S 1929 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER`yIIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. - $J 1929
F777ItU )ING PROJECT IDEN'FIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
/90.2e z.4 SAJ 7 -28
OWNS���t'NAME PIIONL: CON'BAC'I(IIPS NAME: LIC NO:
j �/ge✓lo�As% fi'- NS iKG x68 NIC CONTROI.x
ARC ITP-�I'/h:N(i1NEUR: LIC NO: AD RE.S: ❑
L ) O a r A �o
CUS
'ACT: PHONE: BUILDING PERMIT INFO
J� W r �o' D7-76 Ib `O ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB METH
aSolo ❑ 42r ❑ ❑
LICENSFDCONTRALTOR'S DECLARATION QTY. ELECTRIC PERMIT PF-li
1 bemby affirm that I am licensed under previsions of chapter 9 momnrencing JOB DESCRIPTION
Ganz with Seminn 9(KK))af Uivision3nphe Business and Pmfexsinm CWe,and mylicenw is
RESIDENTIAL,
Im-�0 ' full force and effect PERMIT ISSUANCE
�UF License Class C�C//f Licx acyQel ❑SFDWI. ❑KITCHEN RIiMODEI.
ZU 7-If SJ,,.. t; !- APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RETIVE
Fs m Dine ';J Contractor
U El MULTI-UNIT ❑STRUCTURAL
U,iARCHITECTS DUCLARATI N -
Fr7jtz I matersmndmy plans shall W Used as PUMic records PANELS MODIFICATION
OZ�`� UPTO 200 AMPS El INTERIOR 0CHIMNEY REPAIR
h•�Fly Licensed Ful'es.sionm 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
�YX; OWNER.RUILDERDECLARATION OVEkIBBOAMPS ❑14ATHREMODEUREPAIR ]DEMOLITION
C C Q I hereby orm that I am exmnpt from the Contacmr's License Law for the
KDyU following reasam(Seen.n 7031.5,Busine,amd Pmfcantans Coca:Any city o,county SIGNS ELECTRICAL Q 0 El OTHER
3
which requires a perms re,construct,alte,improve,demolish.ar repair any stuaamrc A
0st prior to its issuance.also requires[lie applicant Rnmcbpenmiuo Elea signedmiamnnt SPECIAL CIRCUENISC.
fly thmhe islicencropursuant to the provisions ofthe Contractors Liecnsclaw(Chapicr9
D,'OQ (commencing with Section 9000)of Division 3.fere Business and Professions Cole)nr TEMP.METER OR POI.E INST COMMERCIAL'
a.y a a that he is exempt henchman and the basis for Its,alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W y Section 1131.5 by any upplieam fora pennitmbjem,thaaPPllcant to x civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more Chun live hundred dollars($500). IMPROVEMENT
p ❑ I,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL.ELECTRIC
F' will dathework,and Promorctureisnot imendedormieredforsale(Sce.9144,13u1incss ❑OTHER
63� and Professions Code:The Contractors License law does not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves thereon,end who does such work himself m through
his awn employees,provided that such impmvcments am not intended or offered for NEW RISIDEN MAL RLUCTR SQ PL
sale.If.however the building or improvement is sold within one year ofmmpletion.the SQ.IT.FLOOR AREA Vsq 171.
ponc,-huilder,will have the human of proving that he did not build or improve to,pur-
se.f tele.} S�
i]1,m owner.f the property,am exclusively contracting with IlcenneJ enntractats to A
mtxouet the project(See.9(144,Business and professions Cade:)no Contractor,Li-
coast
law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjaas with a con rmaoubs)Imon.red pursuanun the Con rknor's .
