S 0491 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILOIN(:.ELECIRICA I. PERMIT No.
BUILDING DIVISION APPLICATIONIPERMIT PL.UMBLNO-MECHANICAL S 0491
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NU. APPLICA'110N SUBMITIAL DA
� � l�. 8 9- /5-- 9 7
OWNIiR'S NAME: PHONE: C T'RACTONS NA ? I/.IC/�NO:
S —loGG f �fY 7 NIC CONTROL#
`�-ARCIII'I ECI'ANGINEER: LIC NO: ADDR .'S:� �f/� w 1 ❑
\ CONTACT: PHONE: C/l( BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MCCH
❑ ❑ i — ❑
LICENSED CON'TRACIOR'S DI!CLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Thal 1 am licensed under provisions of Chapter 9 fcommcncing JOB DESCRIPTION
WOO OO with Section 7000)of Division 3 of tho Business and Professions Code.and my license is I'fiRMl'1'ISSUANCE RESIDENTIAL:
IW x. efec. ❑SPDNL El KITCHEN RFMODI]
License Class Lic.p<—U
APPLIANCES-RESIDENTIAL []ADDITION PFlPEING RE-PIPC
yQ L Dam Contractor
p,Dm ARCIB rEC'IS DECLARATIONI'ANEIS ❑MULT'1-UNIT El S1
Z O N Z 1 understand my pbv,,h.11 be used as public records MODIFICATION
Ln—MUP TO 210 AMPS ❑INTERIOR Ll CHIMNEY RTAIR
H`:.F.W Licensed Pro&x.vinnnl 201-1100 AMPS IMPROVLMENT LJSWIMMING POOLS
OWNER BUILDER DECLARATION
tY Y OVER unto AMPS ❑BATH RILMODEI/REPAIR ❑DEMOLITION
Q I hereby affirm that I am exempt from the Contmemrs License Law for the
x 31 O following reason.(Section 9031 5,Business and Pndossinnx Codo'.Any city ut county SIGNS ELECTRICAL ❑OCHER
W W y which negmres a Permit to construct,alter,improve.demolish,or repair any slmcmrc
0.1 prior to its issuance.also"items the applicant for such permit m File a signed statement SPECIAL CIRCIATIMISC,
tothat Le is licensed pursuant the ft be Commcmrs Licunm l,nw(Cha f 9
} pSectio of Division
per
W(Y�at (ce,he is ixemitM1 Sectincon andIn a teoi,nor of the al Buseged exemismoand ote.,wGNel or TEMP.MLTER OR POLE INST I COMMERCIAL'
a a e thm M1c is exempt therefrom and the basks for the aRcged exemption.Any viomtion of ❑NEW BLDG/AUDITION ❑DEMUTH[ON
W m W Section 91131 5 by any applicant for o permit wbjcdn the applicant ,,u civil penalty of POWER DEVICES
�ria SSG ❑TENAN C El FOOD SERVICE
room ore than live hundred dollars my employees
IMPROVEMENT). Ih1PROVF:MENT�I,as owner of the property.onnyemployees with w'agewz their sole compenzmion, SWIMMING PIX)1.ELECTRIC
F will Jo the work,and the stmcwrcts nofmmnJcd nr offered for sole(Sec.9(144.Bucine,x ❑OTHER
aim and Prom,xion,Core: no Comracmrx License law doo,not apply m an owner of OUTLIi1:S-SWITCHES-FIXTURES
property who builds or improves thereon,and who dons such work himsslf or through
his own employees.provided that such improvemenu are not intended or o@red for NEW RESIDENTIAL F,LEUR �T
sale.IL however.the building or improvcnient is sold within one year ufcompletina,the SQ.FE FLOOR AREA VSQ,FT.
owner builder will have the burden of proving that he did not build or improve for pur-
poseofsale.). A
�} /1 '
C] Lax owner of the proper%int exdo,00ly carand"ing with licensed contractors In TOTAL: p
construct the project(Sec.9044,business and Professions Cale:)The Contractors Li
cerise Law does not apply to an owner ofpropenywho builds orimpmordthemon,and QTY. PLUMBING PERMIT FEE S�
whcontmtls for such pmlectx with u mnwpursuant cmgs)licensed pursuano the Contractors P
License Law' PERMIT ISSUANCE 1�[
❑ 1 am exempt under Sec. .B&P C for this reason CITYI
ALTER-DRAIN&VENT-WAIER(F.A)
Owner Dam V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm muter pcmdty of perjury one of the following declarahoox'.
