S 1992 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PUSITNO. 1I•LJMNGMECHANICAL992
BUILDING DIVISION APPLICKPION/IERMIT
BUILDING PROJECT IDENTIFICATION
BU1LDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Di
1030 e95 (2-k c3 -
O 'SNA laHONE: C RACIOR'S NAME: LIC NO:
6 C`— J f NIC CONI'ROLM
ARCHITECI]IiNL NEER: LIC NO AI R 'S: Sa /1 q a'w� F-1CONTACT': PHONE: 11'x/¢ BUILDING PERMIT INFO
/ ❑ Consultant Fees Pail by Applicant(Initial) BLDG ELECT PLUM= MP❑CH
l J '�!8 ❑ ❑
C/L•LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby ammrthat I tan biomed under powi,inns of Clamber 9(cammteren, JOB DESCRIPTION
IQ1�04Z Oc, with Section of Division 3 ohne Beninese and Prd'eaam,s Code,and my license is RESIDENTIAL:
(• ,— infillforceandeReaL PERMIT ISSUANCE ❑SFDWL L1 KITCHEN RIiNI
aUV License Class Lic.g APPLIANCES-RESIDENTIAL. ❑ADDITION EMM. BING RE-PIPE
F+�W Dutc Commctor
m m ❑MUI.TLUNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
F H 2 1 understand my plans shall he used as public records PANELS MODIFICATION
QZ4Q UPT0200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
z W Liccm,d Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
id OWNIiR-BUILDER DECLARATION OVIiR 1000 AMPS
❑BATH REMODEI/REPAIR Ll DEMOLITION
aL I hereby affirm that I am exempt from the Contractor's License Law for the
�aOLU following reawa(Section]1111.5,Business and Professions CWr.Any city or county SIGNSELECTRICAL [1 OTHER
❑1 LLO y which requires v permit m cnnmmct,altar,improve,demolish,or repair any smtn tra
prion,itsmuoue,alsII re,fres theapplicant hasuch permit In li to it signedamement SPECI AL CIRCU I'1'/MISC.
} that he is licensedpustart to the provisions nfthe Contractor's License Law(Chapter9
I+I�pO (commencing with Section]00B of Divisionlof the Hu>iness and lhafessions Care)., TEMPMETERORPOLEINST COMMERCIAL:
dy of� that he is exempt therefrom and the basis for the alleged exemption.Any violation of Es ❑NEW BLDG/ADDITION ❑DEMOLITION
iCm{C Seclinn 70315 by aayappllcant for a perntitsabjects the appliat (roc civil penalty ofPOWIiIt DEVICIiS IMPROVEMENTIMPROVEMENT❑lHNAN'I' ❑FOOD SERVICE
�..� motor.than live hundreddollu,($5017.
F r I.mnwncrof the tt,orm emwith woes as diseases,Com tion. SWIMMING I'OOI,ELECT RR []OTHER
ProfK Y Ye P Y g pcnsa OTHER
Q will Jo the work,and the striation,is not intended oroRered for sale(See. Business
m and Professions C ,:The Contractor's License Luw does not npply to an owner of OU')'LErS-SWI(CHES-FIXTURES
�' Qalproperty wbn build,nr improves thereon,and who does such work himself or through
rrk
his own employees,provided that such improvements are not amended ar offered for NEW RESIDENTIAL ELECT' SQ
sale.If,however.the building or improvement is sold within one year of completion,the SQ.17.FLUOR AREA SISQ.FT,
wnerbuilder will have the burden of proving that he did not bid lJ or improve far pur-
po¢a ol'sa1v.).
