S 0447 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIND BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF,RMIT PING PROJ,-MECHANICAL S 6447
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
no )-l- FM oN . OR—
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OWNER'S NAME: DN r�4 CONTRACTOR' NA�(.1E/:) Caj .IC NO:
sr F.L L NIC CONTROL N
4AY\RCHITE IC GINEER: LIC NO; AI�g� SS ❑
•'GAAP FFc YD!� C7 �M I C Caj
Z S'
CONTACT: PHONE: IOJ✓ BUILDING PERMIT INFO
��� �MtG S ���'�n^,. ❑ Consultant Fees Paid by Applicant(Initial) BL G ELECT PLUMB MECCH
LICENSED CONTRACTOR'S DECLARATION I�Y/b QTY ELECTRIC PERMIT FEE
1 hereby anion that 1 am licensed under pmvismm of Chapter 9(commencing JOB DESCRIPTION
with Section 7000).f Division 3 of the Businessand Professions Code,and my license is RESIDENTIAL,
W p PERMIT ISSUANCE
�. in full force anJ dl'ec r' ❑SFDWI. [I KITCHEN REMODEL
IOU License Cl s Lica ES-RESIDENTIAL C1 PLUMBING RE-PIPE
FF. W Dale Cnmracmr
F�rZRI A CHITF.CT'S DECLARATION PANELS ❑MULTI-0NIT ❑STRUCTURAL
Z 1 understand my plans shall be used as public records MODIFICATION
oZr/1G UPTO200AMPS ❑ ❑
INTERIOR CHIMNEY REPAIR
y LL] Licensed Professional 201.10MAMPS. IMPROVEMENT SWIMMING POOLS
LS` -a{ OWNERBUILDERDECLARATION OVIiµ10(NIAMPS ❑BATH REMODEL/WiPAI$� ON
C 1 hercM1y off nn Ohe]W 1 um exempt from the RATION License Law for the
tiy5 L U following reason.(Section 7031.5.Business and Professions Code:Any city Or county SIGNS ELECTRICAL El OTHER
t++ O I" which requires a permit to construct,alter,improve,demolish,or repair any mmcture
primm its icross.,also,egahv1,reapplicam 17,,Tsuch pe—it n file a signed"moment SPECIAL CIRCUIT/MISC. Ry Ft W%U
A N that he is licensed puromm to the provisions.f Me Corhma.f's License Law(Chouaril
C) (commencing with Section]0W)of Division 3 ofthe Business and Professma%Code)of TEMP.METER OR POLE INST.. COMMERCIAL
E 6 0�' that he is exempt therefrom and she basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by onyapplicant forapennit subjecnxtheapplicant loacivil psonaltyof POWER DEVICES []TENANT ❑FOOD SERVICE
a more than five hundreddollars($30O). - IMPROVEMENT
fGI,as owner of the property,or my employees with wages as their axle compensation. SWIMMING POOL ELECTRIC
F. will do the work.and the structure is not intended or offered for sale(Sao 1044,Business OTHER
L 3 and Professions Code:The Commctor's License Law does not apply to an owner of OUTLETS-S W ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NBW RESIDENTIAL ELECTR SQ
sale.IL howevcc the Building.rimpmvemem i"uld within ono yearoloomplalmn,the SQ.IT.FLOOR AREA SISQ.FT.
owner-builder will have the hunden of proving that he did.1 build or improve for pur- PAID
�
you of sale')` P p
❑1,as Owr r ol'the pro,eny,am exclusively contracting with licensed contractors m _ TAI: �"1 , 11
answct the project(Sec.1014,Business and Professions Code:)The Conaactors Li- �� 00r,
g!
