28772 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI]'NO. ^ /�
BUILDING DIVISION APPI,ICATION/PERMIT PI.OBUILDING DEBING-MECHANICAL L L
PROJECT IDENTIFICATION
BUILDING ADDRESS: l SANITARY NO. APPLICATION SUBMITTAL DATE
0103S2 S 4-Zs-R�
0 NER'4N ME: 1 ( PHOONE:MCONTRACTOR'S NAME: LIC NO:
\ L NIC CONTROL#
AR CHITECT/ENGINEER: LIC NO: ADDRESS:
^ IIIW �. ,r x QS! (OOT e'�Z3 BUILDING PERMIT(NFD
Haw.. (C__�1l IC` Y ❑ Consultant Fce9 Paid by Applicant(Initial) BLDG E CI' LU B MF,CH
o8-44b-S$1'
LICENSED CONTRACTOR'S DECLARATION
1 herehy affirm Nm I em licensed under pmvisinns of Chapter 9(commencing QTY ELEMPERMrFFEEJOB DESC IPTIONZ with Sedion]000)ofDivision3aftheBusiness end Pmfessians Cala end my license isWr in full force and effect. PERMITISSUANCDFNTIAIU(] Licenu Clens Lica WL ❑KRCHENREMODELDate Conuacrrt APPLIANCES-REITION ❑PLUMBING RE-PIPE
F.O rat ARCHITECTS DECLARATION PpNCISLTI-UNIT ❑STRUCTURAL
ZO2r, I undenund my plans shall he used as public recordsOZ MODIFICATION
UP302WAMPSERIOR ❑CHIMNEY REPAIR
I; Lr<erned RofemonW 201-I(%pAMPSROVEMENTOWNER-BUILDER DECLARATIONI hereby affirm that 1 am exempt from the Conraetm,license law for the OVER If10BAMPSH REMODEUREPAIR ❑DEMOLITION
following ruon.(Section]831.5,Business and Profeuionx Code:Any city or countyER
SIGNS ELECTRICA
O which requires a 1-1 to com ict,Ober,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
Q� that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
00 (commencing with SeNOa 7")of Division 3 of the Businessond Professions Code)Or TEMP.MEfCR OR POLE(NST, GOMMFR I 1•
p,o that he is eaempt Nerefmm and Ne basis for the alleged exemption.Any violation of ❑NF.WBLDG/ADDITION ❑DEMOLITION
wry
Section 7031.5 by any applicant for a permit subjects the applicant to a civil fatuity of POWER DEVICES
Zp, n mare Nan five hundreddollars(S500). ❑TENANT ❑FOODSERVICE
CLmownerofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC MPROVEMENT
r do the work,and the structure is nut intended croffcud for sale(Sec.7044,Business OTHER
and Professions Code:The Coonewane License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
Propcny who builds or improves Cheuon,and who d«s such walk himself or through
his own employees.Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ FE
sale.IL however the building orimprovemem is sold within one year ofcmnpledo.the Q.FT.FLOOR AREA LSQ.FT.
cr-builder will have the burden of proving Chet he did.1 build m improve for pur-
a of
I]sL Oe owner of the Property,am ex hnivelY contracting with licensed mntmctons 1. �/' A
Imu m ct the project(Sec.]044,Business and Pmfessians Cade:)The Contracmr's I.I.
cone Law does not apply to an owner of propcny who builds or improves thereon,and QTY PLUMBING PERMIT FEE 2G' ,jOa
who contmsts for such projects with a contracmr(s)licensed pursuant to the Cnnwetor's f/ 1,��
Licenu law. PERMIT ISSUANCE Cy��
❑late exempt underSa. .B&PC for this..son CSI I U)- (, IG
Owner Data ALTHR-DRAIN&VENT-WATER(EA)' VALUAT
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy ufrom under penalty of perjury no of the following declarations:
❑I have and will maiwuin a Certificate of Consenuoself-insure l'nr Worker's Compen- DRAINS-FLOOR,ROOF,ARCA.COND.
sation,m provided for by Section 37W of the labra Cale.for the perform nce of the STORIES - TYPC CONSTRUCOON
work for which this pemdt is issued. FI%TURES-PER TRAP
❑I have and will mainuin Worker.Compensation Insurunce,as required by Section ,
LIS
37M ofthe labor Code.for the Performance ofthe work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCO GROUP APN
My Workers Compensation Insurance carrier and Policy number o2:
Carrier: Policy No.: GAS-EA.SYSTF,M-OVER 4 EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFdNDUSTRL WASTE INTERCEPTOR
(Thia section need not he completed ifthe permit is for one hundred dollars(SHMO BUILDING DIVISION F[?F.S
or lesa) GREASE TRAP
I cenify that in the Performance of the work for which this permit is issued,label] PLANCHECKFEC
z oat employ any person in any manner an as m becomesubjceuo the Workeri Coat SEWER-SANITARY-STORM EA.208 FT. ENERGY TEP.
avian anwe of California.Dom WATER HEATER WNENTMI-ECTR
O O
NOTIAppliCE
GRADING FEE
ti NOTICE TO AP.the We l IL after making this Certificate Of of Exemption,you ushould
most WATER SYSTP,M/TREATING
a ; become subject m the Worker's Compensation provisions of the labor Coda you must JE
E-
W QfoMwiN comply-an inch provisions or this permit alrell be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMtl. SQ.FC
U 0 (herebyaffirm thauherc iso issued(See
ding agency fmthe perfamunce of Data Receipt
he work for which this permit is issued(Sec.J09],Civ.C.) '
O Lender.Name TOTAL:
y Lenders Address L —.
[-, y I cenify On I have reed this application and state Nat the above inftmmntam is 'E
G 0 comet.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT PEE
V building construction,and hereby authorize representatives ofthis city to enter upon the -
above-mentioned property for inspection purposes.
PERMIT ISSUANCE
(We)agree m Co.,indemnify and keep harmless the City of Cupertino against C PEE
liabilities,judgments,costs and expenses which may in any way eccme aguinstmid City ALTER OR ADD TO MECH.
in co sequenm of the growing of this permit. G FEEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIAIR IIANDLING UNIT f1O IB.fgp CFM)SOURCE EG LATIONSICAL ,Ef� AIR HANDLING UNIT(OVER 10.000 CFM) CT' NTAXngnareofApplicims" nwct 11 Da J EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE TIGATION PEEWill the applicant orfuwre building occupant store arhandle huwdous material HEATING UNIT TIO IOg800 BTU)
as defined by the Cupertino Municipal Code;Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER H%I.000 BTU) -❑Yes ❑No
VENTILATION FAN[(SINGLE RESID)
Will the mi,icons Or future building Occupant use equipment or devices which Data eceipt a
emit haxwdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(31HP OR 100,000 BTU)
Di
strict? TOTAL:
s ❑NO BOILER-COMP(OVER IOQO(st e read de hawdaus materials AIR CONDITIONER ISSUANC ATErequirtments under Clwper 6.95 ofthe Cali-&Safety Calc,Sections 25505,25533 and 25534.1 understand that if theNEW RESIDENTIAL MECH. SQ.PT.
not cumndy have a mnant.that it is my respria billty to notify the occupantmenu whireafOccupancy.
honsd tgenC Date 'TOTAL: ISSUED BY
OFFICE