B 0181 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
*ILDINA
ERTINO �yi 'Hp BUILDING-EL.ECTRICAL PERMIT NO 1n 0181
VISION APPLICATION/PERMIT '� PLUMBING.MECHANICAL 50001 5 X
BUILDING PROJE=IDENTIFICATION xV `�i
SS: - SANITARY NO. APPLICATION lUNMI"TfAI.DATE
g s"L, N �t z 6 —2L� e
`_ I - PHONE: I CONTRACTOR'S NAME: LIC NO:
M lap L\ \ (O- 3)lb J Ii-Lemm MST. %% NIC CON'I'ROLp
EER: LIC NO: ADDRESS: O ❑
MP6;r�.lintf -bP. S•X.
CONTACT: PHONE
BUILDING PERMIT INFO
❑ Consultant Fess Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1Z E3 El
LICENSED CONTR $DECLARATION Ory ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provision;of Chapter 9(commencing
na'z lh ScctinnttKKp ol'Uivision3nfthe Business and Professions Code.and mylicena is RFS
ID.NTIAL:
t+IOp wn PERMI'I'ISSUANCC
F 11 force and eff t. X.SFDWL ❑KITCHEN REMODEL
m VE+ cm,x . '1 Lro.p 56 BUIL
6 U "0 (�, S1`•lInTLCODS� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
� � m Cummcmr ❑MULTI-UNIT ❑STRUCTURAL
F D to ARCHITECTS DECLARATION PANELS MODIFICATION
I understand my ptan,shall be used as public recm&
ZOZ�, UPT0200AMPS ®INTERIOR ❑CHIMNEY REPAIR
G^E-u0) Licensed Prefessional 201.1"AMPS IMPROVEMENT 0SWIMMING POOLS
GK p5� OWNER-RUILDF.R DECLARATION OVER IOW AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
I hereby afMn that 1 um exempt from the Contractor's License Law for the
��°((' a U following....(Section 7031.5,Business and Rnfexsinns Ctde:Any city err county SIGNS ELECTRICAL ❑OTHER
Y134 y which requires a permit to Construct,aper,improve.demolish,or repair any swcture xmriia I1 skup RAf kid I T
Ip"'�O� primmits iaNaace also re9uircs theapplicant forsuch pe-iuofile a signal stud - SPECIAL CIRCUIT/MISC.
2 }
that he is licensed pursuant the provisions ofthe ConmeloA license Law(Chapmr9
AMMAL:
W J 00 to t he is exempt therefrom
mod the
Division Bmf the B.egad easinalxempt Preon.ny vi CIA,)of TEMP.METER OR POLE INST.
d o
that he is exempt Nercfrom onJ the M1asis for the alleged exemption.Any violation of ❑NEW NLUG/ADDRION ❑DEMOLITION
Section 7031,5 by any applicant for apcfruit subjects thCapplicom m a civil Penalty Of POWER DEVICES ❑TENANT ❑FOODSPRVICE
t more than five hundred dollars(SSW 1. IMPROVEMENT
1,os owneroRhe rt,nrm to sex with wo es es their smlecom ,orlon, SWIMMING POOL ELECI'RI
9 O ❑ pmPe y Yot in y g Pen ❑OTHER
R da the work,and the swcture is not intendede Law du for ale ply to w euaimns
LCm pa,ernfexsiob CWe:Thanes themo Liana Laws sucnmapplytolfownerof OUTLETS-SWITCHES-FI%T
5 property who builds or improves thereon,and who docs such worlr himself Or through
his own employees.Provided that such improvements are not intended or offered for NF.W RESIDIiW A, .'ECTRV 447
sale.If.howeventhe building m improvement is sold within one year of completion,the SQ.Ff.FLOOR AREA 5/SQ.FT.