cense law does not apply 1.an owner of property who builds,,,improves thereon,add QTY. PLUMBING PERMIT /� FEE 0r,
who contracts for such projects with a mmucmgs)licensed pursuant the Contractor's !s b vI O
License Law. PBRMIT ISSUANCE C� 7 '
❑ I am exempt under Sec. .H&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) wtJr.Vpt,UATION
Owner Data - f� `tl'/(d/M ,
�I. WORK[R'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE j1) gJ00
1 hereby off tan under penalty nl perjury one of the fnllOwin6 declarations:
I have and will maintain a Cathie tcof Conant Rsself-insumfor Workers Compen- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONSTRUCTION
union,as provided far by Section 37M of the labor Code,far the performance of the
work for which this peord,in issued. FIXTURES-PER TRAP
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
1100.17the Labur Cods,turns,performance ofths,work forwhich Nispe.biitt is issued. GAS-EA.SYSTEM-1 INC.4 OUTLET'S OCC.GROUP APN
CMy Workarter:" r peruan' nx nyr�c5,quoie Ps,and NryOtyr(bf Ely'f4Y/d. GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIV SIGN PEES _
(This cation need not beeomplete4 ifthepens it is for,,ne hundreddollan(SIM) GREASETRAP C
or less.) PLANCHECK IEE 1A r
r.A
I certify that in the performance afthe work for which this permit is issued,l shall SEWER-SANI'T'ARY-ST'DRM EA.20O FT.
not employ any person in any manner a as to heceme subject to the Workefn'C.mpett- ENERGY FEE
Z ..tion laws fC.Iifam..Data WATER HEATER WNENT/ELECTR
C) Q Applicant n GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Iiscmptum,you should WATER SYSTEM/TREATING SOILS FEE
abecome subject m the Worker's Compensation provisions m the Labor Codc,you mull
{TJ forthwith comply with such provisions cents pormulahall he deemed revoked WATER SERVICE
PJ' O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH, SQ.FT. PAID
I hmhy
eaffifmrhauhere is N
c,,npraion lending agency for the performance of I m ReceipN
E'+ the work for which this permit is issC.)
O Lenders Name ued(Sa.309 TOTAL. TOTAL
W Lenders Address S Q
,{yam 1t I cerlily that 1 have read this application and state that the above information is HUILUIN
into correct.)agisto comply with all city and county ordinances and state laws relating n, QTY, MECHANICAL PERMIT FEE SEISMIC FEE
e
V Z, building construction,and hereby amhodzc representatives ofthis city mentor upon the
aMve.meationed property fee inspection purposes. PERMIT ISSUANCE
(We)agree n save,indemnify and keep handless the City of Cupertino against ELECTRIC Ilia
liabilities,judgments,costs and expense which may in anyway accrue against said CityALTERORADDTOMECIL PLUMBING FEB
in consequence of the granting of Nis permit.
APPLICANT UNDERSTANDS AND Wll .COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFE -
gOU F:GULATIO
�/ AIR HANDLING UNIT(OVER 10.(x0 CPM) CONSTRUCTION X
Si lire of App icanVCmarlem, DateLL/ EXHAUST HOOD(W/DUCD HOUSING MITE) ION IEE
HAZARDOUS MATE ALS DISCLOSURE
Will the applicant or future building Occupant store or handle hacedous matelot HEATING UNI T(TO 100.0M BTU)
as defined by the Colima.Municipal Carlo,Chapter 9.12,and the Health and Safety C.
Cade,Section 25532(0)? HEATING UNIT(OVER 1 Wp00 BTU)
I El Yes VENTILATION PAN(SINOI ) PAID
o A RESIDMule Receipt M1406 '
Will the applicant or foto building ace equipment or devices which
BOILER-COMP(JHP OR 100,000 BTU)
g hose, air contaminants as defmcd by the Bay Area Air Quality M...getncm
District? BOILER-COMP(OVERµ0J100 RTU) t
L]Y.,
AIR CONDITIONER
1 have read de haamlaux dinar iaR regmmmmds uMcr Chapter 6.95.f the Cali ISSUANCE DATE
famiu H.IN&Safety Code,Satiom 255(15,255 aM 25534.1 understand that if the NEW RESIDENTIAI.MECH. SQ.FT.
but 11 it Icummdy temmtrnhmili responsibility to notify the occupant
oII manta whit he met n t us,aofa nut I of25 (]Pcupe4yy
O rte ,carbon .gem s / Uma TOTAL: ISSUED BY:
OFFICE