B 0264 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
BUILDING-ELECTRICAL. PERMIT NO. O
CITY OF CUPERTINO PLUMBING-MECHANICL.AO
BUILDING DIVISION AFPLICATION/I'ERMIT BUILDING PROJECT IDFXI "CATION 50001
SANITARY NO. APPLICATION SUBMITTAL.DAT
BUILDING ADDRESS:
�) 0900f-AN,DE PLACE
OWNER'S NA E: ^fat�es _� PH _g46�`712 CONTRACTOR'S NAME hICNO:
RLI^'� t V'l fl NIC CON'IAOh p
kHCHTTECF/LNGINELR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Contaminant Fees Paid by Applicant(Initial) BLDG HLECT PLUMB MICU
LICENSHD CONTRACIGR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby anion mat I am licensed under move max of chapter v commitment, JOB DESCRIPTION
OW d'Z with Sccuon7&XMaf Division 3 ofthe Busimmsoni Pmfersiom Cede.and myllcemeeis RESIDENTIAL:
WOOi'F.RMIT ISSUANCE
CWin full force and e3ca, ❑SFDWI, El KITCHEN REMODEL
aUF-U License Class Li APPLIANCES-RESIDI!NTIAL C:1 ADDITION ❑PLUMBING RE-PIPE
p.Z W Uwe Cotnramm
teas AHCH]TEC I"S DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL,
Z O,n Z 1 mndersmnd my plans shall be mwd vs Public records I'ANIi1,S MODIIq CATION
OZ—O UP TO 200 AMPS I ❑INTERIOR El CHIMNEY REPAIR
F-4Fu] L"Mroad Professional 201.1010AMPS IMPROVEMENT SWIMMING POOLS
1 a I hereby affirm he I amOWNER-exempt
empt]fromthe omme m's License Law for he GVF.H]IXXI ANTI'S ❑OT ER0 BATH Eh10DEUR1iI'AIR U DEh�Oe N/
O C.U following rcawn.(Section 7031.5.Business and Professions Cro Any city of county SIGNS ELECTRICAL. `���,
3 LL I- which requires v permit ,,consruct.alter,improve,demolish,or repair any structure
r W O e pr if,issuance,alsone'tow,the applicant forstach permit to Men signed shadameart SPECIAL CIRCLE UMISC.
hullmv,locer,ed,...not,at the proAkons l dia Chroo-1111 I Lwtan,c Law(Clapter9
�a�� miumenengw'dis,,tot 90X3nfDVaol 3 of he Brine,and lrodex,in,GNC)or ILM P.METER OR 1101.1;INST COMMERCIAL,:
P,a e C that he is exempt thcrefnnn and the basis for,tic alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEM01,11'ION
-y Section]031.5 by any applicant for a Permit subjects me applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
it not more than five hundred dollars($500). IMPROVEMENT
Spa ❑I.as ownerof the property.or my employees with wages m Brei, hI,compeorawon, SWIMMING POOL ELF,CIRIC
p. will Jct the work,and the.amcture ds not intended oraReted far sale(Sec.]M;Business ❑OTHER
an vnd Rofesions Codu'the Commamm's License Law does not apply to an owner of UVILF.TS-SWI'ICHGti-FIXTURES _ _ -
propcny who halt,of improve,,dahman,aced who docs such work himself or through
- his own cmployccs.provided the,such pomts imrveenare not intended nr offered for NEW RESIOIINTIAh Ii1,LC1'N SQ Icl'.
sale If.however,the building orimprocanall i.,whi within one year of completion.the SQFI'.FLOOR AREA 41SQ.IT.
.