❑ Ihavc and will mainlainn Cerilicme of Conunua self-insure for Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,CONE.
cation,as provided for by Section 39th of the Labe Cute,for the performance of the STORIES TYPE CONS'IRUCfI(
work For which this permit in issued XTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37m ofthc Luba Code.(or the performance of the work for which this Permit is issued. GAS-lin.SYSTEM-I INC.4 OUTLETS
MY Wonky' Camp) 1 cf c trier Id N�y b OCC.GROUT' nPN
Can ierd4ftlle+9ld2o A_✓� oie a:num tura: GAS-EA.SYSTEM-OVER 4(EA)
rof CERT119— C E�jf10N FROM WORKERS'
COMPENSATION INSURANCE GREASE INDUSTRL WASTE INTERCEPTOR
I his section need not be ttxdplded it thepermit is for me hundred dollars($1O BUILDING DIVISION REPS
or lava) GREASF,TRAP PLANCHFCK ITE
I certify thalmthe erfrmarmot,ofthe work for which this pemil ix issued.Ishort l
na am la any person in any manner so ox nt ben SEWER-SANITARY-S'IY)RM PA. PI.
p y nnc wbjecnothe Workers ENERGY PF.E
O Z. ficant laws of Cali(omia.Date
A,
Z , AppliWATER HEATER WNW]'/ELLC R
GRAVING THE
y NOTICE comeTO subject
to the ANI.Work IL attar nmking this provisions
of of Exemption,you a must
WATER tiYSTF.M/1'RFA'1'ING
a , become womtm the Workers Compensationprovisions oft he decided
rCode,you must SOILS LLE
W forthwith comply with xucM1 prnvixionx Dosis pemnit,hall he JecmeJ revoker. WATER SERVICE
Q
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT: PAID
(_j0 Thereby affirm that hem is a mnsfineim lending agency for fire performance of Dale Receipt#
H. F the work for which this permit i,issued(Sec.3099,Co.CJ
0 V Lenders Name TOTAL:
Lemdcrx Address TOTAL.
d 1 verify that 1 have read this application and nate(hat the above infanmtion is BUILDING ILL;
V) correct.I agree mcomply with all city and county ordinances and stale laws riming m QTY. MECHANICAL PERMIT FEE
L) z building construction,and hereby authone,reprownlalives of this city to color upenthe SEISMIC FEF.
above-nnntioned proPery for inspection pur,ov,, FERMI I*ISSUANCE
(Ws.)agree to save.indemnity and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitics.judgmcros,costs and expenses which may in any way accrue against said City ALTERORADDTOMF,CH.
in consequence of the granting of this pemtit PLUMBING FIAT
APPLICANT UNDERSTANDS 99 WILL COMPLY WITH ALI.NON-POINTAIR HANDLING UNIT(TO IQOfNI CFM)
SOURCFREGUI S. 4 MECHANICALFEE
AIR HANDLING UNIT(OVER U.mOCPM) CONSTRUCTION TAX
Si,baBBe.fA,licamosCmithristrim I /Date EXHAUST HOOD OMDUCD HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
WIIltheap,homaor fonne hmidingteeupsmuone or handle M1vardmo mutcriel HEATING UNIT LTO 101,000 BTU)
a,defined by the Co,womo Municipal Code.Chapter 9.12,and the Health and Safety
Cale.Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU)
❑Ycs Fl No
VENTILATION FAN(SINGLE RF_SID) PAID
Will the applicant or future hudding occupant use equipment or devices which Date Receipt X
emit hvurdoux air comundnurb ax defined by the any Area Air Quality ManagementMOILER-COMP(311P OR 100.009)BTU)
Di"n"? TOTAL:
Yes FIN. BOILER-COMP(OVER 100.000 BTU)
I have read the hvnrdous materials requirements under Chapter 6.93 of the Cali- AIR CONDITIONER ISSUANCE
forma Health&Safety Gale,Sections 25505.'_5533 and 25534.1 understand that if the NEW RESIDEN'I'IAI.MECII. SQ.Il'.
hailJing does not currently have a count,in.,if is my responsibility to notify the o,cupam
of the requirements which must b met prior m issuance old Cer heat,of Occupancy.
Ownerormillb iced agent Dam TOTAL:
ISSUED BY:
OFFICE