S 0762 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - 7/y�S
CITY OF CUPERTINO BUILDING-ELECTRICAL PITTNO. O 1 VZ
BUILDING DIVISION' APPWCATIONIPERMIT `PLUMBING-MECIIANICAL J
BUILDING PROJECT[DENI'IF'ICA'fION
BUILDING ADDRESS: f n SANITARY NO. APPLICATION SUBMITTAL DATE
aa3E `q `,JO 4 ICO- 7338 y,S 'Z
O NER'S NAME?: s PHONE: CON'fRACTfIR'. NAME: c LIC NO:
GSA t /R•✓L ZwLS bV 3 .¢ vbHZ} NIC CONTR LM
��pRCHI'I'IiLT GINEER: LIC NO: ADDREti' ❑
CONTACT: PHONE: BUILDING,PERMIT INFO
Ce,eAoP7e "5-4- 4A6 -1-217J Gr1S El Consultant Pees Paid by Applicant(Initial) NLD C1' mu MGCu
U LICENSED CONTRACTORS DECLAMATION
QTY. - ELECTRIC PERMIT FEE
I therebyaffirm that 1 am licensed under provisions of Chapter 9(commencing _ _ JOB DESCRIPTION
ai�Z W Wr
ith Seminal )atDrvide.3 odds,Business end Pmfe,;iam Cafe, dmy license ix - RESIDENTIAL'
PERMIT ISSUANCE
' F- in full force and eRec M 7319LI{ ❑SFDWi, ❑KITCHEN REMODEL.
QUU Littnse Class - LIC.M gpI'LIANCES-RESIDENTIAL ❑ADDITION ❑PLDMBING RE-PIPE
to<W Uate
a CanlraC • ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DF.CLARATIO
F.7 rn PANELS MODIFICATION
�
y Z 1 undemanJ my plans shall be uscf es public rcasNs ZOZ�O UP TO 2N)AMPS [I INTERIOR El CHIMNEY REPAIR
�[!„ Licensed Professional 21Hl-1000AMPS PROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION
DVI?N IIXx1AMPS ATH REMOUIiI/Rlil'AIR C1 DEMOLITION
W 6 hmeby affirm that am exempt frmn the CoulaficsIk m'a e:Any c Law for my
iySOyU IiJl,wingrwwit fSmdnn]mmor Business and Profasians Cnle:Any city or county SIGNS I?LIICrRICAI.'. ER
oaf O1, which rcynlres a ry:rmit m connmct,alter,improve.Jcmnli.h,lir repair any grtslure
prior to its issnunce,also requiresuh Penrvuo ormm
s the applicant for clife a signed serl SPECIALCIRCUU'/MISC. .
a,�, nalbelshetnxedpursuanuo the provisinnsof(be Cumrucmr's License Low(Chapter?
.TOC (contmetcing with Section V0M)ofDiv ision 3 or the Business and Professions Code)or TIIMR METER OR POLE INST. COMMERCIAL
a n oC that he is exempt therefrom and the basis far the alleged exemption.Any violation of [-I NEW BLDG/ADDITION [D DEMOLITION
„y
Section 7031.5 by any applicant for a permit subjects the 1pphexn,to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
not msec llmn five hundred dollars(S50 ). IMPROVE.MEN'I'
E � ❑I.as nwner of the property,or my employees with wagesxs their sale compensation, SWIMMING POOL ELECTRIC
will it,,the work,and the stmmure isnot intended mourned for sale(Sec.]DIG,Business []OTHER
Wamt 1'rofe,dons Cale:The Contractors License Law does not Imply to an ms'ner of OU'1LETS-SWITCHES-FIXTURES
6 3 property who builds or improves thereon,and who dxs such work flamed.,through
his own emplayces.Provided that such improvements am nal intended m offered for NEW RESIDENTIAL ELECIR. SQ ITT.
sole,If,howev,r,the building or improvement issold whhinone year ofcormhoon,the SQ,IT.FLOOR AREA S/SQ.IT.