owner-budder will have the burden of proving that he did not build or improve far par- O A 8 D
peso of side.).• ,M1 licensed comranors w TOTAL
w ' 9' '
I.as o ,dcr of the propcny,am exdusivcly nhimaling wi
c msruet the project(Sec.9600.Business and Professions Gtdc:)That Contractor's Li-
seLaw duesnot apply to an owner ofpntpenywho builds orimprovcathereon,and QTPLUMBING FEE JUL 06 ANSD
who contracts for such projects with a cuntructnr(s)licensed puman,to the Contractors
I.iccnnc Love PERMIT LSSUANCE b
I am exempt tinder See ,It A P C for this reason III 'Ur ECU-CTI I IPI
Owner
^e U yk ALTER-DRAIN de<VENT I-WATER IIIA) VALUATION
WORKER'S COAL NSATION DECLARATION Tl BACK FLOW PHOTI3CF.DEVICE
'';j' 1 hereby off rte under penalty of perjury one of the folhnving Jcclamtiuns:
I have and will mainaina CcniOcme of Consent to self-insure for Worker's Compcn- DRAINS-FLOUR.ROOF,AREA.COAD. STONIILS- TYI'II CONSTRULTIO
.,mina.as provided for by section 3700 of the Labor Code.far,rte pcdnrmanee-fine
4 work Por which thly strait is iswcd. / - FIXTURES-PUR TRAP -
1 hove and will maintain Worker's Compensation Insurance,ox required by Section
3700ofhe LubtrCode.for the performance ofthework forwhich this penmitoissued. GAS-EA.SYSTHM-I INC.J DO]LETS UCC. Rppp AI'N
My Wmkces Compensationle,owee currier and Policy number am: GAS-F.A.SYSTI:M.OVER d(EA)
Cartier Policy No.:
CERTIFICATE OF EXEIMPTION FROM WORKERS' GREASERNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BOB EXNG DIV 1510,PIifS
flumecaion need not he<umplemJ if the pcmnit isfurunehondrtddella¢(81(X) GREASETRAP -
arles�.) I'LANCHLCK I9ili
cetil,that In theperformanenofda,vole litrwhiehhis permit is issued.Isnvll SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any manner so as,,hcutme subject ,,the Workers'Camper- IiNERCY FFF
Z sa,ion Laws of Califamia.Date' WATER HF,ATET/
R W/VENELECFR GRADING ITH
°z o Applicant /
NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you should WATLR SYSTEM/TREATING SOILS FIDE
a , become subject at he Worker's Compenst rat pmvisiom of he Lnbrt Cona.you must
Uj forthwith comply with, un his .it shall Is,demned revoked. WATER SERVICE
Q AID
a' C S'FRl1GTION LENDING AGENCY NEW RF.SIDENTIAhI'],MB, SQ.1T.
Oz' '-'" leading pc ,Uwe Rd.atiptN
U O 'Thereby nlBrm thhnherc is cnn.amc,lnn lcndin I'nnc� rlbrmanceof
W F. he work for which 11h4ovrmit is issued(Sea.3197,Or,CJ
TOTAL;
Lender's Name
U Lender
TOTAL:
Lender's Address '
} a I cenify that Itbavc mad this application and Stam that the above information is BUILDING Frai
,F. to erec,l agree to comply withal]city and county ordinances and state laws relmingm QTY. MECHANICAL PERMIT FEE SEISMIC FF,E
U rZ building construction,and hereby man iia representatives of,his cityto enter upon the
ab,c-mendnnM property for inspection amasses. PERMIT ISSUANCE ELECTRIC FET.
(We)ague,ut save,indemnify and keep harmless the City of Cuprommu against
laiddides.judgmnns,costs and expenses whichmay in any way acerae oguinst said City ALTER OR ADD TO MECH. PLUMBING FEE.
in consequence oldie granting ufthis permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO iff"CPM) MECHANICAL FEB.
SOURCE REGULA'I IONS.
AIR HANDLING UNI'I'(OVER lO.IXlO CFM) CONSTRUCI'ION'IAX
Signature of ApplicarmContracmr Date EXHAUST HOOD(W/OUC , HOUSING MITIM'1'ION FEE
I IAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store or handle hurndeus material' HEATING UNI'f(I 0100.003 BTU)
as delinwl by the Cupertino Municipal Cale,Chapter 9.12,and the Iimlth and Safely IiIiATING UNI I'IDVIiR IIq,1X1t1 IiT1A
CNet Section 25532(a)?
❑Yes E]No VENTILATION PAN(SINGLE RESID) PAID Dam Rmcipts
will he applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR[01.0011 BTU)
emit ha indous air comaminnio s as dclincd by the Bay Arco Air Quality Mamagemcnt TOTAL:
District, BOILER-COME I'(OVER IW,01f]BTU)
❑Yea ❑M,
I have read the Enchant fthjcrftojs hapirearraftax under Charter 6.95 of the Cali- AIR COND]'HONFR ISSUANCE DATE
forma Health N Safety Code,Sections 25505,25533 and 25534.1 undcmand that if the NEW RESIDIII IAL MECH. SQ.PT.
building does not Commonly have a mmanLthat it is my responsibility at notify me ocapant
ofmanu which mus beret prnrm issuance ofa Cenificam of Ocratancy.
&y No,Al To IV 6 C?
Owner m indurir.cl agent r IDme TDTA1- ISSUED BY:
OFFICE