S0001 B0613APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL LING. ELECTRICAL. PERMIT NO.
BUILDING 1) ISION APPLICATION/PERMIT PLUM1lIIINGIs_-MECHANICAL rev I SO�OI QOM
NO
N
OFFICE
DING FERMII INVU
I.IiCI' PLUMB MECI
❑ ❑ ❑
JOII DESCRIPTION
CONTACT. rrlr,rvr_
'Y 7
❑ Consultant Fe. Paid by Applicant (Initial)
LICI!NSIB)CONTRACIIJR:SDECI.ARAIH)N
I hereby dlirnn Thal 1 um licensed made, provision, al Chalne, 9 (Inn ouramang
with Section 9fNN0ofDivision 3 of the Bmincse act Profession, Cnila, undnty license is
in full fanbandeect.
License Class Lic.p
Dalc Cornet,
QTY. ELECTRIC PERMIT FEE
MpZ
NW2
Q U
Nam
PERMIT ISSUANCI?
APPLIANCES —RIillUliNT1A1.
f—
y Z
O Z L� G
ARCIfITECT'S DECLARATION
e used as puic raoMs
1 codeceaad my plans shall hbl
PANELS
UP TO 200 AMPS
F�L'a1 Liccmcd professional
OWNER -BUILDER DECLARATION
C C
X 0 aQ I mushy aWon the 1 am exempt from the Commences License law far the
U fallowing cement (Section 7031.5. Business and Professions Code: Any city or county
u13 u. h¢ which requires a permit to comuuct, affair, improve. demolish. car repair any structure
E-�0.] prime in issuance, I,. mantras the applicant fmmeM1 permit to fleasignedstwemenl
i' } the he is licensed p .... at 0s the provisions of the Cmaractors License law (Chapter 9
ad °'00 (commencing with Section 1000)ofDb'ision3 ofthe Business and Professions Code) or
M d C that he is ex lujo therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a pencil subjects the applicant hr a civil penalty of
w of more than five hundred dollars ($500).
mairsolc cwncation,
XC n I, as no neral'the pnghny ar my nnployees with wages m oml
p. wi 11 Ja the work. anti the sommote is not intended or offered for safe (See. 944, Boancsx
W oo and pndes..on, Cn le: 'I'he Contractor, Liceme Law dues not apply It, an owner of
pnpany It,, hudd, or initiates thereon, and who that, eeh walk handeBit through
his own employees, provided Ibat such impmvmncros am urn Intended or offecd lir
,.It, It, hottest, the mild ing urimprovement issold within amu yourn(mninction. me
erbui lder ill have the burden of proving that be did not build or improve for ma -
2014"AMPS
OVER U100AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLET 'S—SWITCI IES — Il XTIJRES
NEW RESIDENTIAL ELEC'IR SQ FIT.
0 pose of
1, us owner of the portent am exclusively contracting with licensed contractors to
mrwe the pmjecl (Sec. 1144, Business and Professions Code:) Lae Conlmmar'S Li'
cense law Juts not apply to an owner of property who builds or improves lhemon.and
QTY. PLUMBING Pwhocontrams
for suchprojects with acontructnrs) licensedpunuannn theContmctor.sLicense
law.
sin exempt under See . B & P C for this mownALTER-DRAIN
PERMIT ISSUANCE1
NNI
&VENT'-(uner
Datc
WORKC:R'S COMPENSATION DECLARATION
BACK FLOW PROTECT. UIi1hereby
ufWnder Penalty of perjury one of the following deduct ions:Ihaveand will mtort, CeniOcamofCnmenuo sdf-insert for Waders Compete
DRAINS— FLOOR. ROOF. A
tion, as provided for by Sermon 3700 of the Lehr Code. for the pclarmonce of the
y^, it which this permit is issued.
