S 0752 APPI.ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY PFy\�41P NO.
CITPOF CUPERTINO BUILDING-ELECTRICAL V 075.2
BUILDING DIVISION APPLICATION/PERMIT PLUS1FID G-MECHANICAL. J
BUILDING PMUJECP IDE:NI'IMCATION
SANI'IARV NO. APPLICATION SUBA11'PI'AL DA'1"
BUILDING ADDRESS:
OWNERS NAME: 'HON@ CONTRACTOR'S NAM ' LIC NO'. NIC COWPROL#
'ARCIIJTF.CDENGINFER LIC NO: ADORES: ❑
130-1
�1
CON'PACT. PHONE: BUILDING PERMITINFO
V�� a ❑ Consultant Fees Paid by Applicant(Initial) SLUG ELECT PLUMB MECIt
❑ ❑ ❑ ❑
LICENSED CDNTRACTOKSDIiCL.ARAIJUN QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that L am licensed under provisions of Chapter 9(commencing
aa'Z conn Semiom 9fAM))of OWia;on5onne eaninenn and Profeaaion code.and my Eea:m Tit RESIDENTIAL
FacS in full fnrcea^d affw f I'IiRMLT ISSUANCE. 0gT)WI O KITCHEN REMODEL
WU~ License Class C• I/) Lic.p—OqC- APPLIANCES-RESIDENTIAL. ❑ADDITION OPLUMBING RI PIPE
a~i G i Date l9. �17 / 4 7 Contractor D Salim UNI'r 0 STRUCTURAL.
ARCHITECTS D[CLARATION PANELS MODIFICATION
Z FO ti Z I understand my plans shall be ural us public rttnrds
OZt3pp UP'1'0200AMP5 Z �Q )INTERIOR O CHIMNEY R17PAIR
;:4in LimnscA Professional 4111-I(NXIAMPS IMPIROVF,MENT E]SWIMMING POOLS
�ad ? m thin o
OWNER-BUILDIE DECLARXI'ION OVER H)A AMPS O BAHT RHMODEURCPAIR D DEMOLiHON
'� I herchy affirI am¢ mit Ikota the contractor',License Law I...'an ❑(YfHIEIt
O ty U fallowing reason.(Section 90515,Business Imd Pndcsslors Cada Any city or eomay SIGNS ELECTRICAL.
which requites a permit to corturc alter,impmvc,demolish,ar repuir any structure
Fq.LL.O J primlohsissuance,hbo reyuirest icto,icant lbrrvch perminn file a soared.statement SPECIAL CIRCUIT/MISC.
d y that he is licensed pursuant to the provisions nil the Contractor's License Law(Choptero COMMERCIAL;
W�00 (commencing with Seance 7000)ofGo,ision 3 of the Business and Ppfeseloos Cade)nr TEMP.MEER OR POLE INS'('.
116x a thea he is¢ramp,therefmm and the basis for the alleged conniption.Any vinlainto of 0 NEW BLDG/ADDITION 0 DEMOLITION
Wim Section 9011.5 by any applicant for u permiimbpon,the applicant to a civil Penalty of POWER DEVICES (],1"ANT OFOOD SERVICE
nm mom than five hundred dollen 145001. IMPROVEMENT
=O Di.as ownerof the prnpeny,or my empinyecs with wages us aM1eir sole comp¢marina, SWIMMING POOL ELF,CTRIC
CC2 Col HER
willdothewmic,andthestmnurc is not intendedorolfered formle(Sec.]OW,Business
and Professions Cade:The Contractor's Liccnsc Law does not apply to an owner of OUTLETS-SWITCHES-l)1%'IVRF.S
property who builds m improves(hereon,and who docs such work himself err through NEW RESIDENTIAL ELECfR S
bis own employees,provided shat such improvcmouts are sat intended or offered for SQ.IT.FLOOR AREA VSQ.IT.
