00020005 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY on A onv;-
TY OF CUPERTINO BUILDING-ELECT RICA], PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG MECHANICAL
BUILDING PROJECT'IDENTIFICATION
NUILDINGAUDHLSS: SANITARY NO. APPLICATION SUBMIITAI.DAiI
/o]Z/ 'Y14r e•�k � 7 s 3 IZiaZ> 200.0
C� CI NTH 'fORSUN'MkE� _LIC NO:
C•!•M(�B�IGI 4 D NIC CONOTOLx
CI II'1'LCTIENGIN[ER: I LIC NO: j&�6. rr -CI - ❑
CON'LAC'll PIION17 Y `Yisx CJ '�/{ BUILDING PEIiMITINFO
01
❑ Crnsultant FiRs Paid by Applicim l(Initial) BI,DG ELLEEC,T/,f't'tJMB MECI1
❑ LIB ❑ ❑
LICENSED CONTRAUIOR'S DECLARATION QIy ELECTRIC PERMIT FEE
1 hcrcby affirm mat 1 am licensed Dicks,,ov6 m,of Chapter 9(commcneimg JOB DESCRIPTION
OC8Z with Section 7UW)ofDivision 3 of the Business and Profession.Cude.emit my license is RR �II�?FNTIAL:
W OPERMIT ISSUANCE
=�� nfull force and ellen. /l' ! 7 ❑SFDWL El KITCHEN REMODEL
QUV license r�L- ��V ConLie, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPF.
F Z W Du —[--/r--_--r--Contractor
)1 106 ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
F H Z ` 1 undemanJ m I h II he uud.as hlic rcnrNv PANELS MODIFICATION
C' —M yPansx a Im / UP TO 2W AMPS �-
❑INTFiR10R CHIMNEY REPAIR
Fntw Licensed Ptofe,milil 201-10x0AMPS IMPROVEMENT El SWIMMING POOLS
OWNER-BUILDER DE LARATION
CJL .'4i OVER I(0)AMPS ❑BATA REMODEUREPAIR ❑DEMDI,ITIQN
C Q I hm'cb,n1Tum tont 1 an,cxcmpt frim the Contr:mlor'a License Law d'or the
5.2
O d U following mason.(Section 7031.5.Be,iocss end ProtcAuns Code:Any city or amity SIGNS ELECTRICAL ❑OTHER /D<l
{il3 LL N which requires a permit to cnnstmet,alter,improve,demolish.or repair any soccmre
�LLut, priorm its i ourn.,nP.,quires the applicant far such paoku,file'asigned smermal SPECIAL CIRNIT/MISC.
� � that he is licensed pursuant to the provisions of the Contractor's license Llw(Chapter9
�typ� (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or 'fEMP.METBR OR PULE INST. COMMERCIAL'
a a e that be is cxcmpt Iherc(rom and the basis air One alleged cxcmpmom.Any vioLumn of EW BLDG/ADDITION ❑DEMOLITION
W'^,N Section 7031.5 by any applicant fora permit oRjmts lite applicanno%civil penalty of POWER DEVICES NT [I FO
t mum than Eve hundred dollars(S500).
Sp ❑ 1,aemoalof the property,-(my employs with wages as inchoate compensation, SWIMMING POOL ELECTRIC
[- will Jo the wurk.and mertmdure snot intended or onemd for sale(Scc.70,H.Business THER
Wand Professions Cade:The Contractor'sLicense Law doav not apply to an owner Of OUTLETS-SWITCHES-FIXTURES
IL prolieny who builds Or impspoe%thereon,and who dors such work himself or through
his own employees provided that such improvements sere not Intended or nfli rcil for NEW RESIDENTIAL ELECI'R SQ Fr.
xnlc.11,however.lire building uritnpmvemm�tiunlJ within enc ycarnfcompletin.,the SQ.Pf.FLOOR AREA AISQ,[7. .
owiier-hailder will have the burden of proving the hu did not hui1J ser Improve for pur-
pos of sale.).
