S 0264 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEIwIrr No: O ^�S
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J Lb
' BUILDING PROJECT IDENTIFICATION
UILDING ADDRESS: SANITARY NO. APPLICATION S)BMI'17AL DATE
n l v PO
ER'S NAME: PHONE?: CONTRACIOR'S NAME: LIC NO:
/77 !p 55 si CONTROLM
'HITEC'DENGI MR: I LIC No _ ADD 3SS: '. ❑ '
CONTACT: - PHONE: - BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Iniliap HLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECPRICPERMIT FEE -
1 herehy zffam than 1..liccnsd under pnwixions of Chapmr 9(commencing JOB DES_CRI PION
Q'rz withS tion]qe)ofDivisinn3.faheBusinesxandProfessi�nsCde,anAmylicenseis RESIDENTIAL:
u10 0 I'ERMI'1'ISSUANCE
1, — in full Raceand effect. ❑SFDWL 12
as,wrKITCHEN RF.MODEI.
L¢ense Clasfi Lima APPLIANCES-RUSIDEMfIAL ❑AUDITION .l1MBING RE-PIPE
Uam Cnntrumnr
a' ARCHI'IPUT'S DECLARATION ❑h1UhH:UN11' SODIFICATIO
z TRUCIURAL
0v7v/J'b E understand my plans shall he used as public records PANELS MODIFICATION
0z%j0u1 UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
I:`FJ Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
giRJ OWNER-RUILDHR DECLARATION OVER IBXAMPS [I BATH REMODEIIREPAIR El DEMOLITION
Q I herehy elfirm the I nm exempt from the Ci mncmrs License Lew for the
K06G followin ..(Section 7031.5.Ilnsinessand Pmfc ...Cale:An t count GMBER
Yl sF following m. yciYur Y SIGNS I!LECI'RICAL
3 4 0 which requimx a perms m construct,vl¢r.improve,demolish,m repair any xtnnum
OI prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions of the Connector's License Law(Chapter 9
���� (cnnunencing with Sectian](Xg.......
of Vivisi.n3ofthe Business nnA l'ndex.inne Cale)ur TEMP.M111iTCR OR POLE)NST, COMMERCIAL:
d that he is exempt therefrom and the hoia for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'I']ON
Section 70313 by uny applicant Ranprmit subjects tbeopowton m a visit p maltyof POWER DEVICES ❑I FNANT ` - ❑1'001)SERVICE
ILIII......... nottnnre cpm live hundred dollars($500). IMPROVEMENT '
e, 6 1,us owner of Ne ro n SWIMMING POOL ELECTRIC
O (] t pe y,or myemntendes with wages e...lc((See
0nLB sines.
will Jn the work.and the stmdure is Bat intended or offered tarsale(Sec.]IW,Rosiness ❑OTHER
all and Professions Code:The Contractor's License Law does not apply m an owner of OU'rLBTS-SWI'I CHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offend for NEW RESIDENTIAL ELFC 11 :Q F
sale,If,however,thetmilding m improvement is saldwithinone yearofc.mpapion.the SQ.P . A�i ASQ.FT.
wherbuilder will have the burden of proving that he did not build or impacts,for put- J
spose of sole,. U` `8
1,as owner of the property,um exclusively contracting with licensed contractors to _ TO'LAI.: YYY`
the project(Sec.]Me,boduess and anlessions Cale:)The Contractor's La- �^S/� Ray-
construct
cpua[,am does not 1,111. aowner III properly who builds or improves damn,and QTY ; „PLUMOINGPERMIT � F 'y
who nmtracta for such projecls with it contmeorod licensed pursmmt to its.ContmcmrlIt Uh L•yr�frf/N
License Low. PERNHIISSUANCE f 1 Q
I ant exempt under Sec. .B&P C for this mason
Owner Dae ALTER-DRAIN&VENT-WATER(HIM VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECr.DEVICE
1 hereby efRrm under penalty of perjury motor the fallowing national...:
•C]Ihave and will maintains Certiccme of Conum mself-inwrtfar Workers Camper- DRAINS-FLOOR,ROOK AREA,CONT, STORIES TYPE CONSTRUCTION
spino,as provided for by Section 3700of the Labor Cade,for the Pcriom troc.f the
work for which this .it is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3701 oflyhu labor CCode,for the perforpmanc..Rha work for which this permit is issued. CAS-I!A.SYSTEMa INC4OU'1'LF.TS UCC.GROUP AI'N
My/ CarrliSc'(,cr61d iso FIQ/4.tric and PPolcy' k'ka Z ' GAS-FA.SYSTI�OVER4(PA) -
CMTH.TE( 'EXEMPTIONMOM WORKERS' GREASPJINDIISTRI.WASTE INTERCI!I'IOH
COMPHNSAq'ION INSURANCE BUILDING DIVISION FEES
(Thi>saaion need not Mcontpletalifthepermiaisforonchundmddollas($]WI GREASETRAP
.r leu.) PLANCHF.CK RE
I cenify Mat inthe perfor anci,ofthe work f.rwhicluhis Permit is issued,lshall SEWER-SANITARY-STORM F.A.200 FT.
