S 0773 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT rl.un+emr.-MFIDENTICAI. 0773
tlUILDING PRUJEGT IDEN'1'IFICATIUN 1
BUILDING ADDRESS: jSAITARY NO. APPLICATION$UBMITI'N.DATE
p �'O CSA 5 n,J f- � ✓�
OWNER'S AME:,+ ��L PHONE: mss. CONT �J)R'S NSA 7 LIC NO:
Z SS J(/3/ 2, Eft/l" •13 S CON1ROLk
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
Y 5 Jl7r+_ si- 5 J
CONTACT I PHONE; BUILDING PERMIT INTO
5 5 ^✓� j�f 2 —/�3 ❑ Consultant Fees Paid by Applicant(Initial) BLDG LE " PLUMB MECH
.
J ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT EEE JOB SCRIPTION
I beerhy.111.tha 1 am licensed under Provisions of Chap, 9(commencing
OZZwith Seclinn]I11X1)of Division3nf Ne Business and ProfasionsC e,and my license ix RESIDENTIAL,
50 full force nnJ t PERMITISSUANCH
F m ❑SFDWL ❑KI"I CHEN REMODEL
p�U LsenscC ss- 1, C'/V Lic.N �� 54
Q UUj ix-�� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PI.UMBING RE-PIPE
Z W nate Conmwmr
I =)a El MULTI-UNIT El STRUCTURAL
ARCHITECTS DECLARATION
p„7 m PANELS MODIFICATION
x0ZZ I understand my plans shall h avail as public records
In .�_ � UP'1'02W AMPS El INTERIOR ❑S CHIMNEY MINGREPAIR
OOL
I-•�f.W Licensed Pfafesnonal 201-IIIWAMPS IMPROVEMENT SWIMMING POOLS
SY F,; OWNER-BUILDER DECLARATION OVIiH 1000AMPS El BATH REMODELTEPAIR El DEMOLITION
t�%01 Q 1 hereby affirm that I am exempt from the Contractor's License Law for the ❑OTHER
O y U following reason.(Section]1131.5,Business and Professions Codn,Any city car county SIGNS ELECTRICAL.
a fs.F which requires a permit to construct,alar,improve,demolish,or repair any structure _cture anj$ -
I�"�y� prior to ib issuance,also requires the applicant for such pcmtino fileosigned nwtemem SPECIALCIRCDIT/MISC.
G6� th.t he is li¢orad pursu.nnothe provisions of the Commemr's Licenseluw(Chupter9
CO (commenuingwlth Section]W0)of Divlsinn3ofthc Rnsinessonsl Professions C(de)or 'I FMP.METER OR POLB INST, COMMERCIAL
6yx c eG that he is exempt therefrom and the Iasis for the alleged exemption.Any vinlmian of ❑NEW BLDGIADDITION El DEMOLITION
W^ Section 7011,1 by any applicam for a permit subjects the applicant to xaivil Penalty of POWER DEV KISS EITENANT ❑FOODSERVICE
y^' not mom than five hundred dollars(S500). IMPROVEMENT
O ❑I,aeownend the properly,ormy employees with wages as their ale compensation, SWIMMING POOL ELECTRIC
willdo the work,lnd thestmcnt.is not imendedurnffered for vote(See.]044.Business y� El OTHER
Wm and Professions Code:The Cranracmrs License Law does oat apply to an owner of t v OUTLETS-SWITCHES-FIXTURP_S
6 3^ proPeny who builds or improves thereon,and who doe,such work himself or though
his own employees,provided that such improvemcnta are oat intended or i mored far NEW RESIDENTIAL FLECK SQ PT.
