B 0373 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF
CUPERTINO BUILDING.ELECTRICAL 1 PERMIT;V0373
O_,.0 3 7 3
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECHANICAL SOOOI T//d�-`/'
IDENTIFICATIONLDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICAi'IDN SUBMCTT,ALgDATE
OWNER'S NAM' PFy;NF'�� CONTRACT 'S
,'VV.•,J/``✓h5 NIC CONTROLp
ARCIII'1'ECF/ENGINEER: LIC NO: ADDRESS 10 ❑
CONTACT: ,//�/yPHONS /a//CSI+] BUILDING PERMIT INh0
zbexw /rte/ � ❑ Consultant Fees Paid by Applicant(Initial) B DG E.ECF PLR .CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section7fl00)ofDivision Sof NC Business an�Qjlk�ofe�ssionsCde and mylicensc is RESIDENTIAL:
WOO
full foreeaadc modint�1 PERMITISSUANCE
WOO m •••�rrr////'-"�Yyf��T7" � ❑SFDWL ❑KITCHEN REMODEL
QUU Iacen,c Lic.N APPLIANCES-RESIDI3NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FF Z Uam Cnmmdor
I Eah RCHITECTSDECLARATI PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O n z I understand my plans shall be used as public records L GD MODIFICATION
OZ- UPT0200AMPS ✓•✓ ❑INTERIOR ❑CHIMNEY REPAIR
Liccnac.I Pml'csaio is[ 201-1002AMPS IMPROVEMENT E]SWIMMING POOLS
s¢� •aj OWNER-BUILDER DECLARATION OVER]Bud AMPS ❑BATH BE 0 E PATI ❑DEMOLITION
ff
1 hereby urm that I am exempt from the Contractors License Low for the-
O y UF. following r<uon.(Section 7031S,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
C Na which requires a Permit to constmet,alter,improve,demolish,or repair any manure
rt
.F. .J pdoo its issuance,also requires the applicant for such Permit o file a signed statement SPECIALCIRCUIT/MISC.
} that he is licensed pursuant to the Provisions of the Comactones License Law(Chapter 9 a
(Commencing with Section](If107of Division Sof the Business and Profession,Centel. TEMP,MBTER OR PULE INST. 'R "
W E n�' tum Be is exempt therefrom and the basis far the alleged exemption.Any violmiun of ❑NEW BLDG/ADDITION ❑DEMOLITION
..m Section 7031.5 by any applicant for a permit suhjma the applicant to a civil penaly of POWER DEVICES r ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(5500). IMPROVEMENT
Iq�6 do the nerofthcro norm titededwith woe asthel(Sm.cam Ilan, SWIMMING ELGCI'RI
TfAAYY G ❑ P Pe Y Ye P Y Bes pens, � TTtER---���
will Jn the work,and the structure is not intended or offered fosale Isec.]044,Business
and Professions Code:The Contmens's License Law does not apply N an owner of OUTLETS-SWI'TCHE5-FIX'fUNES
propcny who builds or improves themmt,and who does such work himself or through
his own employees,provided)that,such improvements are not intended or od'cred far NEW RESIDENTIAL ELECTR SQ
ii� in
side.IL however,the building or improvement is sold within one year of completion.the 1.90,FT.HOUR AREA L .CF.
wnerhuiWar will have the burden of proving that he did no Pu
build or improve for r- r J U N' O 8 190
pose oa%ne .F^ I •7
❑Las owncr of the pmperty,eat exclusively contracting with licensed contractors it)
✓V u
construct the pmject(Sec.70a L Business and Professions Code,)The Connector's Li.
cense Law does not apply to an owner ofpropeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE nb
whoeooracns for such Limoco
Limiters with a contr(s)licensed pursu nd to the Commctors of
License Low. PERMIT ISSUANCE
I um exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WAIER(HAL VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of Perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen. DRAINS-FLOOR,ROOF,ARE ,GOND. STORIES TYPE CONSTRUCf10N
sution,as provided for by Section 3700 of the Labor Code,for the Ferfonnance of the
work far which this permit is issued. FIXTURES-PER TRAP
Cf'1 have and will maintain Worker's Compensation Insurance,as required by Section
ofrthe�Laabor Carla,for the perfonnance of the work for which
kthis
-pe.is is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS. OCC.GROUP APN
My Caner: r� n fi sumnce cvriePlcy No.: `x •47- GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed if the permit is for one hundred dollars(51 had GREASETRAP
or IcssJ PIANCHECK FEE
I certify Nat in the perfmmencoofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Cnmpen- IiNERGY HE
Z cation Lnwsaf Califiodi.DateWATER HEATER WHEN VELECI'R
7 Applicant ) GRADING FEE
:I N NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should a WATER SYSTEM?BEATING become xuhject m the Workers CnmPemafinn provisions of the Labor Code,you most SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
.a7. z CONSTRUCTION LMDINGAGENCY NEW RFSIDF.NTIAL PLMH. SQ,FT. PAID Da¢ tte' p
U work
which
ahthisthat emere isacurtuuc.i3097.lending agency for the performance of the work for which this permit is issued(Sec.J09J.Civ.CJ
01--' Lenders Name AL:
U Unders Address TOTAL' s
W I county that 1 have reed this application and shite not the above information is BUILDING FE
Lo") correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V 4 building construction,and hereby aulhoHwe representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for in,,rlinn pnrpnecs. PERMIT ISSUANCE D -ELECTRIC FEE
(We)agree I.save,indearify and kegs harmless the City of Cupenino agninsf
iubidities,judgments,costsand expenses which may in any way accmeagainsf said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. - PLUMBING /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICA.HE
SOURCA elkLATIONS.
(//�"y AIR HANDLING UNIT(OVER 10.0011 CFM) CONSTRULTI NTAX
n m Applic�f a�mr Date EXHAUST HOOD(WDUCI-) HOUSING MITIGATION FEF,
HAZARDOUS MATERIALS DISCLOSURE ASO
Will the applicant or future building occupant store or handle ham -
endous material T- UNIT(TO 100.000 BTU) • 0(
as defnal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532nd? 1 ' HEATING UNIT(OVER 100,000 BTU)
E]Yes 1{NJn _ VENTILATION FAN(SINGLE RESID) PAID Date I Receipts
Will the applicant or future huilding occupant use equipment or devices which BOILER-COMP f3HP OR I(gI,OW BTUJ
it Nomilous air contaminants as defined by the Buy Ama Air Quality Management TOTAL:
em
UixtrictP
❑Yee No
BOILER-COMP(OVER 100,000 BTU)
�
I have read the haysrdoos nsamrials rmimmuleaa under Chaplet 6.95 of the Cali, AIR CONDITIONER ISSUANCE DAA
Sealant 8
ford.Health&Safety Code.Se505,15533 and 25574.I to dersrmal that if the NEW RESIDENTIAL MECH. SQ.FT. Q r- �Tly
building res torumlyhaveatenant,that it ismymsponsibllity tonmlythenecupent (�
olrhe
of "which must a met proton issuance of a Cer ifi to Q
er rt%Morino agent oat TOTAL a ISSUED BY:.
OFFICE