B 0617 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FLECTRICAU PERMIT NO.
RUIhDING DIVISIONAPPLICATION/PEC.000`RMIT PLUMBING-MECHANICAL. 11Go� ,7
BUILDING PROJECT IDENTIFICATION `�
BUILDING ADDRESS: n' •�,.,�,�, D C05x,/ 4::
NITARY NO. APPIACATION SUB%II1TAL DATE
(IWNER'S NA L I10NP, CONTRACTOR'SNAME: LI
C a ea Qy .� CONTROLp
VwIl ARCH ECT/ENGINEER: V LIC NOZI �A DRGSS: oCONTACT: � PUONE: BUILDING PERMITINFO
�� p �1/ Consultant Fees Paid by Applicant(Initial) BL❑UG ELECT_ PLU❑h18 h11"OCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE LJw�
ace, I hereby affirm that 1 am licensed under provisions of Chapter 9 be torturing JOB DESCRIPTION
moo wanSection 70f10)of Decision 3ofthe Rminesand Pmfexsions Ced,and my becro,w PERMIT ISSUANCE RESIDENTIAL:
F es_ in full lbrceand effect. 0SFUWI, ❑KITCHENREMODEL
='UF Leame Caox Um.W
6 V APPLIANCES-RESIDENTIAL ❑ADDITION ❑PIIIMBINGRE-PIPE
vFi Q L Date Cam actor
F'q ARCIIITECr'S DECLARATION PANELS ❑MULTI-UNrr ❑Sl'RUCTURAU
m'Z 1 undenl:md my plan,shall bed ax usepublic mcord MODIFICATIONOZ�� UPTO200AMPS ❑INTERIOR []CHIMNEY REPAIR
F.~41 LiceneN Ptdessional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDIiR DECLARATION OVER 1000 AMPS ❑BATH REMODE;LREPAIR El DEMOLITION
q w d 1 heathy affirm that 1 am exempt from the Contractor's License Law for the x 3 L V following reason.(Section 7031.5,Business and Pmms fessioCode:Any eery nr enmity SIGNS ELEC'1'RICAI. [:I OTHER
W LL vFai which requires a permit to construct,alter,improve,demolish or¢pair any stmmum
F-LLOJ
poor to itsalso 9 the applicant for such Permit tfile a signed statement SPECIAL Cl RCUI VMISC.
w0c aha 1 Jp u N p fIh C u I r.L Law(Chapler9
Wftp0 fsonmcneingw'ih Secton](Xq)ufDiision3ofthe Bu'nc.aandP (:ionsCode)or TE-MIR.METER OR POLE INST. -OMS AS
a.p,2, that he is exempt themfmm tend the basis for the alleged exemption.Any solation of ❑NEW BLDG/ADDI'I ION ❑DEMOLITION
W..y Seelion 7031.5 by any applicant for a proud subjects lite applicant to acivil pewlly of POwCft DEVICES ElTENANT ❑FOOD SERVICE
not...,ban five hundred dollars 15110).
IMPROVEMEN 1'
6 0Laxowmerof the pm pengormyemntended oroffegesmlhei(See70n.nosiness SWIMMING POOL.ELECT
will do thewons nails The
isnot intended I-me doesmd r sale ntapplao an nosiness of ❑OTHIiR
63 m and Professions Cade:The Cantmcror's License law Jas not apply to an owner of OUTLETS-SWITCHGS-PIX'NRES
property who builds or improves thereon,and who does such work himself or through Q
his own employees,prnvided that such improvement,are not intended or offered for NEW RESIDEN 1AU ELECIR SQ FT
sale.If.however.the building or improvement is sold situatone yearofcompletion,the I%& FE . ORA .A / FT,
owner builder will have the burden of proving that he did not build of improve for put,fsale). �pq 2 4199
8'I,ax owner oLno propvd,are cacl000rly contracting with licensed contractors m 'rf 1: O Y
consumer U the es not (Sec.own.*neinof ad fay who buion%lds
ds or i The Contractor and
erose Lawds for such
plyman with
a cofpmpcny whored paresimpmvice thereon,and QTY PLUMBING PERMIT FEE
who contracts far such projuts with a nmtmemr(s)licensed pursmm to the Contnaor's f�
License Lw. PERMIT ISSUANCE By
6 I am exempt under: ,B&P C for this mason
Owner Date ACIER-BRAIN&VFMr-WAT A) VAI.UATION
3 ON DECLARATION BACK FLOW PROTLLT DEVICE
I herthy vff sounder penuh dpdo oncof alio lizllowing declwntions
•❑Hcocand will maintain a Certificate of Comentto self-ii,am for Worker's Comped- DRAINS-FLOOR.ROOF.AREA,GOND. S"IORI[S TYPE CONS'I'RUCI'ION
satmn.as pravided for by Section 37M of the Lahr Cade.for the performance of the
work for which This permit is issued FIXTURES-PER 9"RAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of the Labor Cole.lin the Nrformureeof the work for which this gemmOx issued. GAS-ITA.SYSTEM-I INC.J OUThIffS FICC.GROUT' MIN
My Worker's Compensation Insurance carrier and Policy number are:
Carries Policy No: GAS-F.A.SYSTEM-OVER q(EA)
CERTIFICA)'E OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTR.WASTE INTERCEPTOR
('Otis section aced not beatmpleed if the permit is fnrouc bnndred collars(81!)1 XBUILDING DIVISION FEES
or less.) GREASE TRAP PI.ANCHECK FEE
I certify that in the performance of he work for which his permit is issued,[Quell SEWER-SANITARY-STORM EA.200 FT.
