S0064heel ICANTTO FILL IN WFORMAMN WITHIN RFn LINES. USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPIACATION/PERMIT PLUMBING- MECHANICAL.
HUII.DING PROJECT IDENTIFICATION
PERMIT NO. n n n G n
Uzi
O
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
1012 N. DE c>,1?� moo• Cv�2T�No
OWNER'S NAMIi: PHONE:
G rj �O
CONTRACTOR'S NAME: LIC NO:
ii �( /I' .J
�•Y T
NIC
❑
CONT NOL p
ARCHITECf/ENOI HR: LIC NO:
GO 20
ADDR . S:
r L&W( S 20 20
CONEACT: PHONE:
BUILDING PERMIT INFO
LDG ELECT PLUMB MECH
L -���-61�
❑ Consultant Fees Paid by Applicant(Initial)
LICENSED CONTRACTOR DECLARATION
I hereby of oto Nm I mm licensed under Pmviiami r of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOBEESCRIPTION
PERMIT ISSUANC17
APPLIANCES -RESIDENTIAL
with Section 7000) ofDivision 3 ofthe Business and Professions CWe, and my license is
I. full 1'rrce andeBey - 4,e S4,l^�
- License Class K Liep
>
1 Dam Comrvctrr
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑ MUI.TLUNIT ❑ STRUCTURAL.
MODIFICATION
E] INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
BATH REMODRF.PAIR ❑DEMOLITION
C3 OFFER
ARCHITECTS DECLARATION
I mmersmnd my plans shut] he adia public records
I Licensed Professional
OWNER -BUILDER DECLARATION
i 1 hereby union that I am exempt fmm the Convector's License Law for the
following reason. (Section 7031.5. Business and Pmfewsions CWe: Any city or county
PANELS
UPTO 2WAMI
201-1000AMPS
OVER lnM AMPSElEII
SIGNS ELECT
which requir, r. improve, demolish, or repair any structure
3 prior to its issuance, also requires We applicant for such Permit o file asigned statement
hat he is licensed pursuant m the provisions of the Contractors License Law(Clurper9(commencing with Section 70130)of Division 3 of the Business end Profeisioa Code)or
L that he is exempt therefrom uod the basis for thealleged exemption. Any suds ion of
Section 7031.5 by unyapplicum lora permit subjects theapplicant m a evil pointy of
SPECIAWIG),
'LIMP,
OMM R LAI
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[I TENANT ❑FOO #RV]CF
POWE
n not more than five hundred dollars ($500).
❑1, as owner of the property, or my employees with wages as their sole cmnpenation,
wJl Jnthe work, and the stmcwrcisnotimenJW nr nRcmdf�r salt lSec.7044. Rosiness
and Professions Cole: The Comwaors License Law, does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through-�e�\_K"T•
his own employees, provided that such improvements arc not intended or offered for
sule.IL howeveq the huildingoriinprvvememusalJ within one yemof mnplefrn.Los
IMPROVE
❑O'fH1iR
•/� �p�[�
SWIMMING PLO( M F. RIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL I..LECfR SQ IT.
SQ. 1+1'. FLOON AREA
LSQ. FT.
owner-hudder will have the burden of proving that he did not build or improve for Pat-
TOT
I, ru ownown of s
❑ er protracting with cnnwcmm i-
E]the property, l. euess
QTY. PLUMBING PERMI F.
o and :) The C
rose a the project (Seeapply o an Business and Professions builds improves The Contmmors rid
cense Low Jmsmmapply tonnnwncrnfpropeny who.ed,
at.thr Conn•and
who convuctxfor such projects with ncomracnrt(s)IlcenaeJ pursuant to the Cnnmacmrs
IA /�
Y''
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
License law.
1 am exempt under Sec. . N & P C for this reason
% , b
Vg1,UATION
owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dMker., C s:
❑ and of Wodcra Comped-
HACK FLOW PROTECT DEVICE
L]
C
S O •U�C
TYP CONSTRUCI'10.
