B0439 fR'S
NITTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CvPF:RTINO BUILDING-ELECTRICAL PERMIT NO. /I A
NG DIVISION APPLICATIONIPERMIT PLulMnmc-MEcxgNlcAl S0001 �O4 9
BUILDING PROJECT IDENTIFICATION
DDRESS: SANITARY NO. APPLICATION SUBMITTAL MTI
AME: PHONIi: CONTRACT RS NAME: LIC NO:l . Tn �v r G p3 NICfONTROLN
2!JGINEER: LIC NO: ADDRILSS'. ❑
�Tsu NAL
�QZ S
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB h1ECH
G3' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing
06'Z with Sedion'/000)of UivizionJ of the Business and Pndessioru Cook,and myliwnu is R SIF EN•IN TAC:
WOO PERMIT ISSUANCE
F1_ in full force and,.eIt ❑SFDWL ❑KITCHEN REMODEL
%ut Llcensc Cl'." ;ft-Az Ric.N APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBINGRE-PIPE
�
Pzw Date2 x3Lm Cotlmemr
enQ6 ❑MULTI-UNIT [I STRUCTURAL
.>y AR ARCHITECT'S DECLARATION PANELS
,�,� 1 understand my plans shall W used as public rccoMs MODIFICATION
o.zr M UPT02(%TAMPS
7-0
❑INTERIOR El CHIMNEY REPAIR
F•�f'{�4 Licensed Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER late AMPS ❑BATH RESIODDEELITEPAIR (]DEMOLITION
1 hereby affirm that 1 am exempt from the Coatrooms License Law for the ❑OTHER 5E//L +a�
0 �IST�H
o�yx O V following reason.(Section](D I.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W�+ F' which requires a permit to consumer,alter,improve,demolish,or repair any swctute 7
F-.- prior to its issuance,alm requires the applicant for such pcnnit 1.file.signed xmemem SPECIAL CIRCUITIMI$C.
;vW!�JN
that he is licensed proranuo the provisions of rhe Coatmdors license Law(Chapter 9
W C (commencingwllh Secdbn]1XX))of Divisinn3ofthe Business and Professions Codel« TIiMP.METER OR I'(JLE(NST. COMMERCIAL;
ccs:cy Nat he is exempt therefrom vad the basis far the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
X m_4 Section]OJLS by any applicant for a permit subjems floc. to a civil praney of POWER DEVICES �'TENpNT ❑FOOD SERVICE
�ZN not more than five hundred dollar($NX). IMPROVEMENT
C [ Las owearofthe property,or my employees with wugesn,dreir sole compensation, SWIMMING POOL ELECTRIC ❑ THER
willJmhe work,and are structure is not intended oroRcrd forsole(Sec.](44,Business � O
L 3 and Professions Cale:The Coatracui License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES X !tel' •r I H+
,.pony who builds or Improv..thereon,and who does such work himself or tonight
his we employees,provided chat such improvements ore nor intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
see.If.however,the building or improvement is sold within one year ecompletion,the 'I 'PT 171 01b Y A
obuilder will have the burden of proving Nat he did not build or improve for Dur- LSL ! I U U
�mrof sale.). ;C
E]1,as owner of the property,am exclusively contractingO with licensed contractors ns T r 7 AY 0 4 199
common the project(Sm.]DN,Business and Professions Cei The Contactorpg
Contactors Li. !.r r
cense Law dmnor apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Itll
who commets for such projects with a commemr(s)licensed pussosnt to the Contractors
License Laa,. PERMIT ISSUANCE
❑1 am esempr under Sec. .B&P C far this reawn �sl
ALTER-DRAIN&VENT-WA 1
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIC D O
1 hereby ill mai under pcaalry oeperjury one o self following declinations:
❑Ihuvc and pravidl maintainsCertificate of theeafloCode,fonder Worker's Compem DRAINS-FLOOR.ROOF,AREA,COND, STORIE. TYPE GONSDtDCTIDI
tion.as which
frJ for mi Section 3700 of the Labor Code,for the perfnvnmce of
(aprk for which Nis,across is issued. FIXTURIi.S-PER TRAP
rLl'CS.h r and will maintain Workers Compensation Insurance.as require)by Section
J](Xl of th LeWr Gde.fonhe performance o(the work for which this psrmit is issued. GAS-EA.SYSTEM-I INC.i OUTLETS txC.GROUP / rA�NN
My
CarrWieor.rk � ineatln vameand Policy
GAS-PA.SYSTEM-OVERJ(PAT
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEgNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Gbrl s«rionteed not be completed ally,permit is for one hundred dollars(it INP1QTY. MECHANICA1.FPERMITFHE
RAP Martless.) I'LANCHEI enaifythat inthe paffonnmttofthe.,akfimold,hdri,pernot isisowL Is bullANITARY-STORM EA.2W FLnot employ any person in any manners ns ] suhjem m the Worker'Cmoen, ENERGY OZcation Laws of Ceh ate re ATER WIVEN'1'IELGCTR GRADINGzO Applicant • /L aftermaking 's CertificateofExemption,you should $TEM R VrTING SOILS FEh«nme subjecl m the Workers Comprmation provisions of the Labor Gale,you mustforthwith comply with such provisions or this perit shall W doomed revoked. RVICE ('AIDCONSTRUCTION LENDING AGENCY IDENTIAL PLMB. SQ.14.(JI hereby affirm thatthere is n conswerion lending agency forthe performance ofUF the work far which this permit is issued(See 3MI,Cie C.)
OU Lenders Name
U Lenders Address TOTAL
1m 1 certify that I have read this application and state thin rhe above information is IL 1 G FEE P
pal correct.l agree to comply with all city and co only indicates,and state laws relaying toMECHANICA1.PERMIT FEEFIiF 0U7, building construction.anal hereby authorize mpmsenmtives of this city m enter upon theaWvenmcrarmaJ property for inspuninn purposes. SSUANCE F. IC IEE
I We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenms which may in any way meme against said City ALTER OR ADD TO MECH. PI.0 BING FEE
in nmaegaenre of the gormar,of 's permit.
APP( UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO RL000CFM) ME ANICAL FEE
$ CE .'ULATIONS.
AIR HANDLING UNIT(OVER IO,tXlOCFM) CONST CTION TAX
g umof Applican b a Uate 414 EXHAUST HOLD(W/DUCD HOUSING ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE _
WIINeappllcasn a furore buildingnemporommeralrndle huznrdousmmenal HEATING UNIT(101W,00)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.U2,and the Health and Safety HEATING UNIT(OVER 100.(KKJ BIVI
Cade,Sc 25532(e71
WWI C1 No VENTILATION PAN(SINGLE RESID) PAID
Date Raeipyg
Will N<upplicanwr(vturc building«cupam use equipment or devices which BOILIiR-COMP(JHPOR 11X1,000 BTU)
cony h zaNnns air more rants us de0ned by the Say Area Air Quality Management TOTAL:
District, BOILER-COMP(OVER H 0,000 BTU)
Des ]No
IhavemaJ rhe hum.:Mous m:uenuls requircnmms under Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
Poria Health&Safety Cale,Sections 25505,25533 and 25574.I understand that ache NEW RESIDENTIAL MECH. SQ.UT
Wil ' rcutren0y ha vent,Nat it is my responsibiliry to nmify Ne«mpmt
ate TOTAL' I
e requcesmems ichm t 'a ro issuance of u Cen'ficales tpanry.
e or euthori ag t f(��,.- DSSUED BY:
OFFICE