00010075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY ao100-77
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONlPERAIIT PLUMBING-MECHANICAL.
LLUILDIN(:PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMITTALDATI
or,/ ✓01141VVIte_A/ D/le - - z- Zoo �
OWNIiN': ME: _ / l��H�NE: CONTR NAMIi: LIC NO �
6/x/6 G %V /l!/✓G N/C CON]'kOLp
,III'l l?C/ENGINEIRTIC NO:
❑
)NTAM.
PHONE: BUILDING PERMIT INFO
3/ q / ❑ Consultant Fats Paid by Applicant(Initial) BLDG ELO PLUMB MECH
j LICENSED CONTRACTOR'S DECLARATION 6 QTY ELECTRIC PERMIT FEE
1 werhy affirm But I am liccnxd under provisions of Chapter 9(commencing JOB DESCRIPTION
O*IZ with Section 70uldof Division Sof the Bmine,s.nd Profession.,Cade,and my license is RESIDENTIAL:
u100 In PERMIT'ISSUANCE
F fullfarceand clfem. �' ❑SFDWL ❑KITCHEN REMODEL
=<UuWr Lacots Class I.n.N APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING I PIPE
N z W DaIC GnIIImCIar
ARCHI'IP 'Sl 11)leCLAR 'I [:I MULTI ❑STRUCTURAL
Z~O vOi Z 1 understand my plan shall record as public records PANEL'S MODIFICATION
OZ-a UP TO 200 AMPS I ❑iwERIOR ❑CHIMNHY REPAIR
1=.�Fu1 Licensed Pmfevocanal 201-IIX10AMPS IMPROVEMENT E]SWIMMING POOLS
C W Q I hereby affirm ha I on exemp LG mEhse Contraor's License Low,for he OVER 100in AMPS ATH RIiMODELREPAIR [I DEMOLITION
X 3 a U following reason.(Sation 200 sine
1.5,Buss and Profession,Crack:Any city or countyancountySIGNS ELECTRICAL [I OTHER -/���
W LL QI
EF which acquires a permit to construct,altar,improve,demolish,or repair y stracture
O poor to its issuance,a]%n requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT'IMTSC.
that he is licensed pursuant to the foodstuffs ofhe Contractors License Law(Chapter 9
u)�00 (camanalmg with Section 90Xo of Division 3 of the Business and Profession,'Code)ar TEMP.MIS I'HR OR POLE INST. COMMERCIAL'
E p,o C than he is exempt themim in and the basis for the alleged exemption.Any vinlmion of El NhW HhUG/ADDITION E]DEMOLITION
al N Station 911.7 L5 by anyapplicant ora pnvdt xuhjctlx he npplicvnt one lvll penalty of pDWEIt DEVICES ❑TENANT ❑FOOD SERVICE
not note hon five hundred dollars($50(d. IMPROVEMENT
'
FSC C] Las owner of the property.or my cmployces with wages a.their sole contpensmion, SWIMMING POOL GLECTRIC
F. will do the work,and the structure is not intended or offered for sale fSecA(41.Business [I OTHER
W m and Professions Code:Tine Contmetors License law does not apply to as owner of OUTLETS-SWITCHES-FIXTURES
it'3 property who builds or improves thereof.and who does such work himself ser through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL.ELEC R
sale.ILhowever.the building or improvement lssuld within one year ofcompleam.the
SQ.II'.FLOOR AREA 3/SQ.FT.
