S 1830 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CAL
CITY OF CUPERTINO ,� _ n BUILDING-ELECTRICAL • PE
L5%NO, 1830
ItUD.DING DIVISION ' APPLICATION/PERMIT TING PROJBINC-MEGBANIFICA
BUILDING IBOJ P:CI'IDEM'IFICA'I'ION
BUILDING ADDRESS: SANITARY 410. AIWLICA'fION SUBMITTAL DATE
!o S E
OWNER'S NAME: PHONE: Cp `TOR;eAMB �' JCC NO:
ill /+/Vk YY V F /V( NIC CONTROL#
Pq CHT171=/ENGIN'Ek: ` LIC NO: OR : ` ❑
00
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG, / ELECT PLUMB MliCll
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby amrnt mal 1 am licensed enter pnrvishms of Chimer v(commencing JOB DESCRIPTION
OCZ is cOinn]WB)nfoivision3oflhe Buxinessand 1vokoiionxcoJe,ondmy F....cis RESIDENTIAL'
5,18 PERMIT ISSUANCE
F�� .full force and sB ! - ❑SIUWL ❑KITCHEN REMODEL
aVU Liven .Iu _ Lia# APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RIE-PIPE
f-•zW Datc Contmaor
NQq ❑MULD UNIT ❑S'rRUCTURAf.
S.Om ARCIi1T1ELTS DECLARAI ION PANELS
z p y Z l ondemm�d my puns shall he used m public re oNs MODIFICATION
OZ^� UPT(I200 AMPS ❑INTIERIOR El CHIMNEY REPAIR
F+en,FS" Licensed Pmtcuioad 2014000AMPS IMPROVEMENT E]SWIMMINGPOOIS
OWNER-BUII.DER DECLARATION OVER IINNJAMYS ❑BATH REMODEUREPAIR [I DEMOLITION
a LL 6 I hereby erlirm Ohio 1 am exnnpl from the Contractor's License law for the
Xq 0.U following rmson.(Seaman 7(11.5.Business and Pofico nos Cute:Any city or comply SIGNS ELECTRICAL ❑OTHI?R
led 3 C HQ which pididles a punion m eunswa,cher.Improve,de:m,Bsb.nr repair any nwctore
rn.] priormits ismnnae,also requircvM1e applicant for such permiun Tile a.wgnalgmeme^t SPECIAL CI RCUIT/MP`C.
p. Walinearicenscd pursuanumhe pntvisinnaof the Contrennr's License Lamm,Cod erg
QO (mnvnencing wim Senioo 701)0 of Oivision3afthe Bnsinevv and PntksslomCele)or 'TEMP.METP.R OK POLE INSq'.
q p,o y thio he is cxempr merelimin nnJ me basis far me alleged excmmion.Any violation of EW BLDGIAI ITION ❑DEMOLITION
W..y
Section 703J.5 by amy upplinmtfor a permil.atbjects tbcapplinmuo.civil penally of POWER DEVICES ❑TENANT [I FOOD S17RVICE
not more Ihan rise hundred dollars(%500). IMPROVEMENT
Z^,QI]Lax awnerof thcprnperty.rnmy employeeswithwages as theirsnleeompcnsminn, SWIMMING POOLELIiMRIC
CCs. will do the work.and theswemre innrn intended nroRcmdlin sale(Src.]fVW.Husiness ❑OTHF;R
wd Professions C<xle:The Cummctors License Imo notes
not apply m:m cons,of OIIT-E'fs-SWITCHES-FIXTURES
B'3 pmpcny who builds m improves pertain,and who Joon such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RIESIDENTIAL ELECTR SQ FT.
sale.IL however,the holdingorimpmvennent ix solA withinoneyeaot c.mpleiun,the SQ.rr.FF711AR A VSQ I-L
Owner build.,will have the burden mf proving Ihm he did nal build or improve far .pmr p
socol'salc.). PAID
f
1,as owner of the Pro,waY,am exclusively commeling with licensed contractors to TOTAL
umamre the projca(Ser.7044,Business and Pmfexsions CWa:)'1'he Contractor's Li-
axatse Law does not apply toanowner ofProperty who Wilds orOpposes lhcreoo,and %GREASMNDIJSTRLwAsrEi
PLUMBING PERMIT IS JUL 13 ANT
wImempowl for suchprojectswith acomraetor(s)licensed pursuant to the Contmcme,
Licamse Law, SSUANCE
❑Ianexnnptnnder Sec. ,B&PClnr Ohisrearon
ALIT-It A VIiNq'-WATER(EA7 A R)N
Deaner Data
3 000
WORKER'S CGMPIENSAI'ION DECLARATION OW I'R(TITiCT.DEVICE
1 h meth,wiffmo under penalty of Pe jury one of the follow ng dcclamtions.
