S0001B0293 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NOsw 0 2 9 3
APPLICATION/PERMIT PLUMBING-MECHAN'ICAI,
BUILDING DIVISIONBUILDING PROJECT IDENTIFIC'A'I'[(IN "0001
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBM1"ITAL DAH
O tivvzef-1Z�
OWNER'S NAME. ,
HONE: CO T CfOR'S NAME: LIC NO:
NIC CONTROL"P . 974 Tfor
ARC IT C�`IEER: LIC ND: ADDRESS: ❑
CONTnCT: PHONE: 'l dU1LDING PEkMI'f INFO
❑ Consultant F es Paid by Applicant(Initial) BLDG liflJ�iC-l' PLUMB MECfI
a W � 5—
LICENSED CONTRACTOR'S DECLARATION Dry ELECTRIC PERMIT FEC
1 bemhy affirm that 1 am licensed ander previsions of chapter v(commencing JOB DESCRIPTION
0�2 with Sedian 70(0)of 1), "on3ofthe Bu,inesx anJ Pmfes.iom Code.and my license is r RESIDENTIAL,
WOO G PERMIT ISSUANCE
F�WF n full forcewnd effect. 3 / ❑SFDWh 3(ITOIENREMODEL
.,UU Licemc Class Lic.p AI'PLIANCF.S—RLSIDEN]'IAL ♦ ❑ADDITION ❑PLl1MDING RF:-PIPE
F Z W D:nc Cnnv:minr
`mad ARCHITECT"S USCI N'ION ❑MULTI-UNIT ❑Sl'RUCIURAI,
Z'
'Doh
I undernumJ my plans shall he usN a,sn is rccoNs PANELS MODII'ICNION
OZ-0 UP TO Im AMPS ❑INTERIOR ❑CHIMNEYREPAIR
F:.(nIW Licensed Professional 201-1000AMPS Ih1PROVF:M4:N'I' SWIMMING POOLS
C Q I hereby affirm that I
OWNER-BUILDER
rae exempt In+mECATIN mC onrmcOur's Liccnve law for the OVER IOm AMPS ATH RIiMODIiI/REPAIR 0 DEMOLITION
[I OTTER
W3 F following reason,(Section 7031.5.Business and Professions Code:Any city ar county SIGNS ELECTRICAL
..`O which"miss apc a..emothur,Hit,imp derami,lb,.1 repairY lhoorme
pro t t, hame,alsohr,uu,do.,plicant for suchpc t to File it signedstatement SPFCIALCIRCUI IIMISC.
yi mato 1 Ip n th p t' Ilh C t t / 1 i (Chpmry
CC a`3 a,s COMMERCIAL
W ypO gam nagwiO Section](NN))ofD Division Jnfthe Businsss JI duns ons CoJe)nr TI:MP.METdR OR('OLE INS'(
11 c that he is exempt therefrom and me basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDI'HUN ❑DEMOLITION
Xm Sect 7031.5 by anyapplicant fora permit subject.me aPPIiOmh m a civil penalty of POWER DEVICE. ❑TENANT ❑FWD SERVICE
0t mom than Five hundred dollar(55th). IMPROVEMENT
fS�
Fll.as ownendthe property,or my emslnyeo with wager as theinnk compcnsatinn, SWIMMING POOL ELECTRIC [I OTHER
wpm will do the work,and thewuemre is not intended or offered mrsale(Sec.7044,Business
and Profession,Cade:'ITe Contmaer',Liccnve Lnw does not apP11 to on owner of OOH.ETS—SWI'rCUEs—FIXTURES
M.
pmperty who builds or haprovns thcmon,and who docs such work hincelf or mmugh
hi,own employe...pr'vided that such impnrv.amm¢are not Intended or oflercd far NEW RESIDIiNTIAl.1?L1;C'Ht SU h1'.