ne'loilder will have the bar of pmv,.,that he ofd nal huild or improve for mor-
'cenfsale). TOTAL: -
1,as owner of the progeny,am exclusively contracting with heenwil contractors m PAID
conmmct the protect(See 707,Business slid l'mression,CaacJ The Contractor's Li
cense Low does not apply to as nwner of property who builds or improves thereon,and QT CW' PLUMBINGP 4y TEH
who callmos formmh projects will u contmemr(s)licensed pursuant to the Contmemrs ii
- DEC 18
Licero,Low. I RMIT ISS N F: cu
I am exempt under Sec. ,B&P C for this reason
(]caner Date N.TI?N-O &VESIT E ❑(EA) I�Irr�
WORKER'S COMPENSATION DECLARATION BACK PLOW PR(ffECT.DEVICE
I herchy aRimh under penalty of perjury one of the following declarations:
❑lbws and will for by
370,of the La ltoCod i.for Cher Wadersce of the DRAINS-I1.f30R.ROOF AREA.COND. STORKS TYPECONSTRUCTION
moan,as provided for by Section J]UI of the InMr Cale,for the Performance of the
work for which this Peril is issued. 19 X'1'IIRES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
J]Ipafthe[abit,Code,falls,perearescrof the work far which,hi,vena,is issued. GAS-PA.SYS]EM-0 INC.G OUTLETS OCC.GROUT' APN
My Walk elx C�q+fnsutiuyLhsurance farm r tend Policy ioIDer o -
Ca.... .. F 't 'r sAA.A' Policy Na: ��7���� GAS-HA.SYS1FM-OVER4(EA)
CERTIFICA'T'E OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASEYINDUS1'RL WASTE.INTERCEMOR
oche completed iDho t is tor one handled Italian 1$I(X) - BUILDING DIVISION FEES
This section need
petrol GNIiASE'I NAP
lir Icss.) PLANCIIIiCK 191E
I certify that in the performance oRse work for which flux Permit is issued,Ishall SEWER-SANITARY-STORM F.A.NX]Pr.
not employ any Person in any manner so us m become xubject to the Workers'Campen- ENERGY FEE
O Z moan Laws of Califtoma.Date WATER HEATER WNENT/ELECfR GRADING FEE
Applicant
Z
y NOTICE TO APPLICANT:IL after making this CeAficale of Exemption,you should WAT HE SYSTEM RFATING
a ; become subject to the Workers Compensation previsions of the Labor CMC,you must SOIfS FEE
Lkl forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
U O CONSTRUCTION LPNDINGngency NEW RESIDP.NTIAL PCMB. SQ.fT. PAID
y
I herchaffirm that there isaam,nmclinn lendingg agencyENCY for The performance of Dam cceipf
tet the work far which this permit is issued(See.3099.Cil.C.)
OI" Lenders Name 'TOTAL:
WLemlersnddrexs 'r0"I'Al.:
P. I coolly that 1 have read phis upphcation mW slat,lhut the drove information is _ BUILDING PI1P
h Corea,Iagreemcomply witha11 city Ind county andulnce,and safe laws relmlng ,, QTY. MECHANICAL PERM IT r FEE
U huildfngcnI..ruaian,and hereby authorize represcnlativcs nT this city to cn¢r upon the SEISMIC FF.
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)eS S.to Save,indemnify and keep humdcss the City of Cupertino agoras, ELECfR1 PIA?
Iiabil'mfcs.julgntenhs,costs and expenses which may in any way same against said City ALTER OR ADD TO MECH. PLUMBING TLE
in consequence of the granting of ffix perNt.
APPLICANTUNDERSTANDS AND WILL COMPLY Will IT ALL NON-POINT AIN HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL 'EE
iL-9 y7 AIR I IANDLING UNIT(OVER 10,000 CFM) CONSTRUC ON TAX
ognamre of mlicunf/ ontraeor 11 Dare EXI IAUST HOOD(W/DUC) HOUSINGH rRIATION TLB
HAZARDOUS MATERIAE S DI ..OSURI?
Will the it,licanl or furore building occupant marc or bundle hazatdoa,plamrial IiIiATINfi UNIT(TO 100,000 BTU)
as defined by Om Cupertino Municipal Code,Chapter 9.12,nod the Health and Safe,
Cock,Seems 25532(x)7 / r HEATINGUNI'r(OVER I00,001)131-U) _
Q Yes VI:N,1H.ATION FAN(SINGLERESID) PAID )hmc Receipt If --
Will the applicant or future building occupzml use equipment or devices which
,coif hazardous air emotions. s os ,Cited by the[toy Area Air Quality Management BOILI?R-COMP(3HP OR IfX).Ug)BI IF
District? BOILER-COMP(OVER 100.000 BTIH
E3Yes
I have read the hazardous meerials sequiremems ands Chapter 6.95 of the Cali AIR CONDITIONER IS.IJANCEDATE
formic Heahb&Safety Cade,ScoWinn,25505,25533 and ZS534.I undcmmad door if the NI2W RESIDENTIAL MECH. SQ.FI',
building does nm currently have a tenant,that it is my mrpmsihllay to notify the rempam
of the i,,loinear l wbill mus,bemelpdonoi.ssuance ofa Cenifcal,of Divergency.
Owner or amhonsed agent Dale TO'I'AI,: ISSUED BY:
OFFICE