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APPLANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY G4 q 1 I (_J I R%
CITY3F CUPERTINO _ I - BUILDING -ELF.CI'RICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
THRMITI40• — r I
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BUILDINGADDRESS.
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SANITARY NQ
APPIACATIONSUBMFFI'ALDATE
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OWNfiR'SNAME: PHONE
i;
O 1'34 C O'S NA IC NO:
NIC
CON'IROLN
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❑
ARCHITECT'/IiNGINEER: LIC NO:
A)D P'S:
CONTACT. PHONE:
BUILDING PERMITINFO
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((7 G/�/ / r (/
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
/H�(
LICENSED CON I' RAC I' OR'S DECLARATION
1 hereby affirm that I ant licensed order provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT ITE
JOB DESCRIPTION
PERMIT ISSUANCE '%�
vv+
widi Stafena](1(111,ef Dyisvision/3�f the Business and prufecsiCons C�ndicaannddar,icenscis
rce
force
RESIDENTIAL:
'CIS FOWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
inClfull
y`�' Lic.a �J� `+'we'
Dam Oj(qqContractor
CHITECrS DECLARATION❑MULTI-UNIT
I understand my plans shall Mused a public mcmds
[I ADDITION ❑PLUMBING RE -PIPE
❑STRUCTURAL
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
PANELS
UPTO 200 AMPS
I.kcnned prolc.Gunal
201-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby aRrm that 1 am exempt from the Conlraeo rs License Law for the
following reason. (Section 9031.5. Business and Professions Code: Any city or county
[I BATH RIiMODEUREPAIR (]DEMOLITION
[IOTHER
OVER FIX) AMPS
SIGNS ELECTRICAL
N I -
/ / Q /'/ X-� 4M, _
which requires a permit to constmct, alter, improve, demolish, or repair any .structure
prior to its is nuance. oRo requires the applicant for such permit,, file a,ignW statement
I SPECIAL CIRCUIOMISC.
that he is licensed pursuant to the provisions mf the Contractor's License Law (Chapter 9
(commencing with Section 9000)of Division 3 of the Business and Professions Coast or
TEMP, METER OR POLE INST
COMMERCIAL:
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 9031.5 by any applicant far a permit subjects the upplmmaba o civil penalty of
POWER DEVICES
[-]TENANT ❑ FOOD SERVICE
not mine than live hundred dollars (550(0.
01. as owner of the promy. or my employees with wages as their sole compensation.
will do the work. and the structure is not intended or offered far sale ----- __ Business
IMPROVEMENT ,
❑ OTHER
SWIMMING POOLLI: E1
OUTLETS -SWITCHCS-FTXTUH sic
C21(—
and Professions Code: The Contractor's License Law does not apply to an owner of
NEW RESIDENTIAL ELECTR SQ 7
property who Wilds or Improver thereon, and who docs such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. If, however. the building or improvement is sold within one year of completion. the
SO Fr. FLOOR AREA
S/SQ Fr.
owner -Wilder will have the burden of proving that he did not build or improve for par -
p,, of sale.).
E]L as owner of the property. am exclusively cunrrcting with licensed convectors to
TOTAL:
tmoum the project (Sec. 9tw4, Business and Professions Cede:) The Contractors Li-
cense Law does not apply to an owner if pmpcny who builds or improves thereon. and
(yrY. PLUMBING PERMIT FEE
who coni fur such projects with acrimonious) licensed pursuant to the Contractors
PERMIT ISSUANCE
Liecaw Law.
Ej I am exempt under Sea ,11& 1' C forth,, mason
Owner Dam
WORKde,,amOb1PIiNSAT10N DECLARATION
ALTER - DRAIN & VENT- WATER (HA)
RACK PLOW PROTECT. DEVICE
VALUATION
I hereby ulllrm under pcwlay of lmrjuryone ut the following Arnaamtinnv.
Q
0 Hasse and will maintain a Certificate of Cortarosell-arum for Workers Cnmpcn-
sutler, as provided for by Section 3900 of the Labor Code, for the performance of the
DRAINS -FLOOR. NOOIs. ARF„GOND.
