31379 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO. IT (]
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 3 J
BUILDING PROJECTTDF N'I'IF'ICATION
R ILDINGADDRMS: SANITARY NO. APPLICATION SUBMITTAL DAT(
/06753 H01001A#4 RD. IWo , CA 5014 D?�
NER'S NAME: PHONE.: CONTRAC'1'ON:SNAME: LIC NO:
ALZ" A.
LI �Z I NIC CONE Bit.0
6?ARCHITECT/IiNGINCIiR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fifes Paid by Applicant(Initial) BLpT/ ELECT PLUMB M IGH
LICENSED CON'I'RACfOR'S U;,ion, l Chap QTY. ELECTRIC PERMIT EEE
I hereby ufiinn Thm I um licenceduatJur provisions of Chapter 9(armmenming JOB DESCRIPTION
0 a'Z with Seetis.40Wlof Division 3 of the BmiaOssand ProlTssions Code,and my license is 0SFDRESIDENTIAL:
{�O O PERMIT ISSUANCE
W• in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
aUU
License Class LieN APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBINGRE-PIPE
N Q Eu Dat[ Commnor
ARCHITECPS DECLARATION ❑MULTI-UNIT El STRUCTURAL
F D m PANELS
z O In z I understand my plans shall he used as public records MODIFICATION
oy:o UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Use...d Pm@xxim act 401-1000AMPS IMPROVEMI?NT
OWNER-BUILDER DT;CLARATION OVER UXX)AMI'S ❑BATH REMOUEVREPAI MONITION
C W< I hereby aHirin that 1 am exempt Found"Cnmmdnr's License Law I...The
X3Q.Up.. f.11coang reason.(Secdon 9031.5.13mainssanJ l'rofesainns Cale:Any city or coumy SIGNS ELECTRICAL ❑OTHER
til LL N which require,a permit m[onamcl..Ret.improve.dam:B.h.or mpair any saucmre
FLLOg Prior o its issuance,also requires the applicant for such Permit o file a signed statement SPECIALCIRCUFUAUSC.
}' that he is licensed pursuant o The provisions of the Contractor's License Law(Chapter 9
u1�00 (commeT ingwith Semlrin]IXXI)of Divisionlofthe Businexsund Professions Ctd[)mr TEMP.MITER OR POLE INST. / COMMERCIAL:
that he is exempt therefrom and the basis for The alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
o, Section](131.5 byany,upplicum fora permed ubjec,theinsiicanmd
noucivil petyof POWER DEVICUS []TENANT ❑FOOD SERVICE
W anmom,than five hundred dallum(S5fX0.
.F..z.Y IMPROVEMENT=6 1,as owner nl the progeny,nr my employees with wages as their sole cmmpennutinn, SWIMMING POOL ELECTRIC
QFC will Jo the work,and the gmmare is not intended croflhred far.sale(See 70,9,Buxiacs. []OTHER'pj m and Professe ions Code:'ITC Contractors License Lew does nm apply to an mans,of OUTLETS-SWITCHES-FIXTURIS
a 3 progeny who builds or improvthemon,and what docs such work himself or untaught
his own employees,provided that such improvements are not intended offere
r od for NEW RESIDENTIAL ELECTR SQ FT.
sale If.howeven the building or improvement is sold within one year ofcompletion,theSQ.FT.FLOOR AREA VsQ.FT.
er-builder will have the burden of proving that he did not build or improv[for pur-
Ixrm oleate.).
❑ 1,as owner of the progeny,am exclusively summering with IicemW conwmod to P A 1 D
mstmet the p oj.1(Sat.9(90,It me,,and P..I ..ions Cale:)The Contmaor'.v IJ..