FT.FLOOR $/SQ.Pf.
sale.11,however,the building at improvement is sold within one year ofemoution.the SQ.
owneolbuilder will have the harden of proving that he did not build or improve for put,
. pose of sale.). TA
1,as owner of the prapeny,am exclusively contracting with licensed emorctorsto
mxtmet the pmjcd lSw.]IW4,Businoss and Iholbaxinn,pdcU'Ihe Conummr's Li- /1 I
etme Lew dive.not applymart owner of property who buildsor improves thereon,and QTY. PLUMBING PERMIT FEE A
who contracts for such pmjemx with a connractods)licensed pennant o the Contractor's
License Law. PERMIT ISSUANCE DEC 1 am exempt under Sec. .B&P C for this rayon {/
ALTER-DRAIN&VENT-WATER(EA) V ON
Owner °°" CI I N-
I.
`1WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (Jl+th�INO
Iherehy uRrm under penalty of perjury one of the follnwin6 dedamtinns:❑Ihnve unA will maimuinuCcnipcatuof CanaenI maulf-in.xofe for Workers Cmnpen- DRAINS-FLOOR,ROOF.ARE A. RIEStion,as provided for by Section 3'/00 of the Latin Code,for the verfarnano of they�tfor whichthis permit is ironed. FlXTURES-PER TRAP0`I.be and will maintain Workers Compensation Insurance,as mo uited by Section3700 of the Labor Cade,for the performance of the work ffoor which this permits issued. GAS-HA.SYSTEM-I INC.4 OUTROUPMy Wor r'.s Cutnpysation Inure ruse Pand NayparGAS-EA.SYSTEM OVER4(EA)Carrier: CrYGCERTIFICATF.OFEXE "ION FROM WORKERS' GREASFRNDUSTRL WASTE INTCOMPENSA ION INSURANCE BUILDING DIV(ThixseenamaeediumbeampletW ifthe permit lsforonehundreddollam($100) GRHASETRAPEE
I cenifythat intoe pulormamouffs,walkfar whichthis permit is issued,l shall SEWER-SANITARY-STORM EA.20X1 FT.
not employ any person in any manner so as to become subject o the Workers Campion- ,HNERGY FEE
Z ratiaw
on Ls of Cahoon..Gore WATER HEATER W/VEM'/ELF.CTR GRADING FEE
Z Q Applicant
ti NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMOREATING SOILS FEE
a7 become subject to the Workers Compensation previsions of the Labor Cade,you must
W forthwith comply with such nowisimmul this permit shall be deemed revoked WATER SERVICE
a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,PT. PAID Date Rs ttl
W
U z Ihembyaffmthpe
t at there iso construction lending agency for the rfnrmnnw -
the work for which this permit is ixaed(Sea 3097,Cr,.CJ TOTAL:
O U Lender's Name
TOTAL:
U Lender',Address
p, I certify that 1 have read this application and swine that the above infetmatiun is BUILDING
cn correct.l agree to comply with all city and county ordinances and state laws rclmingw QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U
building consiuction,and hereby authorize representatives of this city to enter upon the
ebnve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FE
(We)agree m save,indemnify.nd kap harmless the City of Cupertino against
ludilides,judgments,costs and expenxs which may in any wayaccme against id City ALTF.RORADDTOMECH. PLUMBIN I.
n consequence or the granting of this permit.
4NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR II ANGLING UNIT TO 10.0(10 CFM) MECHANICALFE.
SOURCE ULATIONS.
AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCTION TAX
Signature id Applmant/Contmctor One EXHAUST HOOD(W/DUCO HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle houtdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety HCAT]NG UNIT(OVER I IXttXlO BTU)
Code,Section 25,532(a)?
❑Yes Na VENTILATION PAN(SINGLE RFSID) PAID Dato Rceey,#
Will the applicant or future Wilding occupant use»uipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit haufdom air embermn ds ai defined by the Bay Area Air Quality Munngemenl TOTAL:
District? / BOILER-COMP(OVER 100,000 BTU)
❑yes "D-(FI\
I havereadthehmmdnus mnteriils 'pier 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
requimmcntx under Che
fomiu &Snfmy Code,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
hu' mg does neatly havcarenanL that it is my responsibility to votify the teapeol
the�uiremat whit must emet Fnnnoiemarrcc o(a Cenificmc of Occupancy.
O fauths ed.,cut Uma
TOTAL: ISSUED BY:
OFFICE