STORIES
TYPE CONS 'I'RUC'I'[ON
work for which this permit is issued.
FIXTURES- PER TRAP
'I have and will maintain Workers Compensation Insurance, as required by Section
191 of the Labor Code. Eaflic performance of the work lisr which this permit is issued.
GAS-FA.SYSTEM-I INC. 40UTLEIS
OCC GROUP
APN
My Work rs Coopetradionnim, ra camerand Policynumbcram:
Caier �I�js Policy No.:
Cancer
llD/l1
GAS - ITA. SYSTEM OVER 4(E A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASI%INDUSTRL WASTE INTERCEPTOR
BUILDING D]VISION IBES
(Thissenlon need not he complemd il'thepemtit is burns, hundred dollars (S I W)
or Icss.)
GREASE TRAP
PLANCHECK 1tiE
SEWER -SANITARY -STORM EA. 200 FE
ENERGY FEE
I,citifyohm in the performance f,he work for which this permit is issued ,shall
not employ y person in any manner so as to become subject to the Workers Compcn-
an
WATER IIEATER W/vpNT'/ELIiCI'R
[TRADING Flili
ojinon Laws of California. Date
A,Awanl
NOTICE TO APPLICANT: If, after making this Certificam of 12xempaon, you should
become auhjecl to the Workers Compensation provisions of the Wlssr Code, you must
NATER SYSTEMOT EATING
SOILS FEE
WA'ER SERVICE
NEW RESIDENTIAL PLMR. SV. FT.PAID
forthwith comply with such provision%(irt this permit shall be, deemed revoked.
CONST RUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency for the performance of
r1 n _
M1, /Oath Ruip,#
f
lU T OTAL.
the work for which this Permit is issued (Sec. 3097. Civ.
C.) the
Lender's Ni a
T(YI'A h:
Lcndcr'n Addm,,
1 certify that I have mad this application and nate that the above information is
corect.I agrcemcomply with dl city anJ county ordinances and slum laws relating to
hni Wing can structimn, and hereby authoom mpresenatioc, of1hk city m cmer upun the
QTY. MECHANICAL PERMIT I FEE
EISMIC FEE L
PERMIT ISSUANCE
ILUCTRIC FRh _
above -r want mted property red inspection purpose,
(Wn) agree to rove, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING IEE
Iiabilitics,judgmenls, costs and expcnws which may in anyway same against said City
in consequence of the granting of this permit.
AIR HANDLING UNIT (TO IOJMXI CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURC IiGULATIONS.
AIR HANDLING UNIT(OVER 10.08(1 CFM)
CONSTRUCTION TAX
/'/�f'// d4m&
Signature of ApplcanVComictur Date
HAZARDOUS MAIERIAI4 DISCLOSURE
EXHAUST HOOD,(Will
1 IOUSINGMITIGATION FEE
HEXIING UNIT (TO 100A 0H'I'U)
bQk
Will theapplicanl affiance building uecupum store m icandle hosardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health unit Safety
Cudc. Section 25532(u,/HEATING
UNIT (OVER 100.W0 BTU)
VEN111,AC10NpAN(SINGLERISID)
❑Vas No
PAID
D:ne Receipt N
BOILER-COMPIJHPOR IUI,(XX1 BTU)
' Will thea applicant a future Wilding memo sot use e 1 or devices which
PP gr P Area
emit haeardous air emmminann as Jcfincd by the Ray Arca Air Quality Management
DisnicQ
[:1 Ya, Nn
T(
HOILT:R- COMP(UVER 100.0W BTU)
AIR CONDI'TIONI?R
,na,lireem, uer Chapter 6.95of the Cali-
I have mad theh esusmamridmnd
forma Health & Safety Code. Sections 25505. 25533 and 25534. 1 understand that if the
hui,dmj nnlcurendy have a tenant that it is my responsibility to notify the nVempanl
ISSUANCE/DATE
NEW RESIDENTIAL MECH. SQ. FT
ol'I nisw ich tM1cm tat,it... ixnum¢v ofo Call-c'a nl (lc m vmy.
ISSUED BY:
TOTAL:
Oachlawfintiffismims.,mad Dide
OFFICE