wrier-builder will have the bunden of proving that he did not build or improve fm par-
. puce of sale.). TOTAL:
❑1,as owner III the property,um exclusively Contracting with licensed contractors m
construct the project(Sec.]M4,Business and Professions Code:)The Con r—ou s I.i-
a,Law we.not apply low owner of property who builds m impmves thereon,and QTYjPrRMT
PLUMBING PERMIT FEE
who contracts for such projects with a eontractogs)licensed pursuanuo the Comracmrx
License Low. UANCE❑1 wo exempt under Sec. ,B&P C for this masonAIN&VENT-WATER(EA7Owner DamWORKERSCOMPENSATIONDGCI-ARATION A"(ITECf.DEVICE 'a 0 �J
1 hereby aMrm under penalty Of perjury one of the following declaratimm:
I have and will maintain aCciificate of Consennn self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,ARBA.GOND. E11,RTP1UP] TYPECONSTRUCTIO
,anon,es provided for by Section 32(10 of the Labor Cade,for the perfmotmee of the
work for which this Permit is issued. FIXTURES-PER TRAP
I have and will maintain Workefs Compensation Insurance,as required by Section
3200ofthe labor Code,fur the perfonrunce of the work for which this permit i.,issued. GAS-EA.SYSTEM- INC.4 OUTLETS APN
y rk%e), pcnsaunn Insurance carrier and Policy nu tbe, arc:
Ca7Aer. SMS OL 41+nom Policy No.: (VllsiAl GAS-EA SYSI'EM-OVER 4(EA)
CERTIFICATE OF ME"MPfION FROM WORKERS' GREASFIINDOSTRL WASTE INTERCEPTOR
loCOMPENSATION INSURANCE BUILDING DIV ISION IDIS
(Thisseaa aced not be Completed ifthe permit istomme M1undmldnllars(SI W) GREASErMAP
or less.) PLANCIt1iCK FEE
l certify that in theperfemance of the work for which this perhat is issued,Inhall SHWeR_SANITARY-S'I)RM EA.20014.
not employ any Person in any manner a a m become subject to the Worken'Compeer- ENERGY FEE
z0 Applicant sot California.Dae - WATER BEATER W/VENTRA.Em'R
GRADING LPH
NOTICE TO APPLICAN'F.If,after making this Certificate of Exemption,you should WATER SYSTEMICOMAt'ING
f' SOILS IPE
; become aubjee m the Workcfs Compemaima provisions of the Lahr Cade,you most
n„ forthwith comply with such provisions or this Permit shall be deemed mvokul. WATER SERVICE
+J Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
I hereby nffirm the there is acovswction lending agency for Performance of Dore ceiptx
"J the weak for which this permit is issued(See 3097,Civ.C.) 'TOTAL:
Q U Lenders Name TOTAL:
fill la,mer's Address BUILDING IPE r
G 1 certify that 1 have mail this application and state that the above information is
h coned,l agree to Comply with all city and county ordinances and state laws Odming to QTY. MECHANICAL PERMIT FEE S171SMIC FEC
U building construction,andherchyauthome representatives ofthunity toemer uponthe _
above.mentioned property for inspection purposes. PERMIT ISSUANCE. EI.ECTRIC FEE
(We)agree ,,sa.c,Indemnify and keep hurmins the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way CO.,uagainst snid City ALTER GRACE)TO MECH, PLUMBING E
in consequence of the granting of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO I0,001(ICPM) MECHANICA sE
SOURCE REGULATIONS.
AIN HANDLING UNIT(( VLRIO.OIN)CFM) CONSTR TAX
Signature OfnpplicanVCommucmr Date EXHAUST HOLD(W/DUCT) HOUSING MITI GATION'IF.F
HAZARDOUS MATERIALS DISCLOSURE _
Will the appheant or future building necuPantshare err handle hazardous material HEATING UNIT(TO 100.(I(I(IBTU)
as defined by the Cupertino Municipal Ctde,Couple,9.12,and the Health and Safety
Code,Sce,mn 2553200? HEATING UNIT(OVER 100,B(kl BTU)
❑Yes ON. VENTILATION FAN(SI NGLE RESIII) PAID Dam RereiPtp
Will the applicant or furore building Occupant tau equipment or deciees which BOILER-COMP QHP OR[00.000 BTU)
emit hazardous air contaminants as defined by TO Bay Area Air Quality Management - 'f0 A
District'' BOILER-COMP(OVER 100.1100 BTU)
❑Yes ON.
I have had Ne hemayms materials mquiremesns under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foods Health&Safey Codc,Sections 255(15.25533 and 25534.1 understand that if the NEW RI?SIDENTIAL MECH. SQ.FT.
building does not Currently have a Imam,Nara ismy responsibility To modify the cocupant
of the requ rcrowN which most be met prior m issuance Of a Cenificam of Occupancy.
Owner or audsorival agent Date TOTAL: ISSUED BY: L'�M
OFFICE