S 0421 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'I'RICA]. PERMIT NO. A(Ai/a/�11
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S O'TLi
BUILDING PROIECTIDEN'1'IFICATION
BUILDING ADDRESS: SANITARY N(1. APPLICATEON SUBMITTAL DATE'
[9 'S NAMEi _ , �I� 404 y CONTRACTORS NAME: LIC NO:
K L��+1�1 C�/t/E NIC CONTROL#
A7t(,'yyT 7MIENGINEF,R: LIC NO ADDRESS: ❑
COKKNIILLTAAACf: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I ELIC) PLUMB MECII
LICENSED CONTRACT ORS DECLARATION QTY ELECTRIC PERMIT FEE }�.a ❑
I hereby of,.Ilam 1 am licensed under provistons of Chapter 9(commencing JOB DESCRIPTION
Cmz with s«tion 7000)af Division 3nRnc Business and Professions Ctdc,and mylicen.c i, RESIDENTIAL:
ADO in PERMIT ISSUANCE
F-ty� lull lima and et= ❑SFDWL ❑KITCHEN RIiA10DIiL
aUU License a Link APPLIANCES-REsikid: 'UAL DITION Ll PLUMBING RE-1'11'17
F+a LLI Unlc Cnnl�uclnL
F-Dy ARCHITF,CTS DDCLARAT[Osell PANELS MULTI-UNIT [I STRUCTURAL
Z O H z 1 understand my plans,hall focused republic me 1, MODIFICATION
OZ�O UP T02(01 AA1PS ❑INTERIOR C1 CHIMNEY REPAIR
FQ•So17m Licensed Professional 201.1010AMPS IMPROVEMENT E)SWIMMING POOLS
CY SM' OWNER-BUILDER DECLARATION OVER I(NN)AMI'S ❑BATH REMODFiUREPAIR ❑DEMGI.Iq'[ON
%W, 1 hereby affimt thin I ant exempt from the Cuntmmor's License Law fur the
C W Q following reason,(Section 703 1S,Business and Profession Code Any any or county SIGNS F.LEC'CRICAL D OTHER
ul u.F.
� which restrict,a permit m construct,after alterwalnut demolish rc or mpair any slowtu
FS P.
to prior to its issuance,also requires the applicant lot such permit to file a signal statement SPECIA L CI RCUILMISC.
f.y Not he is licensed pursuant m
to the pv,roneol'the Conaarow,License Law(Chapter9
�aC,00 (commencing wins Section 70(mpd Division 3ofthe Business and Profession,Code)or 'TEMP.ME TER OR POLE I NST. COMMERCIAL:
C.
y o a that he is exempt therefrom and the basis for the alleged uxamption.Any viWmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
n Section 7031,5 by any applicant for a permit subjects the applicant as a civil penalty of POWER DEVICES
u]•-tn ' ❑TENANT ❑FOOD SERVICE
ret marc than five hundred dollars(ES W).
IMPROVEMENT
p=Q Los owner nRhe propny.onny employees with wages as theirmle compcnsminn. SWIMMING POOL ELECTRIC
2 F� will do the work.and the snocture is not mmeJed eroffered f...le(Set.7(A1,Business ❑OTHER
G3 m and Professions Code'.The Contractor's License Law does not apply m an owner of OUfLE'CS-SWI'1'Ck1E5-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements am not intended or offend for NEW RESI DENTIA(.ELECIR SQ FT.
sale ll.however,the buildi ng or improvement is sold within one year of completion,'he SQ.FI'.FLOOR AREA S/SQ.En
mi-builder will have the burden of proving that he did not build or improve for par- 1
past,of role.).