no,employ any person in any manner sn as to become subject o the Workers Compen- ENI!RGY FEE
,Z• Italian Uwsof California.Date WATI!R HHATIiR WNCNHUELECTR
Applicant t GRAVING FEE
N NOICE'IO APPLICANT.IL after making this Certificate of Pat, ptmu,you should WATER SYSTIiM/1',EATING
a becntnesuhjecno the Worker's C.mpemcrion Provisions of the LxMtr Code,you moa SOILS THE.
LkI borthwiah comply with such pooldo.a or this permit shall be Jcetned roc.ked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW lil!SIUEN'IIAI.PLMB. SQ.PI', PAID Uate e' tM
L) Q Iherebyaffirm natios,ass cnnatreaion lending agency fix the per6xmunm of
— the work for which this permit is issued(Sec.3097,Civ.C.)
0 lenders Name TOTAL
O LJ Lc.Jer'.ItAddrees 1Y
} 0. BUILDING FEE cenify that I have real this application and Blanc that the above infomation is
iF. h csmect.l agree to comply with all city and manly oNi...resenduamiawsrelaingm QTY. MECHANICAL PERMIT FEE
building conction,and hereby rumors, city menmrupnn the SEISMIC Bili
gtn
above-mentioned pm,ery for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC I' H
Iiahiliae,pollments,ewsnM es,a,cs which maylmtmy way oanma'ansa said City AM OR AVD BY)MUCI I.
in a....r,emce ofine printing this rental PLUMBING ITE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to,"CPM)
SOURCE REGULATIONS. MECHANICAh :P.
AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRIICI'If
Si na reof ApplicardCommut-r Date EXHAUST GOOD OVIDUCT) HOUSING MITIGATION FIE
HAZARDOUS MATERIALS D LOSURE
Will the applicant orfumre building occupant store or handle bvardoas material HEAT]NO UNIT(TO 100.0011 BTU)
as derived by the Cupertino Municipal Code,Chapter 9.12,and the IIcahn and Safety
Code,Section 25532(x)? HEATING UNIT(OVER IM OR)B'fO
E]Yes El No YEN TILA'HUN FAN(SINGLE RUSIDI PAID
Dmc Receipt.
Wedom;l the upequitit orfumrehef cal h,mcng
ALA it Quaent lity
Mcur,ves amh BOILER-COMP0HP OR I00,01ID BTU)
canto homrdnws air cnmaminanas us JeBnetrhy the Bay Area Air Quality Mnnngemcm TO MI.: �
District? -
[-1 Yea [:J No BOILER-COMI'IOVI!R I(Xl,lgp BTU) _
I have read the haaWous materials a under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATES
re.2
f.miagdoes&Safety Code.ea tina255(1$.25533and 25534.1 understand)unifth ohmifthe NEW Rai\IDI!NI'IALAfECH. SQ.FT.
buildingdrci.not currency have a mettptomo is ua ceof a Crodi uaratifythe osucy. t
of the tryuiremen¢which nun he me prior to issuance of a Cmifcae of[kmpatmy.
Owner or authorized agent Dam TOTALI ISSUED BY:
OFFICE