DRAINS - I LtIOR, ROOF AREA, COND.
on, as idedfbymaintains tion 37M the Labor Code, lot the
workas provide i for by Section 37W of nM Labor CWe, for the performance of the
k bar which this pcnnin is issued.
have and will maintain Workers Compensation Insurance, as required by Section
glut the LaborCode, for the Pctiormance ofthe work for which this permit is issued.
PI%'fT1RE5 -PER TRAP
OCC. GROUP
AI
APN
GAS-FA.SYST'P.M-I INC. OUTLETS
GAS-EA.SYSTEM-OVER4(EA)
My Work In ',.ad Policy nu
Carrier: l�`rVY�LIL Il./fXs'S^ Policy No: n"s�1w ��
GREASFIINDUSTRL WASTE INTERCEPTORCOMPENSATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
BUILDING DIVISION FEES _
GREASE TRAP0
PLANCHECK FEE
(Thissection needrimbecompleted ifthepemtitlsforonehundrWdollms(SIW)
r leas)
I certify thimmine perfsmanceofthe work for which this pe.if is issued. I shalt
not employ any person in any manner so as to become nobject m the Workers' Comed- p
SEWER -SANITARY -STORM EA. 200 FT'
7A
ENERGY TEExx
WATER HEATER WIVEN'LELECIR
GRADING P[C
SOILS FEE
F ...inn Laws of California. ]late
7
Applicant
NOTICE TO APPLICANT-. If. after making Nis Certificate of Cxempnion, you should
become subject m the Worker's Compensation f the Labor Code, you must
i rK ermit math
faahwith comply with such provisions or permit shall he deemed revoked.
WATER SYS'fEMIIREATING'
WATER SERVICE.
CONaITONLI?NDINGAGENCY
is ann that ere is construction lending agency for the Performance of
Iherehy off race
the work for which this permit is issued (See. 31197, Civ. C)
PAID
Ilam eceipnM
NEW RESIDENTIALPI,MB. SQ. FT.
TOTAL:
TOTAL, :
Lender's Name
`) Lenders Addrcs V
BUILDING
SEISMIC • 7�
y1 codify that I have read this applicmion and smelled the aMrve information is
A correct,IagreeIncomplywithallcityenitcountynobiancesaadsmtelawsretmingto
Z building construction, and hereby amhorim representatives of this city m enter upon 'he
abase-memioneJ property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgmems.towns and expire. which may in any way iceme against said City
QTY. MECHANICAL PERMIT FEE
PERM IT ISSUANCE
ALTER OR ADDTO MECH.
ELECTR •F.E
PLUMBING fE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNET TO I0.00(i
MECHANICA FEE
SOURCERFAULAT12NS.
/� [/
r/AnUY(Co�mred�/ N9T,
AIN HANDLING UNIT (OVER IU,g10 CFT1)
CONSTRU ON TAX
Sngnat\ddra[ff` U
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building recupom More or handle hanardois rof
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Crude. Section 25532(x)' -
EXHAUST HOOD (WIDGET)
HOUSING TION FEE
HEATING UNIT TO 10.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESIDE
❑Yes 1�s'o
PAID
-D.lc timid
'
Will the applicant or future building occup rl use equipment or devices which
emit Incautious mr romaminants as defend by the Bay Area Air Quality Management
BOILER - COMP EHP OR 1000M BTU)
DT
BOILER- COMP (OVER 10,000 BT U)
District' y�%" F'] No
AIR CONDITIONER
ISSUAN E DATE
Y\
I have read the hazardous materials requireine m, under Chapter fi 95 of the Ceti-
NEW RFSIDEN'TIAL MECH. SQ. ET.
forma Health & Sanely CWe, Sections 25505, 25533 aM 25534.1 mWerswnd Nat if the
building dresnm curtenlly vcarenant, the' smyr risibility m notify tM occupant
of the require ewhi un be and p' n ofaC nf,14a a ata
A 1
ISSUED BY:
TOTAL:
Uwnern uth gem ate
UI -rice