safe.IL hawcver,the building or impmvemmn is sold within one year of completion,the
enhuildar,will have the burden of paving that faint not build or improve far pact
"000fsale.). T 'AL: /
0 I,as owner of the properly,am exeluovely contracting with licensed corroarn is no
connounual the project(Sec.9034,Business and Professions Code:)The Contraetol Li- C
se EI
cenlaw does not apply to an owner of propcny who builds or immrc
ps thereon.and QTY. PLUMBING PI7RMIT FEE y�1
whit contracts for such projects with a contractions)licensed putsuanno Ne Comment's
License law. PERMIT ISSUANCE DEC
0 I am eacmpt under Sec. .B&P C fill this reason
- ALTER-DRAIN&VENT-WATER(13AI VALU
Owner Date
.• WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE Oi
I hereby alRran under penalty of perjury one of the following declarations:
O l have and will maintain a Cenificure of Comenno self-insure for Worker's Compete DRAINS-FLOOR.ROOF,AREA.COND. STORIES N9'Bl1CT10
,roan,m Provided for by Section 170(1 of the Labor Cola,for the performance of the
work for which this permit is issued. FIX'PURES-PER TRAP
Z I have and will maintain Worker's Qegensation Insurance,as required by Section
1700afthe Labor Cale,for the perfnnnummof tat work for rwhhich this permit is ixsucd, CAS-BA.SYSTEM-I INC.401)1'LE9ti OC'C.CROUP AI'N
My Work i.sOmpetyte.th,I amr,micrPullcy NoyA14111 I sea Z� GAS-EA.SYSTEM-OVI;IR 4 WA)
Carrier. —- inmi
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFIiNDUSTRL WAST(?INTIiRCIIV]nR
COMPENSATION INSURANCE BUILDING DIVISION FEIS
(This sredonneed not he completed ifthc permit is Torose hundred Jellars($100) GREASETRAP
Pf.ANCiiIiCK FIJI
ar lens.)
Loy on,prom
the performancenfthe work far which thispermitis mIltio- SEWER-SANITARY-S'i'ORM EA.30(1 FT.
not employ any perso y manse u.m b come s b'ecua @e Workeri Cnmpen- - ENERGY FtiE
ZZ cppMam caf Cal' am - WATER HEATER WNENT/ELECTR GRADING FEF.
to NOTICE TO APE L AT,If,site ma:u ug this Can a of Exemption,ymt should WATER SYSTEMaREATING SOILS FEE
4 teennmtian p
s subject to the Workers ComPemvisirns of the Labor Codc,you most
ai sem. forthwith comply with such prnvhiri this permit shall be deemed revoked. WATER SERVICE
Q
CON59RIJC'DON LENDING AGENCY NEW RIiSIDENTIAI.PLMB. SQ.<T. ('AID
I herebyaffrm that there is a amstmctlon lending agency for the performance of Dom Recaiplp
W F the work for which this permit is issued(Sec.3097,Civ.C.)
TOTAL:
rs Name
V danders Addrcxs TOTAL:
y1 certify that I base read this application and state that the above information is BUILDING PEE
h cancel.l agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICALPERMIT FEE SEISMIC FEE
V Z building construction.and hereby authorize represeemser of this city to enter upon the
ahove-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE 7,70
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiooi lilies,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MSCI I. PLUMBING FEE
in consequence ofthe granting to perntit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'010.00I CFM) MECHANICAL[:HE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVEI<111,000 CFM] CONSI RUC'I ION TAX
Signature of Applica /Contrucor Done EXHAUST HOOD(W/UUC'L) HOUSING MI'I'IOATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr,future milling occupant alone or handle functions material IMATING UNIT(TO Ifli 1111)
as defined by the Cupertino Manicipul Cale,Chupmr 9.12,end the Health and Safety HEAPING UNIT(OVER 100,00)BTI)
Code,Stenon 25512(apf
E3 Yes C]No VENTILATION FAN(SINGLE RUSID) PAID part ReceiPtg
_ Will the applicant or tenure building occupant use equipment or dee ices which� BOILER-COMP(3HP OR 1(IO,INIII NTLI)emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Diarict4
BOILER-COME(OVER I00,(KK)BTU)
❑Yes ❑Nn
(have newt the hazadnus nwterinln rcyuirenanu under Chapter 6.95 ofthu Cnli AIR CONDITIONEISSUANCEDATE
furniu Ile lth&Safety Cale,Sections 255(5,25511 and 25514.L understand that if aha NEW RF,SIDENUAL MECH, SQ.FT. / Z )^'1 --IV/;7
b^ildrag does not currently have a annual That it only resfxmsibility to ratify the occupant
nfther-,Ohmemswhieh munbe into prior n:ixsnance nfu Cenificme of Occupancy. s� Tam
Owner or amhnluJ agent Dam
TOTAL: ISSUED BY:
OFFICE