B 0656 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LKCFRICAL 1 /��7 PERMIT D. �pp
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOO0�
BUILDING PROJECT IDIUM IFICATION
BUILDINGADDRTSS: SANITARY NO. APPLICATION SUBMITTAL DATE
%O(o ,C61-70Al WAY CuP64 7-1 A-) o
PER'S NAME: 'P`HONE: CONTRACTOR'S NAME: LIC NO:
STS✓E N S�/i'L I (FUp -/} NIC CONTROL Is
LIC NO: ADDRESS: ❑ Q O
oNTAeTCe: J PHONE: EUILLECT PERMIT'Edro
B
G'CQ/� El Fees Paid by Applicant(Initial) BLDG ELECT PLUMBAfECIi
LICENSED CONI RAM OR:S DECLARATION QTY ELECTRIC PERMIT FEE
I haft.e m that I am licensed under provisions of chapter 9lbpttlmenchlg JOB DESCRIPTION
WQZ with Secllen 7")ofDivision 3ofthe Business Professions Code.and my license is RF'1)F
wt PERMIT ISSIIANCG
F-ly� in farce and elite, / 36 'SFUWI. ❑KITCHEN REMODEL
FiI U U License Clan. Lic.N
yZW Date Commcmr ES
APPLIANC -RESIDIENTIAL ❑AUDITION CI PLUMBING REPIPE
ARCHITECTS DECLARATION ❑MUCI'1-UNIT' ❑S9'RUCTURAI,
ZOyZ I umdersmmJni,plans shall heu.ved as public redual PANELS .�.y� MODIFICATION
OZ.-, I UPT0200AMPS �. r_ 0INTERIOR ❑CHIMNEY REPAIR
HJ J Incensed Professnmal 201.1000AMPS IMPROVEMENT 0SWI M M ING POOLS
.H4J OWNER-BUILDER DECLARATION OVER 10(10 AMPS ❑BATH REMODEUREPNR �DEMOLITION
1 hereby.Item ed 1 am exempt front the Comrucmrs License taw for the
3 W F fallowing ind,. (Nation]03,5.Business and Thnfessions Cade Any city or county SIGNS ELECTRICAL ❑OTHER
which inquires a permit m amdrec,.Iter,improve,demolish•or repair any amclure
��c5 prim"its kapir,n,also requires the applicant lormch pemtit to file a signedstatemem SPECIAL CIRCUI
E�} that he is licensed pursuart to the provisions ofthe Conuacmrs License Law(Chapter 9
W CMC) (commencing widiSection7000)uf Division 3 ofthe Businessand Profession Coale)or TEMP.METER OR L COMMERCIAL:
that he is exempt therefrom and the basis for Ibu alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLIPION
W-y
Section 7031.5 by any optical for a permit subjects the applicant it)a civil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICEFZ} n�otJW're than five hundred do[].(S500). IMPROVEMENT
Ir�l,aaowner of the property,nr my employee.,with wages as theiranle eompansmion, SWIMMING POOL ELECTRIC
ITT,2 will do0c work,mod lhexuucamena t inmodedoro0cmd formle(See]044,litaora,v, ❑ODIER
ad3-m and Professions Caste:The Conmactors License Law does not apply to an owner of I OUT LETS.-SWITCHES-FIXTURES
6 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such iropmvcments arc tent intended or phrase for NEW RESIDEiN'FIAL ELECR 367aQ FI'. ,Sp
sale.IE however,the building or improvement is sold within one yearofcompletion,the SQ.FT.FLUOR AREA SISQ.FT.