sale.If.however,the building or improvement in sold within one year ofcomplOome,the SQ- ' .I'L(OR AREA 4✓SQ.4T
der-huilder will have the burden of proving mm he did not build ar improve for put- JUL O aO
pose of sales T Tl'AL:
0 L as owner of the pmperty,am exclusively contracting with licensed contractors to
construct the project I...704k,Business and Professions GJe.)tax Contractor's,croe Law dress not apply to an owner of 11,11Hy who builds or improves thereon.and QTY. PLUM N ERMIT FEF. CITY lir IeUFGfllllAJ
who contracts for such projecn with a ennraeo(s)licensed pu¢uunt In the Contracroda l f
Larose Laws. PERMIT ISSUAN
I am exempt under Sec. ,B&I'C for this reason
ALTER-DRAIN k VENT- ER IIA) VALUATION
owner Date
. WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICs
I hereby ldbrm made,penalty of perjury one of me following declarations: T
RI have and wi 11 n ainmin a Certificate ofCnnscnt to self town,far Wmk.Is Compen- DRAINS—FLOOR.ROOF.AREA,CO STORIES I PECONSTRUCTIOD
,ntior,o provld.d Inr by Section 3700ol'the Luba.Cade,to,the perfmmance of the
rwaich thix lit"
i..issued. FIXTURE,$—PEk'IRAI' e
hove and will mwintain Warg,e,Cnm,evedon Insurance,an required by Section
3](X)of the L.Mr Ctdc.❑d the perfnnnanc of the work for which this permit is issued GAS—EA.SYSTEM-I INC.I OUTLETS OCC.GROUT' APN
My Wort C nn Insfdance r r wad Policyn�:Jj�
Carries Policy NS:Mt,5yr 6-wA GAS-EA.SYSTEM"OVER4 EA)
CERTIFICATE OF EXEMPTION MOM WORKERSGREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IEES
('This xcctlan need not N:cwmpleled it he permit is for one hundred dollars pi I00) - GR17ASETRAP ��i
Ile less.) PLANCHF.CK Plil?
1,reily that in the perfemonce,(me work for which this scorn.,issued,l shall
SEWER-SANITARY-S'ICBM EA.21111 PI'.
not employ any person in any m iremr,o is m hecnme subject to the Workers Comped- ENI,RGV ITE
Z nation Ww,mf CLliRtmia,Dam WATER HEATER W/VENT/ELECTR GRADING FEE
O O Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMIPREATING SOILS FEE
a ; Mcnme,object m the Worker's Compensation provisions of the Lahti Cole,you must
fadwith comply with ouch provisions or this served shall be deemed revoked. WATER SERVICE.
PAID
IAL CONSTRUCTION LENDING AGENCY NEW RESOD IIN'I'IAI.PLMB. SQ.PT' pure Rccd Pik
I hereby dfirat that there is u conematlnn lending agcnry for rho perlonneace of
U - the work for which his permit is issued(Sec.3097,Civ"C.) 'TOTAL:
Lender's Name
O 'TOTAL:
U Lender's Adder, II �1
I conn mat 1 have read thio applieminn anJ state that the above information is BUILDING FEE
tiN eonect.I.,.e to comply with all city and county ordinances and state laws relating to QTy, MECHANICAL PERMIT MEF SEISMIC FEE
U z building construction,and hereby authariec representatives of this city In enter upon the /
nbovcanrnuoo;ed property for inspection purpises. ('ERMIT ISSUANCR ELECTRIC FIB.
(We)agree ht save,'m lOnho y and keep ha odes.the City el Cnpcnm,against e
labilities,judgmcros.costs and expenncnwhi.h may in any way attme against,aid City ALTERORA,D'IUMF H PLUMBING FEE.c,n¢yuence of the granting of this permit. e
in
APP (CANT UNDERSTANDS AND W1LI,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL F94i 1
SO CE REGULATIONS, —
AIR HANDLING UNIT(OVER10.000CIM) CONSTRUCTION LTX
awrc of Apphle"I'mmctov oat / EXHAUST HOOD(W/DUCII • HOUSING MUIGAIION FEE
IA],ARDOUS MA'I'I?RIALS DISCLOSURE
Will the applicant orfutumboddingtxevpani.tnrw,rhandlehu'eallousmaterial HIiMING UNIT(IO IN.NX)BTU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and me Health and Safety HEATING UNIT(OVER 101.110)BTU)
Code,Section 25532m)'I
❑Yes X1117 VENTILATION VENTILATION PAN(SINGLE RESID) Ume Rmeipt4
Will the applicant or furore building aeupant use equipmeat or devices which BOILER—COM('OHPOR 100,000 BLV)
tit h,md.ms air conounimers a,delined by the Bay Are.Air Quality Management TOTAL: w
District? BOILER—COMP(OVER❑B00O 13'1'U)
❑Yes
I have rod the haraNiwumalerialn requirements under Chapter 6.95 of the Cali" AIR CONDITION ER ISSUANCE DAP I,
forma Health&Safety Gds,S.ions 25505.25533 and 25531.1 understand that if the NEW RESIDENTIAL MUCH. SQ,IT.
but dox,macurtentlylete M 'Ill.,, is v >Nility to notify the hecmpent
'meats whidLmusebe mpnnna...u
ofVre Ceniticme of OceupancY.
he autow,ed ai Date TOTAL: ISSUED BY
OFFICE