❑I.ns owner se Ij the property,,B exclusively contracting with licensed mmromors m TOTAL:
tame Lo des nor applSvvy
o an Business and Professions Cade)the Com awa,mon.Li-
whoamaccocs notapplytoan with
a of copaabd(ywhobuildsnrimtolhe thereon,and QTY PLUMBING PERMIT FEF.
wbn nmtrae,finsuch projects with n cnntmemr(v)I Icensed puauum nr the Contractor's
License law. PERMIT ISSUANCE
C]I am exonpt under See. ,B&P C motors rcawn
At:[HR-DRAIN&VENT-WATER(1?A) VALUATION
Owner Dal,
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty ofperjury one of the following decdamtions:
❑ I have and will maintain a Cerifcam of Consennn pelf-insum for Workers Compen- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3710 of the Labor Code,bathe perfo ournec of Clot
work lir which this permit is issued. 19 FIXTURUS-1'17R TRAP
❑ I have and will maintain Workers Compensation Insurance,in,required by Section
11
3710ufth hor Cade.fur the performance of the work for which this Permit is iv1mrL GAS-EA.SYSTRM-I INC.4 OUTLETS OCC.GROUP APN
C Wm a Cn ppensa'� sura ,cu ' sdicy No, GAS-EA.SYS'U7M.OVER 4(EA)
MyW F1m alley Nn.:
CERT( CATE OF EXEM ION FRO WORKERS' GREASHINUUSq'RI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be emr,lctul Uthe email is Tarns,hundred dollars($100) GREASE]RAI'
or less.) PLANCHECK FRE
L certify that inthe Pedarmanceofthework for which this permit isissued,)shall SEWER-SANITARY-STORM EA.200 ET.
not employ any person in say manner an m m become subject the Worked Cnmpcn- ENERGY FEE
Z scion laws of California.Dene WATER BEATER WNENT/HIECI'R
- W
O Q Applicant GRAD( G 'EI' S/
F7 w~N.r N(B ICE TO APPLICANT:If,after making this Certheare of Exemption,you should WATER SYS1'ESYTREATING
(•" > become subject m the Workers Compensation previsions of the Calor Cale,you must SOIL. FEE s
Loll A mn .ith ..,Iy with such pammitumor this permit shut]lo deem ad revoked. WATER SERVICE n
CONS'T'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ,FT, G
�a z P�
U 2 l hereby affirm that them is a construction lending agency for perfordance of Dene EM a
the work for whish this permit is issued(See,3092 Civ,C.) 11 Ur
ULender',Name O T�y TOTAL:
lender's Addre,s I f
6. 1 certify that I have read this ap,lictucar and state that the alove information is BUILDING FEE
y corrt l agree to comply with all city and county ordinances and sole lawsrclafngm QTY. MECHANICALPERMI'T FBI:
V 7, building comtmction,and herchy uuthorim representatives of this city m enter upon the SEISMIC FEE
alsnve-mendenal property Iia ar,,slinn pugtose, PERMIT'ISSUANCE
(We)agree m save,indemnify and keep hornless the City of Cupertino against ELECTRIC FEE
Iiabilitics,judgmems,costsmal expanses which may many way amain.,ons,said City ALTER OR ADD9'0 MECH.
in consequence of the graming of this permit. PLUMBING PEIi
APPLICANT UNDERSTANDS NO W .CON LY WI'I'll ALL NON-POINT AIR HANDLING UNIT(dl)10,001(FM)
MECHANICAL.PE
$Cllr Aq' )NS.
AIR HANDLING UNIT(Dy1?R 10. W CFM) CONS'rRUCr)ON TAX
Sigonuren pliant onmamr Dutu EXHAUSTH(l(lD(W/DUCT)
HOUSING MITIGATION FCfi
HAZARDOUS MATERIALS a mmeli
.OSUR
Will the applicant or Tenure loilJing rccupam,tnre orhanAlchmurdouz material HEATING UNIT fI'O 10(1,00113TU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)] HEATING UNIT(LIVER 110,001 B1 U)
E3 Y. ❑No VENTILATION IIAN(SINGLE RESID) PAID
.
Data Re,eipr p
Will the applicant orfuture building occupant use equipment artdevices which BOILER-COMP(lHP OR 10X,000 BTU) CD
mit hazardous air ttmommano us defined byythe Bay Area Air Quality MnnrrManagement p F
District? ROUTER-COME(OVER 10.000 BTU)
E]yes ❑No
I have read the hammlous materials requirements under Chapter 6.95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
India Health&Samy Calc.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. � 2
building does not,mmody have a tamear,that it is my mspmsihility m many the exact,am
of therequirements hudo must he met priorm issuanceofa Certificate ofOesa,mcy.
Owner ur amhnrized agent Dam TOTAL: ISSUED BY:
OFFICE