owner-builder will hue the burden of proving that he did not build or improve for pur-
pamofsale.). IOTAL:'.9ap (p 29 ?-5 z6SE
I,as owmilitary,
ner of the pten exclusively counted,with licensed commit to r r
co mucr the projal(Sec.7044,Business and N.6pesion Code:)The Contortion's Li-
com Law does not apply to an owner of proparty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE �j
whoaw
netsu
forch rs
projects with a a oration licensed national Tothe Conduct.,a (fie
License Law. PERMIT
I.exempt under Se ,B&P C for this reason
ALTIER-DRAT V AI'ERIW) VALUATION
w.. ORKE :S COMPENSATION DECLARATION BACK FLOW PROTE .DEVICE j 'gN VJ O
I hereby e0irm under Penalty of perjury one ofthe following dalardtions:
]Ihavc and will nmintaina Cerificnmol Conunnnself-Insure for Workers Cntnpea- DRAINS-FLOOR.ROUR All EA.C ) ORIES TYPE CONSTRUCTION
. tion,as provided for by Section 3]W of the Labor Code,for the performance of the ^ �C ex^
work fm which this Permit is ismed. FIXTURESyy
-PERTRAP a
1 have and will maintain Workers Compensation]asoma.as eequiecd by Section
3'l00ofthe Labor Coca,for the perfo..harofIs
the work for which this perndt issued. GAS-IEA.SYSTEM-1 INC.4 OUTL .GROUP APN
My Workers Compensation Insurance cancer and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CUBIT FICATC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIEASEANDUSTRL WASTE INTER
('Ifiis section need not M completed ifthe permit is for one hundreddollars(SIM) 1 DING DIVISION PEES
nr lea.) GRHASETRAP PLANCIIEC 10
I certify that in the performance of the work l or which this permit is issued,Ishall SEWER-SANITARY-STORM EEA.201 PT.
not employ any person in any manner so as to become subject the Workcrs Compen- INERG
Z
section Laws of California.Dam WAi'ER HEATER WNIENTIELEC'IR
z Applicant 1 GRA
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should WATER SYSTENLrTRIEATING
a' become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
W forthwith comply with such provisions onhis permit shall be deemed revoked. WKIIER SERVICE.
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PE PAID
UO l hereby often that bem is a construction lending agency forth,perfrmance of Data Receipt#
L� the work for which this permit is ieurl(Sce.3TN7,Civ.C.)
0 U Lender's Name
Lender's Address TOTAL: r
1 ccrify that I have read this application had state that the above impartation is BUILDING FEF, Va'
VV1 coram.l agree to comply with all city and county ordinances and stale laws relining to QTY. MECHANICAL PERMIT FEE
U z buildingcontmction,and hereby common representatives ofthis city menverup ream SEISMIC FEE
above-mentioned property for inspection purpose,.. PERMIT ISSUANCE
(We)agree to rove,indemnify and keep ha mess the City of Cupertino against (ELECTRIC FEE AMY:
liabilities.judgmcnI is and expenses which mayin any wayaccmeagaimtmid City ALTER OR ADD TO MECH.
inconscgvenceo egr ring of this pcemit. PLUMBING FEE
APPLICANT DEER: 'Abr)S ANDWILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNI'I'LTO io,ofto CFM( n
SOU CE RHC tl.Al'If 5. G MECHANICAL FEE Or-
�/ AIR HANDLING UNIT(OVER 10,036)CFM) CONSTRUCTION TAX
Signature of Appliand/ ommcmr Date EXHAUST HOOD(WIDUCT) HOUSINGMITIGATION FTI;
HAZARDOUS MATERIALS DISCLOSURE
Will thcapplicant m future building occupantsmremr,handle hmallous material HEATING UNIT(10100.000 BT U)
as defined by the Cupenum Municipal Code.Chapter 9.12,and the Health and Safety
Coda Section 25532(0! HEATING UNIT F(OVER 100.01)HI'U)
❑Yes
VENTILATION FAN(SINGLE RESID) PAID 1
Will thea applicant or had building t use ep ni t or devices which Uatc Receipt M
pp gby the
Aman BOILER-COMP(3HPOR I00.B(I(i
remit haxallous air contaminant as def red by the Bay A.Air Quality Management
OTA,
LIN"Ifid, / BOILIER-COMP(OVER IW,WIIIiTU)oil /1r"'AIRCONDDIUNER res M uxardoua Immriala rrymrtmcnt undcrGhapter 6.95 of the Cvli- ISSUANCE DATE
Imy .rode,Sau m,25505,25533 and 25534.1 understand that if the NEW RESIDHNU IAL MIECH. SQ.FTt yhavca lenem,dLtitismyresp.nsibilitytonntifytheiecapant
knur ustbemetpriorminuancemfaCertificateofIXcupamy.
.an gem Dale 'IYYI'A L: ISSUED BY'.
OFFICE