License Lew. PERMIT ISSUANCE
❑ I am exempt undo,See. ,B&P C far this mason
Owner Date ALTER-DRAIN&VENT-WATER U!Ak VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TfIiLT.DEVICE
1 hereby affirmmai under penalty of perjury one of the fnllnwingWorkerni.re:
❑on.us and will for by eCen 3700 of Comers m Codenmrefer Camped-the DRAINS-FLOOR.ROOP.AREA, STORMS TYPE CONSTRULTIOI
tion,m'provided for by Section 39IX1 of the Labor CWe,for pert"mmnea of the
for which this permit is issued, I:IX'fU1tES-PER TRAP
w 1 have and will mainland WorkeCs Compensation Insurance.us roquireJ by Seeti.n
30110 of We LabarCWe,lbs the peri'nnamce of the work linwhiuh this pcmtitis i.eweJ. GAS-HA.SYSTEM-I INC.4OU1'LFTS OCC.GROUP APN
Car nr a ompe ami n lnsumneec moue and cy Policy rytZt�a Ai 64101 GAS-EA,SYSTEM�OVER 4(1?A) 1
CERU CA'fE OP EXEMPTION FROM WORKERS' GRIiASFIINDUSTRI-WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION_ FP.6S__ _
(This.seclion need not be completed firm permit is gohundred dollars($100) GREASE'I'RAP OT le".)(This i•EI?
I cenifymat in froperformareeaftheworkfimabicit thisperrim isismed,lshill SEWF,k-SANITARY-STORM FA.200 IT.
net employ any pars".in any manner so a to become mbjeel to the Workers'Creation- ENERGY FEE
z Union Law,of Calif" Uatc WA TER HEATER WNEN9'/El.ECT R
Z� APPlicmt fo.k a 57 4 GRADING IF.Ii
y NOTICETO A'pi.ICAN'R l nRer nmking this Certificate of Exemption,you should WATER SYS'IENI/IREATING SOILS FEE
become subject to the Workers Compensation Provisions of the Labor CWe,you must
W forthwith comply with such provisions ort his poicaushallM deemed revoked WATRR SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
Date Receipt
U O Iberehy ufbmtlhat there iaumowginn lending agency for the pert"nnam'e of p
D. F the work far which this permit to issued(Set.3097,Co.C.)
U Lenders Name 'T'O'TAL:
Q Lenders Address TOTAL: BUILDING q
EE Y ^
y 1 rarefy that I have rail this application mal state that the above information is Sl
F V1 corner[agree to comply with all city and c"uity omiiances and state laws relating to QTY, MECHANICAL PERMIT FEE
Z building construction,and hereby outhonre representitivesofthis city mm
cerupon the SEISMIC I:EE
above-memi.mW proper)'forinspection pimprove, PERMIT ISSUANCE
Use)save,to save.indemnify and keep harmless the City of Cupertino against P.LECTRIC FEE
Iiahiliec,judgments.coawandeapenses shichnuoy in any way reemc against said City ALTER OR ADD TO MECH. PLUMBI 0 f4cu-
in consequence of the greeting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIFoO IQ(IWCFM) MECHANICAL ME ttgSU
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.005 CFM) CONSTRUCTION TAX
Signature of Applicant/Cnmracmr Data EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr furore building arspant store.,bindle buzam.ms ntmclud HEATING UNIT(TO 10a"BTUI
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the[health Unit Safety
Code,lection 25532(x1^ HEATING UNIT(OVER IOOAIg)Brut
E]Ye" EN. VENTILATION FAN(SINGLE RESID) PAID
Date Receipt N
Will the applicant or future building mcupam use equipment or Jev Ices which BOILER-COMP(3HP OR IMOOB BTU)
emit M1asmous air ttmmminmtx as defined by Ne Buy Arca Air Quality Managemem 'TOTAL:
Distinct? BOILER-COMP(OVER Ififf"BTU)
❑Ven E]No
I have real the hammoas materialsEar 6.95"f the Cali- AIR CONDITIONER ISSUANCEDATEunder Cha �F
famia Health&Safety CWe,Sections 25505,25533 and 25534.1 Understand that if the NEW RESIDENTIAL MECH. SQ.FT. �--a
buildingdo....Imtmnl,have.o.ant,thin it is my responsihild,mnsxify the occun /pm '
of the aci ffl emams which must he met to...no issuance of a Cenificam of Occupancy.
eg n r`
Owner nr.uthnmed"gm (late TOTAL: ISSUED BY: �?„
OFFICE