S 1329 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECCRICAI. 1329
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 700 S D.=AW2Ahl-11,0
(IWNER'S NAME: / yVO 6�PHONE: — CONI'ItAC TON'S N�M E. — -- ,1 I �LICNO,
�G// "'_`eCAa'!^.'L'yf'`R/L Od 7 NIC CONTROL p
C
HIR LIC LIC NO: ADDRESS: ❑ ���
:)2
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
I,ICFNSIiD CONTRACTOR'S DI?CI.ARATION
I hereby nfOnn that I am IicenxJ unser provisions of Chv tar 9(commencln QTY ELECTRIC PERMIT PEE
HQZ
p g JOB DESCRIPTION
with
F W S«in full force and ceand effect.eInf Diviaion3ofthe Business end Professions Code,and my license is PERMIT ISSUANCE
G License Class Lie. RPSIDENTIAL:
O
C (- CSPKITCHPN REMODEL
Z U p
DW'L C
FZIu Dae Contractor APPLIANCES-R[51DENfIAL ❑ADDITION El PLUMBING RE-PIPE
''ran ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
Z O z I understand m Ian..shall be used us hlie records PANELS
, YP pu MODIFICATION
oz-- Up 10 O Mb AMPS
F[n.,7Iy�j Licensed Professional ❑INTERIOR ❑CHIMNEY Rl OOL
ay'7; OWNER-BUILDER DECLARATION 201-IINX)AMPS IMPROVEMENT CSWIMMING POOLS
C 4s C Q I hereby affirm that I am exempt from the Committees License Law for the OVER 100JAMPS C BATH REMODEUREPAIR ❑DEMOLITION
k01 U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county C OTHER
1+1 3 LL y which requires a permit ns construct.slag improve,demolish,or repair any arvewNS ELECCRICAI.
re SIG
f COQ prinrtr its issuance also requires the applicant hnsuch pemuuo file vsignrd swwmed SPECIAL CIRCUFEMISC.
yG� that he is licensed porsuanuo the provisions of the Commemr's License Law(Chapter 9
..00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 'HIM R MIN ER OR MILE INST. '
d p rL rico he is exempt therctrunt and the basis for the alleged exemption,Any ululation of - ❑ C NE G/ADDITION C DEMOLITION
W..y Sicilian 70315 by anynpplicant fora pematshort,the appliento n civill'enalty of POWER DEVICES 'NANT ❑FOOD SERVICE
not more than live hundred dollars($50m.EPROVHMENT�C ❑ SWIMMING POOL ELECTRIC
Las owner of thepropeny,or my empinyceswith wagesas their snlcenmpennaion,
will do the work,and the nuucmre is not intended or offered Irritate(See7] .Business COTHER
63 we and 1'mfessions Cade:The Contractors License l,aw does not apply to an owner of OUTLETS-SWITCHES-FLX URES
property who builds nr improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECJR SQ pT.
sale.If.however.the huildi ng or lmprevermad is sold within one year of completion,the SQ.FT.FLOOR ARIia VSQ.FT.
0wner-builder will have the burden of proving that ha did not build or improve for per-
nmas own.
