTLISI'S-SIVI'I'CIiF.S-PIXTURF.S
property who builds m imp se,themon.and who it.,such work himself or through
his own employees,provided that such improvemems are not intended or oRered for NEW IiESIDIiN'r1Al,ELECT it SQ rI'.
,.It,If.however.the Wildingmimprovemere k wIdwithm one yeornfcompinion.the SQ.FT.FLOOR AREA VSQ.FI.
owner-milder will have the burden of proving that he did not build or improve for lour
302- 0
lose of ole 1
❑ I. f thepar,rit,ad,cs,1.,i,ciy ramarame,with licensed cots a t t IOIAL
ecoushructrait project(SII)iJ Business and Pt si Code:)ThContractor's
L _
c• seL ee.n t Oplyt on fp pony n b Id p rah m J QTY:..', /. MBING PPRMITl,i../ /tIr (l14TEEtr sf.
whoc n f hp ) t withocanaamods7l'censeJpursu mI theConuan rs
Lice I 476
PERMIT ISS
❑lam exempt under Sec. ,B k I'C for this reason
,Other Date ALTER-DRAT. -WAT'F:R(EA) VALUATION -
WORKERS COMPENSATION DECLARATION BACK FLO ' OI'E f DEVICIi O 73 '
I hereby affirm no penalty of perjury one of he Iollowing drelamtlone
I baveand will maimaina Cerliricmc of Conttm mself-:rmurefm Workeh Cnmpen- DRAI . -FLO OF AREA,COND, STORMS TYPE CONSTRUCTION
safmt,as provided looby Section 3]W of the Labor Code,for the performance effort,
work for which this Kwan is issued. PIXTURIS-PER'III
❑1 have and will maintain Workers Compensaian Insurance,as required by Section
37tMlo1 the rCwle,funh pert m rc of she work forty ch this permit is isxned. GAS-EA.SYSTEM-1 C.40UTLEIT
OCC.GROUP APN
My Waders o 1 ur c d '
Garside GAS-EA.SYSTEM OVI:
CIIRTIFI, TE ) rXE ON FROM lypRKF.kS'
�.,ttoue.Y.'CIf�J/ GItEASC/INUUSTiiI.WASTEI EPf BUILDING DIVISION FEES
(Thissmnion ocean ane cnmplaW ifNe permitix(or one hunerW dollars($IqR GREASE:TRAP
or less.) PLANCHECK FEE
Iayary thou,the performanceoOs 1 work for which this permit isisso,l.lnhag SEWER-SANITARY-S'fORM EA.200 Ff.
�r not employ troy persmt iaany mannas so as m become whjem m the Wnrkcri Compen- ENERGY PEE
O 2 nation Laws of California.Dote WATER HEATER W/VENT/F.LECTk
Z Applicant GRADING FEF.
rq
NalICHnk Aro the Wo:1L after making this Certificate of Exemption,you should WATER SYS]ls1/I'RIiAI'ING
a ~ become suhjea to the Waders Co..m o,loon pm.u,hal of the Labor Calc,you must SOUS PP.E
kl I� forthwith comply with such provisions or mis permit nhvll be Jecmed revoked. WATER SERVICP.
0
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.Pr. PAID
U 0 l therebywhich this
issued ee,30lendin,agency for performance of Dam Rewind of
� � the work for wM1ieM1 this permit is issued See,3097.CIv.CJ '
O U lender's Name 'IOT'AL'.
B.I Lender'.,Address TOTAL:
F0. I cenJy than I have read this application and state that the abuse r of ! r. t . . ., r BUILDING FEF.
tr V) correctl agree to comply with all city and county ordinances and state laws relungt QTYMECIIANICAI PERMIT JFrI !r/'4FEE '•r'
U building consuucton and hreby authorize mpre,ematives or this aty m enter upon the - /" rrs,r. .r f- rJ SEISMIC FEE
abnve meidamonA property for mspeam.purpnu''
(We)agree m slow,Indian dy and keep Iwnoles,the City of Cupertino agai PERh11T ISSUANCE usn ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD'IO MECH. PLUMBING FEE
nc tth<gm I nfthis pcman
APPL t UNDERSTANDS AND WILL COMPLY WITH AI N N-POINT AIR HANDLING UNIT(10 L000CFM) MECHANICAL PEE
SOI' 1c`o iECUI�TION �� P�
/ AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signauue of AppXanVC 2F Dane EXHAUST'HOOD(WMUC'1) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harnrdous material I IEATING UNIT(TO 100,000 If ED
as defined by the Cupvrtino Municipal Code,Chapmr 9.12,and the llmhh and Sourly
Gale,Section 25532OP ,kkk//// HFATINO UNIT(OVER 100,000 RTU)
E]Y" 0Na PAID .-
VENT]LAI'ION I�ANISIHOLE RESIDI Date Receiptb
It Will the applicant or fumre building occupant use equipment nr advises which 11011 ER-COMP(JHr OR 100,Of1(1 R'fU)
emit hazardous air contaminants a,defined by the Bay Area Air Quality Management TOTAL:
District".
E]Yes BOILER-COMP(OVER 100.000 BTU)
Nn
AIR CONDITIONER
I h:av safestit harrrdeusdiamondsion, 5 requirements under such ,1 and 6,95of thethe,Coli- Q ISSUANCE D .• x.a�
fnmia cahh ffi Safety Cale.Smiom 25505,8531 and 2553J.1 understand the if Ne NEW HISIUIiNTIAI,MECH. S .PC � ��yl�
build' nes notcurremItno amncl fit,I....myrespnnvibiluy o atifyl earrul'ant — -200p
oft lite en hatilishyre oro Cot � cy. e
raw orlrod Date I TOTAL: ISSUED BY
OFFICE