S0001B0446 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO...%
BUILDING DIVISION APP IACATION/PERMIT PLUMHhNG-MECHANICAL S0001
BUILDING PROJECT IDERTIFICA'I'ION
tl UILDING AUURGSSSANITARY NO. APPLICATION SUBMITTAL DAU
: '
s s dzr�,aN�Y �=9
OWNERS NAME: PI E CONTRACI'OMS NAME: LIC O.
-���� NIC CON'BOLx
RCHI'FECr/ENGINEER: LIC NO. ADDRES W2 ❑
VX A&AIC14A (311"
CONTACT: PBONE1 BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECi' PLUMB MEc11
LICENSE[)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCM15TION
I hereby affirm that I uln licensed under provisiouN of Chapter 9(commencing
�O�z with Section7000)ofDirision Sof the Haziness and ProfensionsCde.znd my licenx iN RESIDENTIAL
C1_
W 0 in full force led ellen PERMIT ISSUANCE FDWL 0 KITCHEN REMODEL
Q,UU License Cu.c Lic.I APPLIANCES—RESIDHNTIAI, ADDITION 01'LUMRING RE-PIPE
FZW Date�Cnnorwom El MULTI-UNIT CSTRUCTURAL
N66 ARCHITEC'SDEC.ARATION
PANELS MODIFICATION
7 pNZ 1unJerswnJ lny plum shall he uNW a.c pnhlic rcenNs
UPTO200AMPS
Cz-o ❑INTERIGk OGIIIMNIiYREPAIR
FC?,F,W Licenced lvnfeseinn;ol 201-IO(0AMPS IMPROVEMENT L)SWIMMING POOLS
CYC, OWNER-BUILDER DI: OVER I(XOAMPS ❑BATH REMODELMEPAIR 1)IiMDLITIGN
(Wy C Q I hereby affirm that 1 am exempt from the Contractor's License Law for rhe .HER �jj�Q[, ie;
[,�]d7FO
X it.,U fnllowing tenon.(Suction 7031.5,13n,molx and Profession.Ctdm Any city or county jSWIMMING
ECTRICAL IV rL��
W 3 a which requires a permit to conslrucl,alter,improve,demolish or repair any Ntmcma,
t�: pdurmitx issuance,alw rtquires lM1e."dwmn forzuch pe.if flcasi'mal'u temem :IWL
C.
,�r0�yy'jiJ tha lo,i,li.... purnuum ul the provisions of Oc Cuntmemr'x License Low(CM1up¢r9 COMMERCIAL:
=CC (comnendng with Section 7000)of Division 7 ofthe Business and prnl'cusimn Code)or EINS'I'.
a a e C Ion he is exempt therefrom and be basis for he a11x,W exemption.Any violation of ❑NEW BLDG/ADDITION ❑UIiMOLI'1'ION
xgNSermon 71gl5M1y nny npPlicnnl fornlxrmit mM1lcaxthc appliaum to acivil pcnaltY n( POWER C1 TENANT ❑FOOD SERVICE,
not nmte than fee hundred dollars Wait Si PROVI?M ENT
f= 01.as owner ofthe pmpeny,or my employees with wages as their sole compensation. CTRIC ❑ "HER
-7C will an the wnrk,anJlcaruchuc is nt moundcd arnftered farxule(Sec.T)W,Business1'3and ITofessionc Code:The Comm it—License Law does not apply'to an owner of -PIX'I URESpropcny who builds ar improves thereon,end who Docssuch work himwlf m IhrougM1 F.CIR SQ Fr.
his own employees,pmvidal that such Intpmvemenleate nrn intended or of Bred for SQ.17F FI.00R AREA VSQ.FT.
sale.If.however,the building or impmvemcm is sold within one year of completion,the
owner-Wilder will have the burden of proving that he did nor(wild or improve for pur-
poseol' aI0. 'IOFAL'
0 1,as owner of the pmpeny,ma exclusively contracting with licensed camranon nt -
onsnad the project(Sec.7044.Business and PoAccsions Casio!)The Contractor's Li-
cense Law does not apply to an ow net of pmpc'ny who builds or irnm,tvc%thereon,and QTY. PLUMBING PERMIT FEE
whocnntmets for such projcetc with o amoacme(s)licenmd purst anus the Contmtlar'e
License Law. PERMIT ISSUANCE .35-50
0 1 am cscntpl under Sec. .R&P C fur d,is reason
ALTER-DRAIN&VTNT-WATER(EA) VALUATION
�)wn<r Date
Wm under S COMPI3NSAly on DECLARATION RACK PLOW I'ROI'ECT.DEVICE
I heathy affirm under penalty of perjury one of the following Jalarations
�ihnvc end will lnvinwin aCeniticu¢of Cnnsenun self-insure for Workeh Compen. DRAINS-FLOOR.ROOF,AR G.COND' S'rOR1ES 'TYPE CONSTRUCr1O!