nervhuilder will have the burden of proving that he did cot build or improve for pur-
psscof sale
01
1,m ownene
r of the Ennui am exclusively contracting with licensed<onoaaors n+ 'A L:
construe be pmoser(Sec.90.14,Business and Prof siom Codi The Contra cu+r's Li-
«nse la+w does not apply to an owner of property who builds or improves beacon,and QTY. PLUMBING PERMIT FEE
who attracts fur such projects ,,It a nor ru,mgs)licensed persuam(o the Conouaor's
License Law PERMIT'ISSUANCE
❑ I am exempt under Sec. .H&1'C for this reason
Owner Dae ALTER-DRAIN&VENT-WATER(EA) /VVAALUATION
WORKERm 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2
I hereby ahrunder penalty of perjury one of the following declarations. 5 J
I have and will maintain a Cenificam of Consent In self-inure for Worker's Compete DRAINS-FLOOR.RWF,AREA.COND. STORIES TYPE CONSTRUCTION
as provided for by Section 37R)of the Labor Code,for the performance of the
ork for which this permit is issued FIXTURES-PER TRAP
base and will maintain Worker's Compensation Insurance,asrequired by Serio �j
IMI of be Labor Code,far the perlhmmucc of the work for which this ltamtit is issued. GAS-EA.SYSTEM INC. OUTLETS OCC GROUP 7�NJ7
My Wodcr'sC cn- 'n nes carr and Policy lm
Curri, nu Polley No.'. 0 OAS-I:A.SVS'I'IiM-OVER4(EA)
C15RTII'IG Ili Oh
EXEMPTION FROM WORKERS GREASOIN DUS IRE,WASTE INTERCEPTOR
COMPENSA'I[ON INSURANCE BUILDING DIVISION Fri
('1TIlssection nee nmMromplcredit the pentad is foronc hunJmJ Joll.n(EI W) GREASETRAP
o+r less) PT.ANCHECK FEE
I ceridy that in he performance of the work for which this permit is iawli ishall SEWER-SANITARY-STORM EA.2011 FT.
not employ any person in any manner sato.tkxbc9f+ •ybiwwthe Workers'Cori ENERGY RG
Z ',tion Lawsof Califican r>A-� T/��'e lJV WATER HEATER WNENDELECR
OQ Applicant '— GRADING FEE
'Zr' NOI ICE'TO APPL tar making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
become suM1jul to t e Wnrkah Cnmpenpmian pnry Binns of the Labor Code you omen
W fonhwih comply with such provisions or this permit shall be deemed revoke, WATER SERVICE
Q
a' CONSere iso [ONossa LENDINGAGENCYNIiW RLSIDIiNI'IAL I'LMB. ti0FI'. PAID [)ate Receipt0
U p Iherchy affirm thin there isoeonarvninn lending agency fnnhe perfimn:mcc of
U. 1-' he work for which This partial is issued(Sec.31199.Civ.C.1
O U Lenders Name TOTAL: t"S
lender's Address TOTAL:
>. W 111
0. 1 certify that I have read his application and state hat he above information is BUIL�ING FEE lJ In`�
F ,G namO.I agree in comply with all city and county ordicani and s,am laws retaingm QTY MECHANICAL PERMIT FEF, L "-
U Z building consouction.and hereby auhoron mpmwnt ives of this city to enter upon the SETS, f1.FEC:
aMrvc-mentioned praperty for ual'o nom Parini PERMIT ISSUANCE
(We)agree to as ,indenmidy and keep hartnlcsa the City of Cupertino against F:LEC 11 ITE
Iiabilhls.judgment,anus and experses which may in any va,00mve again.dmid City ALTER OR At)[)To MECH.
PLUM G IEI3
APPLsequence of Lha Booming u(this Isomil.
1CAN'1'UN -.RSTAN[)S AND WILL COMPLY WITH ALL NONROINT AIR IIAN[)LING UNIT(TO Ia,(xI)CPM)
SOURCE REG TONS. MECHIN[CAI.FEE
O AIR HANDLING UNIT(OVER I0.000CI'M) CONSTBp TION'PAX
Signature of ApplicanUCommnor DueEXHAUSTEXHAUST HOOD(W/DUCCI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant orfature wilding occupant store urhandlehomdoa,material HEATING UNIT(TO 100,000 BTU)
to defined by he Cupertino Municipal Cee.Chapter 9.12,and he Health and Safety
Code.Section 25532(a)l HEATING UNIT(OVER 100.000 BTU)
Cl Vcs n No
VENEI'ELATION PAN(SINGLE RF_SID) PAID Date Receipt p
Will the applicant or four,huilding twuupmt use mo,mcnt or devices which
ni haardotu air contaminants as destined by he Nay Area Air Quality Management POLLEN-CllMl'pHPOR IUI,g10 P'IU) IOTAI.
cornet" HOILER-COMP(OVER 100,01X)BTUI
❑Yea 0N
I have read the Infractions materials requiremcna under Chapter 6.95 of the Cali.. AIR CONDITIONER ISSUANCE DAT17
E
arn.Health&Sa Cee,Sections 25505,25533 and 25533.1 understand that if are ,NEW RESIDENTIAL.MECH. SQ.FT.
doeesnot nllYhavcaienni.halitismyre%,.rbl yming woc,mist — zC>`Ccrem hieh must he met prior m issuauc p[p tlfl Wily.
amhunnd agent Me TOTAL: ISSUED BY:
OFFICE