S 0183 APPLICANTTOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMITNO,
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING-MECIIANICAL S 0183
BUILDING PROJECT IDENT F'ICATION
BUILDINGDRESS: r SANITARY NO. APPLICA HONSUBMI'FIALDATF
:%IS '?157 84-VQQ::T IsJ0 "i-&-l -2-9 6.X1049
OW ^'S ua ' ' � COMR CfOR'S NAME: rn IC O; SIC CONTROL#
IT"
IN ARCHRESCP/ENF; C•ER: LIC NO: ADDRESS; _ IFCA� ❑
CONTACT: ,///•���J ~Af• PHONE; - BUILDING PERMIT INFO
❑ Consultant Fels Paid by Applicant(Initial) BLDG ELF. PLUMB MECH
V/ II• LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOE DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9 fcommencing
Its
"Z with Section 7")of Division 3 of the Business and Professions Cade,and my license is RESIDENTIAL,
u 00 i PERMIT ISSUANCE
FF F n full force and effect. �'T 1��I„1,►�I ❑SFDWI. [I KITCHEN kEMODIiL
UkJ L¢ense Class Lic.# 11 APPLIANCES—RESIDENTIAL. DUHON [I PLUMBING RF.-PIPE
F W Eaac Comrucmr
til Z)o ARCHITECTS DECLARATION PANELS MULTI-UNIT '�MOGIFISTRUCTATIO
Z O)nK I understand my plaudits I lie a sed ss Public records UPT02IXIAMPS MODII9CATION
❑INTERIOR El REPAIR
94 {i Licensed Professional - - 201-IWAMPS IMPROVEMENT C]SWIMMING POOLS
Yy
OWNER-BUILDERanir DECLARATION Con ION OVER 1010 P ❑BATH REMODEIJREPAIR O DEMOLITION
I hereby affirm that 1 um exempt from the Commnor's License Law Little ❑OTHER
NLU following mason.(Section 7031 5,Business and Professions Code:Any city or munry SIGNS ELI: 1
, which mquims a permit to construct alcor,imptose.demolish.or rcput,any structure
prior o its issuance,also requires the applicant for such psrmiro file a signed statement jPFCIALCIRCUI MISC.
y thus beescing wit pursuant 70th)Provisionso off Business
License Law(Chapter COMMFRCIAI•
W GC
(commencing with Semion7IXp)nf Divisinnr the al Business and Professionslinde)av • 'MP.MEI'ER OR'POL ST.
a{it5 c C
that be is exempt therefrom and the basis for the allege)exemption.Any vinWtinn of ❑NEW BLDG/ DDITION I
W^rn Section 7031.5 by any applicant far o permit subjects the applicant to a civil penalty of POWIiR DEVICES. [I TENANT T�FOOU Sf:RVICE
F6of come then five hundred do[]. - IMPROVEMEN V
Lea ownerol the norm em to eeawith wa nos their sole cam nsutinn, SWIMMING POOL ELECTRIC
0 ❑ thele Y Y P Y 8 pe ❑OTNF��
III dothe work,and thehe Contisnota Livens Lawddfarot a(Sea.9t W4,owner
V('
a� mA Professions Code:The Cnmracmrr License Law dies not apply to an nwncr of OUTLETS—SWH'CHFS—FIXTURES
property who builds or impmves thereon,and who docs such work himself or through
his own employees,provided that such improvements on,not intended or offend fm NEW RESIDENTIAL ELECTR SQ FT.
aide.If,haw)vee the Wilding or improvement is sold within'
year o(complrion.the S .F7.11�µ(�.AyyREs�A�I LSQ.FF.