❑1,as owner of the property,am exclu oily contracting with licensed comrecon,to 'TOTAL'
instruct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
s,Law does not apply to an owner of property who battles or improves thereon,and QTY. PLUMBING PERMIT FEF,
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
I] I oro attempt under See ,B&PC for lhon, on
Owner Dae ALI FR-DRAIN&VENT-WATER(17A VALUATION
WORKER:SCOMI'ENSATION DECLARAHON HACK FLAW PROTECT.DHVIC�
I 1 y
I hereby affirm under penalty of pegury nuc of the hollowing declarations: ` `��
❑I have and will maintain a Cenificatc of Consent to self-insure for Worker's Cmnpcn- DRAINS-h R'
cation,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES 'CYPE CONS'I'RUCUW
work for which this permit is issued. Fl IAV
❑I have and will amintaiit WorkerLs Compemaion Insurance,as required by Section
3700ofthe Lahm Core,Podia pedorntanecol life work l'or which Nit is i s permissued, OA. -EA.SY ' v I� S DEC.GROUT' APN
My Worker's Compensmlon Insurance carrier and Policy nmnhcr arc:
Carrier: Policy No.: GAS EA.SYS :M-OVER i(EAG
CEKIIFICATE OF EXEMPTION FROM WORKERS'
COMP12NSNTEON INSURANCE GREA I%IN 5'1'RL WA. R
IThissection need not Be comported tribe permit is for one hundred dollars is I Oq BUILDING IIIV ISI NFEIS
or less.) GREA PLANCHECK TEE
Loy any thatin0u any mouance roOhe work for subjech ct to
Permit the WrkersuComfi ll SEWER-SANITARY-STORM EA.200 FC.
act employ any Perron in any munneno t esubjecnotM worked Compere- ENERGYFEE
n
Z mtlon Iawno alilorniu. >v. 4
z 0 A licant N'ATlik IIEATIik W'NGNT/ELECTK
pp f� GRADING ILP
y N(YI'ICF.'f0 APPLE NT:IL after mnkrng Otis Ccnific:ne of lixornptinn,you should
WATER SYSTEM/IREATING
a ; become subject to the Worker's Comperemime provisoaas of the Labor Cafe,yam const SOILS FEE
W forthwith comply with such pmsemouor this permit shall be deemed revoked. WATER SERVICE
a �
.7z CONSTRUCTION NLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FTI PAID RU
UQ work
ewhichly thi lbarman isisued( ee309cnding agency ler the(urmnnanceol' ate Receipts
the work for which this permit is issued(See 3097.Civ.CJ
O U Lenders Name TOTAL:
Lcud r',AJdnss TOTAI.:
Hy I certify thin 1 have read this application ani ,are that the stave Information is BUILDING FBE h
h correct.I agree to comply with all city tend countyordinanaes and stale lawseeladng to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby Truthnrim represemmives of this city to enter upon the SEISMIC FEE
alave-ntennoocd poiNny for inspection proposes. PERMIT ISSUANCEi
(We)agree to save,indemnily and keep hurmle.ss Ne City of Cupertino against ELEGI RIC FIiF,
Iiahilitics.judgmenq coax and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in consequence orlhe granting of this permit. PLUMBING ITEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0111 CFM)
t SOURCES REGULATIONS. ///k MI?CHANICAL FEE
I^' �+/�/,, AIR EIANDLING UNITIOVP.R I0.gNI CFM) CONS'TRUCr10N TAX
Signmum of Appl /Contractor "'��Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO\FEE
HA7/ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some arhandlcheacolons material HEATING UNIT(TO 10),0013'1'U)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 HEATING UNIT(OVER 101010 BTU(
❑Yes fU'No
VENTILATION FAN(SINGLE RESID) PAID -
Date Receipt
Will the air commentators
mtaor future clefired occupantuseCquipmcntor Mminswhich BOILER-COMP DKP OR 100.001 BTU
mit crzaNnus air conmminants as JefnW by the Hay Arca Air Quality Managcmcnt ) TU 1'AL:
District!
Yrs RYIOo BOILER-COMP(OVER 100.000 RTU)
have mad the hmuNao,amends - is under Chapter 6.95 of the Cali- AIR CONDITIONER
n.25533n p ` ISS CF LATE n y
fumia Health&Safety toy ba Sections.that i.25531 and 25531.1 u unit a ohm if the NEW RESIDENTIAL MECH. SQ.FT �•'IL //
building dtcs not currently hove a anent.Not it is my rtsponsibilily m notify the acupam
of rhe term",which mol Ne are prior to iss ,Ola Cend-13f k
64 1 A25
Uwncroriuthorised gent are TOTAL- ISSUED BN. D/J` 9 ,I e
OFFICE