S 0311 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT'RICAL PERNUTNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL C O�j
BUILDING PROJECT O J IDENTIFICATION
11
GILDING ADDRESS: SANITARY NO. APPLICATION SDA
IIBMI'ITAI. "
206(.0 Ef+ -I %1 `0
Nr NAME: • PHONE: CON'fRA(TOR'S NAME. LIC NO. NIC Q CO
N'I'ROLp
ARCHD'CI'/ENGINIiER: LIC NIT DDRt55:� ❑ ry
CONTACT PHONE:: - ' BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial ELECT P
-
LU
UMMB MECH
O ❑
LICENSED CONTRACTOR'S DECLARATION Q'rY ELEC"FRLC PERMIT FEE
1 hereby affirm that 1 am Eeeused ander provision,of chapter 9(commmndeg JOB DESCRIPTION
Q0.'Z I Scetion7(0))ofi)3n3ofthe Businessand Pmtmi n,Coh,andmyhaemscis RESIDENTIAL:
X00 wt PERMIT'ISSUANCE
CWF m full(ince and ellen. ❑SFDWL ❑KITCHEN RFNIODFI
QUU LicezWD.Ivnse Class LimpComment APPLIANCES—RF_SIDENTIAL [I ADDITION [I PLUMBING RE-PINI:
•J 47�— 4\RCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
N Z and d my plans shall h d as md,�
PANELS MODIFICATION
UY'f02W AAfI'S
OZ4O F)INTERIOR ❑CHIMNEY'REPAIR
I=�F' named .. o • ' 201-1000AMPS I IMPROVEMP.NT EJ SWIMMING POOLS
NF.R-BUILDER DECLARATION OVER I(NNIAMI'S ❑BATH RF.MODEUREPAIR ❑DEMOLITION
C ¢ 1 herchy a1Bm hat 1 am exempl tram the Cmnmunor's License Law for the
XO W U following reaum(Section 7031.5,Bovines.,and Pref..in.,Gale:Any city or county SIGNS ELELTR AL OTHER
b. (a.y which requites a permit m comma,alter,improve,demolish.or repair any etmetum
� 0� prior to it,maraca,also require,thenppliwnt fie"uch permit tolilcasignedruteoamt SPECIAL CIR IT SC.
as
that he is li,aae pursuant 1.he pnomomofdr,Can,...Im.,License Law(Chapter 9
�CQO (commencing with Section 7000)ofDivision 3 of the Businec,and Professions Code)or TEMP MET FIR OR I'OL°INSTCOMMERCIAL:
a p,cC ohm be is exanpt thamf.....and Ihe basin for the alleged exemption.Any violmimn of EJ NEW BLDG/ADDITION [I DEMOLITION
� N Senior 7031.5 by ar,inplieam fm ape.it wniceb,he applicant to a civil penalty if POWER DEVICES ANT ❑L'ODD SERVICE
not mote than five hundred dollars(SSW).H Z P IMI'ROVEhfENT
ca Q Lo the
owner(if the prtpcnymmyemer with wages for alei(See compensation. SWIMMING POOL ELECTRIC
ca will pr fe work,and the he ctureCont a not intended swerve Law
of apply t oan Business OTHER
0.3 m and Professions Code:The Contractor's Liad.1 law Jocs not apply to an owner of OUTLETS—SWITCHES—FIXTURES
his own who builds or vided that
thsuch i and improvements
tits such work tied or nr through
his own empinytt,,provided tba such improvement,am not intended or offered far NEW RIiSIDFMI'IAI.ELE, SQ IR RkA�1�A
sale.If.however.the building or improvement iv,)ld wlthinone year of completion.the SQ.fp�QI L/ S/SQ.I?
ncrbuilder will have the burden d proving that he did not huild or Improve lin per- /Y �/
pose of soled.
❑ 1,as owner of the pmpenY am exclusively contracting with licensed eonirways to TOTAL JUL 17
conrmcl the project(Sce.'I0FI,Busmen.,and Pmfeaiam Gxfe.)'fhe Conuanorc Li- W�
nsela.ma,rit uppdy ns an owner of pmpeny who builds or improves thereon.and QTY. PLUMBING PE FEE Will
who conuacts for such projects with a conranortJ IicenseJ pursuam m the C
Licerm lawmmraceKs. PERMIT ISSUANCE CITY OF L;UNEHTINO
I am exempt uraerSax. ,B&PC fonhis reason
Owner nGmam ALTER—IDRAIN&VENAI /7^
VALUAT ON
WORKER'S CATION DECLARATION BACK FLOW PROTECT DI:VICI �`
IhcehY allrm underpenalkyofprury aeof'me alhing
dedantimm:
•�I have and will maintain a Cenificate of Concept to,clf-insure for Workers Compo,- DRAINS—FLOOR,ROOF.AREA.COND.