ver-builder will have the burden of proving that he did no build m improve fm pur- wr.� VU �a�'�
Mtve nfsaleJ' IIl� 'v`
❑I,us net of the property,am exclusively Contracting with licensed convectors to L'
couswct the Project(Sec.7044,Business and Profnsiom Code:)The Contractor's Li-
ecuse,Law docs not apply to an owner of pmpeny who build.,or impmves thereon,and QTY M O P FEE
who convects for such pollens with a commrons)licensed pursuant to Connectors U
License law. PERMIT ISSUANCE
❑1 ant attempt under Sec. .B&P C far Ibis..on
ALTER—DRAIN&VENT—WATE 1 VALUATION
Owner DateA
WORKER'S COMPENSATION DECLARATIONBACK FLOW PR(YI'ECT.DIWICE
I hereby alfimn under penalty of perjury one of the following dedumtians:
I have end will maintain aCen areae of Conxnuoself-insumfm Workers Compo- DRAINS—FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCHOb
anion,as provided I by Section 37M of the Labar Code,far the Perfommnce of the
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700oftchLdWr ,Code,for the perfonntnceof the walk for which this permit is issued. GAS—EA.SYSTF.M IINC.401TfLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS—EA,SYSTEM-OVER 4(EA) ' \
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASWINDUSTRL WAST(?INTERCEPTOR
COMPENSATION INSURANCE . G (VISION FEES
(This section need not W completed tribe permit isforonchundreddollars(4100) GRCASETRAP
or leas) - PIANCHECK
I certify that in perfwmumc th a :forwhich this permit is issued,Ishall SEWER—SANITARY—STORM EA.200 VE
not employ any pe n any man to )come sub lel to the Workers Comper- ENERGY PF'
Oz Nation laws of it ' .Ed WATER IRATER W/VENT/ELECfR GRADING 'I
7 O Applicant
q to NOTICE TOA LICANT;IL after making this Clinical,alExemption,you should WATER SYSTESITMEATING SOILS
-(~ 7 laecome subjeC m the Workers Compensation pmemons of the LaMar Code,you must
w. fonhwith comply with such provisions or this permit shall be deemed revokes]. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDIiNDAi.('LMB. SQ.PI'. PAID
U 0 I hereby affirm that there iso construction lendingegency far the performance of Data Receipt It
[Y. H the work for which this permit is issued(Sec.3197,Civ.CJ
TOTAL..
O U Lender's Name
{81 Lender s Adthcss
I calmly that I have read this application vad aam that the above infulocal. is BUII.UING FP. �~
L:V) carter.)agree to comply with all city and county ortinances ond.ytate laws sclutingm QTY' MECHANICAL PERMIT NFEESMSMICFEEV z building convection,and hereby authodm mpresentativeso(chis city were'upon theabove-mentioned property far inspection purposes. PERMIT ISSUANCE ELECTRICP E(We)agree w save,indemnity and keep harmless the City of Cupertino against
Iiobilitanjudgments.coslsandexperces which may irony woyorentuageimst slid City ALTER ORADD TO MECH. PLUMBING) E
onseltant, ft he grnnting ofhemetAPPLICA�NDERSTAN AN I PLY TH ALL NON-POLNTAN I PLY TH ALL NON-POINT AIR I{ANULING UNIT(TO 111.01X)CFM7MECtIANi( L FEF.DNSAIR HANDLING UNIT IOVF.R 10,(X10 CIM) CONSTRU ION TAX
Sign roof Appica ontracwr Date EXHAUST HOOD(WMUCT) HOUSING TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant mEnrore building occupant store or handle haxmdows materinl HEATING UNIT(TO I00,WU PTU)
Adefined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532fe)? HEATING UNIT(OVER 100h000 BTU)
❑Yes FIN. VENT]LATION PANS INGLE RESID) PAID
Dne Aeceip
Wiff the applicant or Powe building weapon use equipment in devices which )]OILER—COMP I7HP OR 1(X1,0(111 BTU)
emit howNous air contaminants as defined by the Bay Area Air Quality Management 1.:
District? - BOILER—COMP(OVER 103,000 BTU)
❑Yes ❑No
1 love mud the haxaWuus maed.]sAIR CONDITIONER ISSUANCE DATE
equirtments erode'Chapter M195 0l the Cali-
Poria Health&Safety Cade,Sections 25505,25533 and 25534.I undratan l that if the NEW RESIDENTLAL MECH. SQ.FT.
Wilding docs nm currently have a tenon,that it is my responsibility to notify the occupant of the mquiremcnts which must be met prior to issuance of a Cenificre of Occupt
Owneror amhmixed agwt Dam ISSUED BY:
OFFICE