S 0688 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL P15ITNO 0 Op
RLILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL. J 00
BBLDING i,RDJEcrLDltNr[TICATHm
FBUII:DING0)DpCSS: � � ' /�/� SANI'I'ARY N(l. APPLICAT�N.l'UI)MII'I'AL UAfB
77
1R' N IT/iDD I'fIQQNL: ( ('RAC 'S NAME:" LIOC'NOv
�SIo 571- N/C CONNN/I�ROI��.#a��
CHIT N I EBR: LIC NO'. ADDRESS: ❑ SpN
CD FACT: /��' f3l.IILDING PERMIT INFO
Consultant Fees Paid by Applicant(lnitialr-� BLDG ELECT PLUMB MELD
O Nrlad.. /rLX�
uCEN51IDeONTRAn OR's UEC.ARA IDN 'QTY. ELECTRIC PERMIT'. Flili
lhastyafnm,Nat Iamf,ha B under pmvkian>oro Capmr9lcallimming JOB DESCRIPTION
DoZ with Sation]IMNB nfDivision3afthe Business and Prn&stints Code,eM mylicensn is 1'
WOp Qs PERMIT ISSUANCE WL ❑KITCf1EN REMODEL
FLLF"m toll farceandeRece 734-36
�UU •nseC as. [,ic.pT— APPLIANCEWE
ADDITION ❑PLUMBING R17 PIPE
FZ AmCnnoannr
Fly HI TE CTS DBCLARATIAN•-•" � PANELS
❑MULTI-UNIT ❑STRUCTURAL.
Z pv�Z 1 undersmnd my ]...,halt be used as public records MODII71CATION
C2=f`� UPT02WAMPS ❑INTERIOR El CHIMNEY REPAIR
Ia:In�M LicensedPodcssi...l 2f1I-HSMIAMPS [MPR O MENT []SWIMMING POLLS
C� ; OWNIIR-BUILDIIR DECIARAT'ION - OVER IIMp AMPS ❑BATH JFJ/R}l'Alk DEMOLITION
w 9 Z 1 hereby aBtm that 1 am exempt from the Contractors License l.aw for the N +/
sL5d d U following reason.(Section]831.5,Business and Professions Cale:Any city or county SIGNS F.LECTRICAI. ❑OI'HC•R
❑1 a LL E' which rWuira u permit to amstmet.elmr,Improve,'em"'L or repair any do azure
t �0 yriorm its issuance,alsomqulres the applicant(orsuch permit rite a signed statement SPECIALCIRCUITIMISCAll,I
w
> that halt licensed pursuant m the pmvisiomofthe Counselors License Law(Clm mit)
oaf (commencing with Scaion]IXp)of Division3 of the Puniness and Professions Ctde)ar TEMP.Mf:I'ER OR 1'OIJi(NZ17.
0.y a C that he is exempt therefrom,and the basis for the alleged exemption.Any violation of = NAAsD�)ONO EI DEMOLITION
lisp ti• Scclinn7831.5 byanyopplicontforo pernili subjects the nppllcvm ton civil penalty of POWER DEVICESQ7HNANT ~R /N ❑FOOD S13RVICH
y nm more Nvn five hundred dollars($51Np.
FZ> OTHER
IMPROVEMENT
=6 (]1,azowneraf the pmpeny.or myempinyces with w�gesa Neirsale compensation. SWIMMING POOL L•LIiCTR
.ESO will do the work.and the structure is not intended or offered for sale Igoe. Business - ❑OTHCR
tail
and Professions Code.The Contrnemr's license Law does not apply to an owner of OUTLETS-SWITCHIS-Fl
d a-' progeny who builds or Improves thereon,and who does such work himself or Ibmugh his own employees.provided that such impmvemems am not intended or olleral far NEW RESIF)FNT1AL HLECsale.If,however.the
building or improvement is sold within one year Of completion.the SQ.FT.FLUOR AREA S/SQ.ITowner builder will have Ne burden of proving that he did not build or improve for par- O 11
poseOLsale.),I,as owner of the progeny,um exclusively contracting wit licensed contractors to
warmer he project(Sec.7014,Business and Professions Cade:)The Contractors Li- 6-J.