,tion.us provic,d lin by Seatian 3700 o1"t he Labor Code.lin the prdmor asst of"'be FIXTURES-PER TRAP
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
W of the hWr Code.for the Wdonnance of the work for which this permit;,i,.ved. GAS-EA.SYSTEM-I INC.4 OUTI d1S OCC.GROUP APN
,Wody Cp T / Pub,No!pe 3�/ s ap en'
Ca r m: r GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE(INDUSTRL WASTE 1NERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
TFllls,eaion seatsol bcemnplaued il'Ihepennil is for nn,hundred dollua(S ban CREASE'I RAP P CHIR'XFEE
or Ie,.)
Loy .ythalinthcan,notnnecoDM1ewod for which this i,permiti,ar,'Co shall SfiN'ER-SANITARY-STORM EA.200 Il'' YFE1i
not'employ any person in any manner sn us to Leeann subjuun the WaderlT Cnmicn- TT
z smionlmwe of California.Date / WATER BEATER WNENTIIiLECTR 0. 00 LNG 1' '
Z
Q Applicant 0
NOTICE 10 APPLICANT:11,after making this Ccnif,au,of Exemption, o.'board WATER SYSTEMC BEATING
F .N. hnotttc wbjcct IT.
the Worker's Compensation provisions of the Lxmr Calc,you maw .,
forthwith comply with such pua,Nion,or this pennitshall be deemed revoked. WATER SERVICE
a0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3, SQ.ET PAID
Dae Rneipl p
U 0 I lurcby affirm that hem is a construction lending agency for the performance of
O — 'he work for which this penin is issued(See.9097,Civ,C.) TOrAI:
UU Landers Name TOTAL: S So
rLender's Address BUILDING IEE
a 1 certify that 1 have read this application and,tam dal the above information is
wF+if) cutest.I agree,comply with all city and county ordinances and sine laws misting to QTy. MECHANICAL PERMIT FEE SEISMIC FTE
U budding ennamdion,nd hcoebymnbariv..o m,mmivxxufthis city treater upon the
aMrvcmentioned oupsay for inspection purlw.cec. PERMIT ISSUANCE ELECTRIC FEE
(We)agree u.zee,indemnify and keep harmless the City of Cupertino against
iubilitio,,judgmcros,cows and expense,which may in any way accmc agunst,rid City AUTERORADDTn MECH. PLUMBING FEE
in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO IB0gCFNU MECHANICAL .13
SOURCyyy'R- . ''TIONS.
AIH HANDLING UNIT(OVER 10,000CFM) CONSTRUC'TIO LAX
S acre of Applicunl/otractor Ovte EXHAUST HOOD(WMUCD HOUSIN . TIG ON FTE
HA%ARDOUS MATI;RIAI S DISCLOSURE
Will the applicant or future building occupant store or handle hamNnus material HEATING UNIT IT 0100.1X0 BTU)
It,della,by the Cupeninn Muu,,,sil Cotler CFupter u,12.and the Health and Safety BEATING UNIT(OVER IW,00013'I'U)
Coale,Section 25532(aT! PAID O Ycs 0 No VENTILATION FAN(SINGLE RESID) Dec Receipt x
Will the applicant or future Wilding uxup rni ex equipment m kvwv,which BOILER-COMP(311p OR 1111.0BTU)
.c
emit hamrdouair contaminants as defined by the Bay Area Air Quality Management (X) TOTAL:
DoInkl'! BOILER-COM Is(OVER 110,0X)III U)
C Ycs ❑Na
NR CONDI"TONER ISSUANCE DATE
1 have ad the h:vmil Sections
dstcquitc33=i u255 Chapterh ou ofthe if ie
brevia Health&Saddy tcomllyha Sections25505,25533and23534.1arMerstadthinmthe NEW RESIDENT'IALMECH. SQ,FL
building Aces not cunt tly hour tJhat it is my msrymsihiliry vmmify the occupant /
of the requirements wh"rn nell 'or m issuance of a Cenilicute of Occupancy.
Owner or uutMnir.ed agent Date TOTAL: ISSUED HY:
OFFICE