I,as Owner of the Property,am exclusively contracting with licensed contractors In )IA"
construct the project(Sec.7044.Business and Prob shone Code:)Me Contractor's Li-
se Law does nil[apply to an owner of pmpeny who builds or improves thereon.and QTY. PLUMBING PERM IT FEE
who commits fnr.wch project with a commaor(s)licensed personal to the Contractor'%
License Los, PERMIT ISSUANCE
[.in cxcmpt under Sec. .B&P C for dtis rtason
ALTER-DRAIN&VEST-WATER(CA) VALUATION
Dae
ncr WORKER'S COMPF:NSA'1'ION DECLARATION BACK FLOW PROTECL DEVICE
I hereby affirm under penally of perjury one of the following declarations:
I have and will aeinein aCcrtiticuteof Comenl loself-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
,anon,as Provided for by Section 370()of the LuMu Code fur the performance of the
Ilk lin which thinpermit isissued #$0443djpI FIXTURES-PER TRAP
invc and will mainmin Workeran
's Compentlon Inurm
sec,ax quaed y Section
71H1
III the Luhnr Code.lin the perhI....mmnfthe work It,,which this permit,issued. GAS-EA.SYSTEM-I INC.4 OUFLETS OCC.GROUP
My WnrkCompcnsmi n u�'i nes currier and Polley mmlh r/ Jay/
Currier: Policy NO.: / O.5 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMFTION FROM WORKERS' GRLASI%INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION EELS
(This asetion need not be completed if the Mnmit is forone hundred dollars 0100) GREASE TRAP
nr less) PLANCHEL'K FEEI certify that in the performance of the work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 Fr.
not employ any Person in any manner so m to subject become subjeco the WOderi Co nfair ENERGY FEE
Z sation Laws of California.Date WATER HEATER WNENT1EA.ECfR GRADING FM
z o Applicant
NUI ICE qU APPLICANT:IL after making this Certificate of Exemption,ymu should WATER SYSTF,MO'REATING
(/) SOILS PE,ii
a ; beanie, oOlp y the Worh Is.Compensation parral hal of the Libor Code,you must
Lk1 1'nnhwitn snntply with mcM1 Prnvninns nr lM1lx Pcnnn nhull be JcctnW revoked. WATER 512RVICE
Q
Z CONSTRUCTION LLNUING AGENCY NEW RESIDENTIAL PLMit. SQ.14, PAID
I hcrchy a)irm that them is o mmtractimn leadingagcncy Pim lire performance of Dole Rewiplx
Othe work for whhh this permit is issued(See 3097.Civ.C.) - ...1"' Lender's Name n ^ n 1 TOTAL:
UJ Lenders Address TOTAL:
} W 1 cenify that I have read this application and state that the above information is 1 11 a BUILDING PF.9
CL. � �11
Z mndingconagree mcomply
and hwith eado,lcilyand countyordinancesof and site lawsreltingto QTY. MECHANICAL PERMIT FEE II I�
UZ builJing<unamctinn.and hcrcby aothomereprtsenmtires-(this city reenter upon the LI SEISMIC FLIT
'Novctnentined Proper,Por inspection pa,Oi%. PERMIT ISSUANCE FE .ECT
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and e%penvs which may in any wayacemeagainst saidCRY ALTER OR ADD TO MECH. PLUMBING PEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) Dv MECHANICAL FEE
SOURCP.NE�l1�AT111NS.
AIR HANDLING UNIT(OVER 10.000CFM) CONS'fHUCTION TA%�
Slgnuturu of APi�snt/Cootractor F Dvte LiX11AUST 11000 OVIDUCT) HOUSING MITIGATION PCC
11AZA RDOUS MA I'ERiALS DISCLOSURE
Will the applicant or future building'ecupant store or handle heartdom material BRAT]NO UNIT(TO I(i,.(a)BTU)
as defined by the Cupertino Municipal Cute,Chapter 9.12,and the Health unit Safety
Gale,Section 25532(%)" HEATING UNIT(OVER 1W."BI U)
�l'es ❑NoPAID
VENTILATION FAN(SINGLE RF5ID) Date Receipt#
Will the applicant or future huilding Occupant use equipment or devices which
emit hmardous air contaminants as defined by the Bay Arca Air Quality Management NOILER-COMP(3HP OR W,IKIO BTU)
District? I:
Dyes ❑Nn BOILER-COMP(OVER IW.f)(10 NTU)
I have read 0e harzNous materials requirements ander Chapter uS5 of the Cali- AIR CONDITIONER ISSUANCE DATE
I ia Health&Safety Code.Sediore 25511.5,2.5533 trod 25534 1 understand that if Lha NI?W RESIDENTIAL MECH. SQ.Fr
ndutottg don%nm etrea,eaat11"llym-Na+miMhlymnmify me acnnum
mroe rcgtdret thrieht nsthe imnl r1O O,ac cul a Cenifiaate n 0
Owner ora thoriaedA eat Date 'TOTAL: ISSUED BY:
OFFICE