wlmc Law does not apply to on Owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
countess for Koch projects with a cnntructm(s)licensed pursuant m the Contmenrs
License Law. PERMIT ISSUANCE CbliffLWl�
I amexempt under Sec. ,B&1'C for this mason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORK17R'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby union under penalty ofperjury one of Ne following declarations: I t
I haveand will maintain.Cenificateof Consem mnelf.irme for Wmkeh Compem- DRAINS-FLOOR.ROOF,AREA.COND.
cation,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I hove uiW will mvimuin Workers Cnmperentinn Insurance,as required by Section
3701 of the Ionic Code,for the performance Of Ne work for which this permit is issued GAS-HA.S YSTEM.I INC.401311.17 iS OCC,CROUP AA
My Worker. ompcnsabnn lnmmnce eerier and Policy number �a / a GAS-FA.SYSTEM OVER 4(EA)
Policy Na.:��J�p�- -`sra
e, ' VI IC BOF fEMPION FROM WORKI;R OREASNINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE III&VICSODYWON FEES
(This section need not be completed if the permit in for one hundred dollars(5100) GREASE'IRAP
Or less) PLANCHF.CKE
lcertifythmin Ne perfnrmanceof the work far which Nis permit o sued,[,hall SEWER-SANITARY-STORM EA.200 PT.
not employ any two on in any manner set as to become subject to the Workers'Comped- ENERGY FFT:
sZ ration Lawsof California.Dam WATER HEATER W/V HNT/ELEC'I'It
Z Applicant I GRADINGFEE
tr fA NGUCETO APPLICANT:IL vflat making his Certificate of Exemption,you should WATER SYSTEMn REATING
a ^ become subject to the Workers Compensation provisions of the Labor Cale,you must SOILS FEE
G fanitwith comply with such ppoi,mm.Or this permit shall be deemedrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAB. SQ.ET. PAID
`7 2 Ihercmt
hereby affirm Nm w
eis aconsction lending agency for the of [)am N 'iM N'
L)� tiro work for which this ponnitls ismed(Sea.3097,Civ.C.)
u' F Isndert Name TOI'AI,:
LU Landers Address T
.I certify that I have read this application and late that the above information is HULLOING Flil? y
E" y correct.I agree to comply with all city and county ordinances Mad state laws relating m QTy, MECHANICAL PERMIT I'I.
U Z building noctruotion.and hereby authorise representatives of Nis city memerupon too SEISMIC FEI3_
above"mentionc l property for inspeetion putloses. PERMIT ISSUANCE /�
(We)agrco m save,indemnify and keep house.the City of Caper inu against ELECTRIC FEE 19
Iiabilities.judgrams,costs and expenses which may in any way amore against said City ALTER OR ADD'1'0 MECH.. w /tl
in consequence of the granting of this permit. PLUMBING FEE Lr
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN I'1'(1014(MM)CFM)
SOU .EREGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT LOVER 10,8(p CFhD CONSTRUCTION TAX
Signature of Applic omacmr Data 13XHAU5'['1I000(WIUULT7 - HOUSING MI'T'IGATION 19111
HAZARDOUS MATERIALS DISCLOSURE
Will applicammfuwrebuilJing a:apam na7m orhandlehmalloux mmedal HEATING UNIT(TO IW,IMIH BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hamm and Safety
Cale,Section 25532(.)? HEATING UNIT(OVER HMLWB DTU)
C)Yes ❑N VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use Nuipmedt or devices which Data Receipt N
itO.Odnus it emitamimsms as defined by the Bay Area Air Quality Management BOILER-COMP GHP OR 100.00( BTU)
TOTAL:
❑Yes No BOILER-COMP(OVER 10),00111"TLD
I have read the hazardous materials requimmemx under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Imam Health&Safety Code,Sections 25585,25533 and 8534.1 understand that if the NEW RESIDENTIAL MECH. SQ,rr.
building d7osootcur,hivbmmIbv naT that ptsnry respnnsibllitymno8ly the nceupunt _ ��/`���{q���•////�
nfthcm{uimmcnts which mustMmet priomnissu.nce nfa Cenificme of 0ceupancy. I��✓' .v
Ownc'miati umdagcm Data ISSUED BY:
OFFICE