nal employ any Nomer in any manner m as o become subject o the Workers'Comped- ENERGY EEE.
O Z cation Ltwa of California.Doc WATER HEATER W/VENT/ELECTR
Z 2 Applicant f GRADING FEE
h
NOTICE TO APPIACANT:IL after making Ibis Certificate of Exemption,you should WATER SYSTENI/IREATING
a ; hcrome object Io the Workers Compcn,mum provisions of the labor Cade,you must SOILS PEE
fonhwilh comply with such prokions or this p mat shall be deemed revoked WATER SERVICE.
UO CONSTRUCTION LENDING AGIiNCY NEW RESIDENTIAL PLh1 B. SQ.FT PAID
I hereby affirm that there is a ronsrunion lending agency for the performance of Wttle Rccaiplp
F the work for which this permit is issued(Sec.3091,Civ.C.)
O U Lender's Name rVTOTAL:
C[1 bender's Address TOTAL.:
1 cetify that I have read this application and sate the,the above information is BUILDING FEE
fail cozma.l agmcm comply with all city unJ anmty ordinances and stem laws rclatingm QTY. MECHANICAL PERMIT FEE
V Z building consimelme,and hereby amhafizC representatives of this city menterupnt the PERMIT ISSUANCE SEISMIC FE
above-mentioned pmpcny for inspection purposes'
(We)agree to star,indemnify and keep homeless the City of Cupemm against ELECTRIC 1 F.
liahilltia,juJSrMnlM1 costa and expenses which may in any way accrue against said City ALTER OR ADDTO MUCH.
in asequence of the granting of this permit. PLUMBING FLVE
APPLICANT UDI ERSTANDS FjnYGLL COMPLY WITH A L NON-POINT A[It HANDLING UNIT(TO IU.WII CFM) / O
MECHANICAL FI7E
SOURCE REG ILL M r� r
AIR HANDLING UNIT(OVER I0.000 CEM) CONSTRUCTION TAX
Signamre App manVConl ten ate EXHAUST HOOD OGDUCD HOUSING MITIGATION DEE
HAZARDOUS MATERIALS DISCLOSURE
7111 the applicant or form building acuparn.antic ar h:mdlc hazardous material (� HEATING UNIT IT 0 100.0s)BTU) 2 Q
m defined by the Cupertino Municipal Calc,Chapter 9.12,nail the Ilathh and iodf,
Cale.Section 25532(a)? ( HEATING UNIT(OVER 11X1,100 BTU)
0 Ye. VENTILATION PAN(S[NGLE RESID) PAID
Will the applicant or future building mention use equipment or devices which Date Receipt p
mil hazardous air contaminants its defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
IOTA[,:
Distic1 ,..,/ BOILER-CONI P(OV ER I OLL000 BTU)
Yes gnu
I have read the nazallons materials¢ Is under Cleter 6.95 of the Cali- AIR CONDITIONER
forr825533 a p ISSUANCE DATE
Whiff Health R Safety Code,Balloon 25505,is my and 255311 understand ih:u if Il1e NEW RESIDENTIAL NIECE. SQ.FT (�
building atm catmnanl.that it is my lesponsihilitymmtifyle cupanl
of the requi he met pilar m issuance ofa Cc ' of a y.
Owact IDxPcj TOT C ISSUEDBY-
OFFICE