I have and will maintain a Certificate of Consent to self-insure for Workers Canteen- FLOOR,ROOF,AREA,CONE). STORIES- TYPE CONSTRUCTIOI
satin.,as provided for by Section 3700 of the Ends"Cale,t.r the performance Of the
work fur which this#o.it w nuad. S-PERT PI haveand will maintain Worker's Compensation Insurance,us requited by Section .SYSTEM-II ..4011TLLT5 (ICC GROUT' AI'N
MY Workg�n Cn�pi,Aon fyyppSe<4rJ'�ynJ I'olicY ,Cameo G/� f�zIL�LE, IiI ubey V00 4 .SYS'IEM-OVER EA)CIERTIFICATE OP EX EML'TION ATOM WORKERS' NDIJSTRLWAs'r6i sRCEP1OR
R
COMPENSATION INSURANCEBUILDING DIVISION ITES
Mi,iecomn neednml+ccnmplcmddlhepemtit isfor onehundreddollao(SIO) GREASIi9'RAI'
or Iess.) PLANCHn
larm thal in the pvionorapecofthe work for which this#e.it is issued.],hall SEWIER-SANI'T'ARY-STORM EA.200 T.
not employ any c unY mmner os m nsyt W.rkan'Compcm ENERGY
z Inion Was n elifnn in d1f WATER HEATER WN EMPELECTR
Apphcam GRADINNOTICE T APPLICANT:11;aRcr making this Ccnificate of Exemption,you should WATER SYSTEM/TREATING
SOLI S Fbwomesubjea m the Workers Compensation provisions of the LahrGtJe.you most
fonhwithmtnply withsuch provisins or thispenmilehall be deentedrevolmd. WATER SIiRVICECON53'RUCf10N LENDING AGENCY NEW RF.SIUEN'TIAI,PLMP. SQ.IT. PAIDI herebyaffirmthe there in a constmction lendingagepcy for the performance of
{USO F the work for which mis permit is issued(Sea NE)],Ci¢CJ TOTAL
O Lenders Name TOTAL:
,0U Lender's Address BUILDING FEE
W I certify tlmt 1 hove mnA This applicnhnn and sum the the above infumunion is
(r to came,Eagrestowntply with all city and county matinees and sate laws relating to QTY. MECHANICAL PERM IT FEE SEISMIC FEE
C.Jz building constmction.and hereby aumnrim representatives oflhis city toenarulant the
abovenu ntionesl property lin inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,Indemnify:md keep harmless the City of Cupertino against
Iwhilities,judgmem
nts,costs and expenses which ay in any is yaccraeaguinasaid City ALTER OR AD)TO MECH, PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONd'O1N'T AIR HANDLING UNIT(' 10,000 CFM) MECHANICAL.FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT IOV, Hk(NNICFM) CONSTRUCT ION TAX
SlE....c of APP]1.mContmnm - Ona EXHAUST HOOD(WIDUM) HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfmum building Occupant onimminmle hazmdo.s mmenul HEATING UNIT(TO 100.000 BTU)
as defined by the Copmdan Municipal Cute,Chapter 9.12,and the Health and Safety HI?A'1'ING UNIT(OVER IW,INNI ITU)
Coe,Sr lion 2553201
❑Yes VENTILATION PAN(SINGLE RPSI D) PAID Date Recciptp
Will lbs applicant pr forum building ttccupam use equipment Or Jevims which BOILIiR_COMP(3111'ORIW3NNUBTU)
hard"?
hazallous air vonmminan ped by the Pay Arca Air Qoaliry Menngemem TOTAL
hard"? BOILI?k-COMP(OVER 10I BTU)
❑Ye, A �
I have read the hoard...material.,tequirememm under Chapter 6.95 of the Cul i- AIR CONDITIONER ISSUANCE DATE
fomiu Health Is Safety COTe,Suctions 25505,25533 and 25534.1 understand mat if the NEW RESIDENTIAL MECH. SQ.IT.
It IT Fd.,n)LaL ontlyhavea pantthathismymspnnsibilitywn Oifyih ct cupnt
oft aqui t 'r w 'c et tre . x ince ofa Cenilicat"f((lcatykryy.-
Pi.rant nrl ag 7 13 "ane
OFFICE TOTAL: ISSUED EY:
OFFICE