❑1,asownerof the
ctproperty,amexclusively contracting with licensedcmrai i- 11)
mama the project(Sec.n an Business ane rry who bei ds or improHis,ves
Comrenon. Li-
whosocove vwd«snotapplyman ownerofpmpery whosedprrimpmvm Contra,and QTY. PLUMBING PF.RM1 FEE
who contrac¢forsuch projects witbacommemr(s)licensed pursuanuothe Commnor's /
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C he this reason
ALI ER-DRAIN&VENT'-WATER(EA1 VAL IATI N
Owner Date
WORKI?R'S COMPENSATION DECLARATION HACK PLOW PROTECT.DEVICE
I herehy affirm unJer penalty of perjury one of the following declarations:
C [have and will maintain aCerificam of Consent toself-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. \ Co U N
sation,as provided for by Section 37M of the IrMsr Code,for the performance of the
work for which this pit is issued. Iq%"NRFS-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section fi
3]1X1 office Libor O,de,for the performance of the work for which this permit is issued. (LAS-EA.SYSTEM-1 INC,4 OUTLETS OCC GROIO � � D APN
My Worker's It to •sin rq fucarr m'I Policy number are: �+
Carrier: a to 'y Nn: GAS-CIA.SYSTEM-OVER 4(IIA)
L'i Ll'IPICnOE OF SA If ORKIiRS' GRHASFJINDUSTRL WASTE INTF.RCEP UCR
COMPENSATION INSURANCE
(This«tion n«dnot berompletN if Nc permit isfonmehondmlJnllurslS100) INDWISI M 6 AM - -__-
orless.) GREASETRAP
PIANCHECK FEE
I certify that in the performance ofthew.6ferwhich this Permit is issued,I shall SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY ICA I Y OF CurEmi
,Z satiun Laws of Califomia.Uam
7O72 Applicant WATIiR HEATER WNIiNT/ELECfR GRADING FEE
Grj NOTICE TO APPLICAN'toIf,after making this Certificate of Exemption,you should WAgUR SYSTEM/fkBA91NG
a ; become subject m the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Lk7 forthwith comply with such provisions ,,his permit shall be deemed mvnkM. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RF_SIDF.NTIAI.PCMB. SQ ET PAIDU O l hereby alarm that them is a construction lending agency for the performance of Dae Receipt p
W the work for which this permit is issued(Sec.Inc Civ.C.)
O U Lenders Name TOTAL:
Lender's Address TO'1'A L:
y1 certify that 1 have read this applicaian and swat that the dMrve Wanton o is BUILDING FEE
Z? coned.I agree to comply with all city and county ordinances and state laws relining m QTY. MECHANICAL PERMIT FEE
U Z building constmetion,undherehy authorize representatives ofthis city to enwrupon the SEISMIC FEE
above-mentioned pmpeny for inspection purpns-
(We)agrecon. .indemmfya phemdes Ne City of Cupertino against PER ISSUANCE
ELECTRIC FE
liabilities,judgments,costs anties
de who ch ay accme against said City AL TER OR ADD TO SUCH. p1.UMBI
me asequence of rice 6ranti ns permit an
APPLIC UNDERS AND 1. PLY "H ALL.NONyOI AIR HANDLING UNI'P(f010,000CPM) MBCIIA ICAIN C
SOUk ,RT UNDT � ON
AIR HANDLING UNITIOVIHt I0,M)CFM1 CONS'1'kUCT
Kk
sere ofAppli...YContrn or Date EXHAUST HOOD OVIDUCT) HOUSING MI ION FEE
HA]ARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building«cupsms..re or handle hmandous material HEATING UNIT(TO 1011,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532m)'/ HEATING UNIT(OVER 100.000 BTU)
ElYes C]Nt PAID
VIiNI'ILAI'[ON CAN IS)NGLP.RF,SID) Date Rcci k
Will the air cicum or future building by(he Bt use equipment in devices which
emit hazardous air rnnmminunlx as defmcd by the Bay Area Air Quality Management 13011.1iR-COMP(3HI'OR IINI,000 BTU)
Disuid? TA
❑Yes [I No NOILL•R-COME(OVER I00,010 BTU)
I have mad the hazard. rials re is u r Chapwr A 95 ofths Cali- AIR CONDITIONER SU E DATE
humid Health&Safety C f m' I , mal 534.I con ersh d that if the NEW RESIDENTIAL MITCH. SQ.Ell
huildingJ«snotcum u'cut eurym mslbilitY the upant
of -quircuit mrtoi enfu CenillF
sea or auv
thoeJ ant ])airg ])air TOTAL: ISSUED BY:
OFFICE