cation,as provided for by Section 37W of the Labor Code,for the performan<c of the STORIES l'YPE,GGN$TRGLTI(
work far which this permit k issued. IRXT'URI'S—PER TRAP
Fl I have and will maintain Worker',Com,romion Insurance,o,required by Section
37Mafthe Lahor Code.for theperformanceafthe work for which this penult is issued. GAS—BA.SYSTEM-d INC.J OUTLETS OCC.GROUP APN
My Wurluu Cyynpe t � ycrolicy No my GAS—EA.SYSTFh1-OVER4(EA)
am
Wi,k,, C •�)IV1
Policy Nn:
CERTIPICA EOFEXEMPTIONFROKIWON&WS'
COMPF.NSM ION INSURANCE (IREASIYINDUSI'RL WASTE,INTERCEPTOR BUILDING DIV 'IO FEES
(Thin section nerd not be,completed ifthe Permit is formic hundred dollars($100) GREASETRAP
or less.) pLANCIITiCK ITE,
Toy any Om in We vi-raiany manner
work for which Nispacraff'heW kc,,' oa shell SEWER—SANITARY—STORM IIA, IT.
not employ any pemnn in any munncr.,o as m became wbjem ht tits Wnrken'Cnmpen ENERGY FEES
Oz salla.law,of Calil'nn-Date WATER HEATER WNENHUM.EC'IR
Z Appharnl GRADING f
NOTICETO APPLICANT:If,after making this Certifivem of Exemption,you should WAT ER SYS I EMn BEATING
a ' become subject to the Worker'.,Compensation prxwk ons of the Labor Code,y a must SOMA FEE
forthwith enmply with such proviunmo,thi,permit sl he deemed rc,Avi. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'LMB. SQ,17. PAID F1 L
L)0 Ihcrehy uRnn that there isnumamninn lending agency for the performance of late ReceiplX
the work for which this permit is issuoil(Sec.3097.Cie C.)
OU Lenders Name 'I'QI'A L'
WLender's AJJres, TOTAL:
IL 1 certify that 1 have read this application and state that the above information in H1MANNG EE
Fla correct.l agree to comply with all city and county oNirences and state laws relating to QTY. MECHANICAL PERMIT FEE
VZ huilJing ann,wni.n,nod hereby amhnriee reporanmtivccofihi.,citymemerupnn the SHISMIJEF,
above mentioned property for inspection putiwse,.
(We)agree m.cox.imktniiry and keep hamdxs ethe City mCupertino against PERMIT ISSUANCE ELECT IC FEE
liabilines,judgnmmv.costs and expenses which may in any way acemc agnict said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit PLG RING FIiE
APPLICANT UNDERSTANDS AND WILL WMP.Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0XIB CFM)
SOU ;REGULA'rPoNS. MB HANICAL FEE
AIR HANDLING UNTT(OVER 10.0(X1 CFM) C(i5TRI1Cf10N TAX
Sugnatumnf App can/Contmcmr Data EXHAUST HOOD(W/DUCT) )URINE MIT'ICATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will tit applicantor lawn building occupant store or handle bazarJom material HEATING UNIT G IW.O(I(1 BTU)
defined by the Cupertino Municipal Code,Chapter 9.12,anti the Health and Safety ^
as Jon 25532(u)P HEATING UNIT
as E3 ) -
❑Yes Fl No YA
V17NI II.A'1'ION PAN(SINGLE RESID)
Will thea lieant nr(mere buildin eta I um t or deices which hate Receipt a
PP gbe pan ea Air
BOILER—COMP(3HPOR I00.000tlTU)
mit humNous air conmminnnr as delinetl by the tiny Area Air Quality Mandgemem
Di,nial TOTAL:
❑Yes ❑No BOILER—GOMP(GVER IW.OfIfI BI'U)
I have and the bvuJows maleriais mquimmcnu under Chaplerfi45 of the Cali- AIR CONDITIONER
ISSUA CE DATE
forma Health&Safety Cvd Smtiam 255(15.25533 am1255-U.I understand that if the NEW RT:SIDEPT IAL MUCH. SQ.FT.
building does not currently have a mount,that it i,my responsibility to notify the occupant
of the requimareci,which must be,met poor to issuanee.f a Cenificate of Occupanoy. Lj/i/X�/S��L '//^/
Owner or authorized agent Date ITYTAh: ISSUED BY� q 2
OFFICE