FIXTURES — PER TRAP
GAS — EA. SYSTEM -1 INCA OU'TLIi Ts
h:rva and will maintain Worker's Compensation Insurance, as required by Sntion
111Nlol the Ls",Cade, for the performance of the work for. m thnsparmll, isx ed
GAS— EA. SYSTEM -OVER 4(EA) Fr
My W... 1reComcrya� 1snc'FXE rierdi Policy
Canis: �n.carrier
[ON Nu: is
CIiR'I'l1 6 E OE COMPENSATION INN PRO W R iR5'
COMPENSATION INSURANCIi
GREASE/INDUS'I'III. WAST : Cli1,11)R
GREASE TRAP
(Thi,smlinn nchJ urn be asmplcmdif the (Mmnil in tomos hundrW dollars ($11X1)
'
lay anyany mrsonceafthewa,ma wubject it) the Wm,'Co shall
not mnpiny any person in any manner ems mbeome subjecmntbe Wnrken'Cntnpem
SEWER- ANITARY-STORM IiA.2 Ir
Z
satins laws of California. Date
t
WATER HE E 'Nli F
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Applicant
NOTICE TO APPLICANT If, o0er making this Cenificte of Exemption, you should
become subject m the Worker's Compensation Provisions of the labor Code. you must
forthwith comply with such provisions or this permit volll W themed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affmuhatthere is a comwetion lending agency forthe performance of
the work for which this permit is issued (Sec. 3091. Civ. CT
Lendar'n Name
Lender's Addrns
1 cenify that 1 have read this application and state that the alive infiltration is
aroma. agree to coanply with all dly end county ordinances and stale laws relating to
building construction, and hereby nuthariic representatives oflhis city menmr upon the
WATER SYS rAl G
WATER SERVIC
NEW RESIDENTIA IL SQ. FT.
'TOTAL:
QTY. MECHANICAL PERMIT FEE
0-"
above -orcin led poPeny for inspection Pugwscs.
PERMITANCE,
(We) once m save, indenmlfy and keep humiless the City of Cupertino against
limbi hit.,, janitorial,cooliand expenses which may in any may achmhngain.q mid Cil,DD
TOMEC H.in
amsequcn¢ of the gruntingof this pcmtil.
APPLICANT UNDERSTANDS ANO WILL COMPLY W11'1I ALL NON. POIN I'NG
UNIT (1010,(lb)CPM)SOURCE
GEGUI.ATI ON/S. �4
NG DNIT(UVHR IO.IMN)CIM)o
irrgContmcl DacOOD(W/DUCT)HAZARDOUS MATERIALS DISCLOSURE.Will do.,plicamerr fumce Wilding occupail Imre err handle hmndommatedlIT(TO
as Jcfned by the Captain Municipal Code. Chapter 9.12, and the Heath and Safety
Code. Section 255321x)!
IgL000 BTU)
HEATING UNIT (OVER 1011.000 BTU)
VENTILATION PAN (SINGLE RESID)
❑Yca No
Wi11 the applicant or furore building occupant use equipment or devices which
emit hmufdoes air contaminants as defined by the Bay Area Air Quality Mamgcment
BOILER—COMP THP OR IOn xi BTU)
BOILER—COMP (OVER 100.000 B'NH
Uisvin't
❑Yc, ON.
J Chapter I Cal
I b mad the1 e,arbmaterials5,
AIR CONDITIONER
NIiW RtSIDP.NT1Al. MECII, 50.1'R
ncts
..ta hatthe
Ise Ilhal&Salary C1 Si .25505 15,534.1 utJa Ithttthe
is25533
bu It yl t allyl t 'ami I y 1 Cenifi It 0, spun
myth
e
nOhs Ian Tun sols hch 'Ih Ipri t un enl n[ 'I suanf Oce patsy
OFFICE
DING FERMII INVU
I.IiCI' PLUMB MECI
❑ ❑ ❑
JOII DESCRIPTION
RESIDENTIAL:
❑SPDWI.
❑ KITCHEN REMODHC
❑AUDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
[I STRUCTURAL
MOUB71CATION
[:1INTERIOR
❑CHIMNEYREPAIR
IMPROVEMENT
C]SWIMMINGPOOLS
❑ BATH REMODELIREPA1R ❑DEMOLITION
❑OTHER 'A
COMMERCIAL
❑ NEN' BLDG/ADDITION
❑ TENANT
IMPROVEMENT'
❑ OTHEB
SQ. FI'. FLOOR AI kA
❑ DEMOLITION
❑ FOOD SERVICE
HIIILUING DNI. ION III'.fiA
PLANCHECK ITH
ENERGY ITE
GRADING FIZE
SOILS PEE
PAID
Dam t
TOTAL:
BUILDING ITB
SEISMIC PEP
HLF:CI'RIC ITH
PLUMBING hili
MECHANICAL I'EE
CONST ;RU CfION'I
ffOUSING MITIGA'I ON ITE
PAID
Dae Her N
TOTAL:
ISSUANCE DATE,
ISSUED BY: G