cove law does not apply it)an owner of property who builds or Improves m[reon,end QTY. PLUMB( E IT FEE
who contracts for such projects with a contortions)licensed pursuant o The Contirri NOV 04
License Low, PERMIT ISSUANCE 1996
❑1 an exempt under Sec. .B&P C far this reams
ALTER—DRAIN&VENT—WATER(G)
.Owner Dam Ur .V f""1Y ITYk/N
Wm under
COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby w al mai under Penalty of perjury one of the following de rkcr,% n.c:
Ihnvc and will;naimnina Cenilicme mf Consent nr xelLinmmfor Worked,Cn;nO:n- DRAINS—PLOOR,RWF.AREA,CONU' STORIES TYPE:CONSTRUCTION
xndon,as provided for by Sectio 3]0(1 of The LufsnCole,for the performance at the
work lin which this permit is issued FIXTURES—PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37W ofthe Labor Code.for the performance mfthe work for which This p[mit is issued. GAS—EA.SYSTEM-1 INC.J OUTLCrs occ.GINUy APN
My Workers Compensation Insurance carrier and Policy number are:
Carrico Policy No.: GAS—EA.SYSTEM-OVER i(EAT
CE RTI IICATH OF EXEMPTION FROM WORKERS' GRFASPJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need i he emmpleted Ethic ptran,is fnr on[hundred dollmx(S 1(X) GRFASETRAP
.it I"'.) P CHEC FEEO
I certify That in the performanceofthe work for which this permit iOmxacd.I shall SF.WGR—SANITARY—STORM HA.i00 T.
not employ any pers n in any manner sat as w hcnnnc object to the Workers'Compen- E RGY EB
Z ration laws of California.Date WATER BEAT ER WNENT/ELECTR
Applicant GRAD G FEE
z NOTICE TO APPLICANT,If.after making this Cenifcamof Exemption,you should WATER SYSTEMITIREATING
[cm
F ; hme s.bjxvt m the W latex Compensation pmvi,io.in The wed,Cade,you must 501 FEE
forthwith comply with such provisions or This permit%hallM deemed revoked. WATER SERVICE
G Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.
V QIbeach,allirm that there i.sarou,nuction lend,ng u,mcy for The perfn it, sof Data Receipt TO
F The work for which Thi,perail is inroed(Sac 3097.Civ.CJ I.
H. lender'.Name TOTAL:
{USI Lcndcrs Address TOTAL. (LDING ECF:
y I unify mal I have read This application soil score ohm Th[above information is
F' (n correct.I agree m comply with all city and county oninancex and sum laws relating to QTY, MECHANICAL PERMIT FEE /q
U Z building construction.and hereby suburbs,represendttves of This city to enter upon The SEI. IC FEE V
ahovemcuumm d property fnr inspection p apsecs. PERMIT ISSUANCE.
(We)agree It,save,indemnify and keep harmless the City of Capra iso against F.LET-fR 'FEE
IinMlllicgjuJgmcnta,coed moil cxpcnnca which nmy inany way aecme againn axil City ALTER(lRADDIOMECH.
PLUMBING
rcqncuce mf The granting atf Ihte Prmru1.
mf 'i
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM)
MECHANICAL[ -t
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,00s)CENT) CONSTRUCTION'fA
Signature of AnplicanUCommnor Date EXHAUST HOOD(W/DUC) HOUSING MITIGATIO EC
HAlARDOUS MATERIALS DISCLOSURE
Will theappllcumor fmure building occupim,tom in handle haxallous material HEATING UNIT ITO 101.000 BTU)
sus defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,S.,...a 25531(a)i HEATING UNIT(OVER IIXI,INNI
Yen No
' VENTILA'TION FAN(SINGLE RCSID) PAID
applicant or future building t use a ui t or devises which Doe Receil
Will Thea M
pp gmacupay Pmsn BOILER-COMP(3HP OR 100,(X10 BTU)emit bmallous air comaminams as defined by the Bay Area Air Quality Managcmcnt TOTAL:
Dlslllnl^
❑Yo ON. BOILER-COMP(OVER IOu"BTU)
I have mail The haauNoms materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
p
lmmuHaiddi&g.lmyCode,Section,25505.�533;i
n125534.I understand that drilic
h:nifine
NEW RESIDENT'IAL MECHSQ
buWin,does m cutreinytovc.wat Mayamarty woutify hesweupum
of the muremnins which nna he nnet pror to issuance at Certificate .FT.
of Occurymcy
Owner or aulhori>ed."at Dale TOTAL: ISSUED BY:
OFFICE