B 0487 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P17RMIT NO. }^Q(7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - p 11 �o4V 1
�► BUILDING PROJECT IDENT'IFICA'TION ' " S0001 i4.��G. VV
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'TF
c7522 b-3 JL07- /ss5— 2�
OWNER;SNµ�' PHO E'. CONTRACTOR'S NAME: LIC NO:
U N/C CONTItOLM
ARCHITE 'EER: L 'NO: ADDRESS: - / r--•
coNTAc': PxorvE: BUILDING PERMIT INFO
�j•_ - IQ ,. I ❑ Consultant Fees Paid by Applicant(Initial) HLLD,G/ EILECCfT III UN it
L SEDC RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
❑ Z 1 her y to ire that I.am licensed under aa,joiam,of chapter 9 mammenei"g JOB DESCRIPTION -
�0ZC with Sermon 7000) FD 3oflhc Business and Pm s' s od an licenais PERMIT ISSUANCE �- 1
�� in fullll hacea
y U1- Licensee LiCN SFDWL
6F Z!� El KITCHEN Rj7PIE
NQI1 Dute Cnmmmor APPLIANCES-RESIUIiNT1A1. ❑Al]DITION ❑PLUMBING RfiPIPli
F-pm ARCHITECTS UECLA Iq
zooez I understand my plans shall he used as public rear Ns PANELS MULTI-UNIT ❑S'fkflCfUkAL
O Z r4 p UP'f0 200 AMPS MODIFICATION
s<F40F't�i Lsensed Pm(esuonal El INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201 Ipp AMTS InIPROVEMENT ❑SWIMMING POOLS
yG CC I hereby nl'finn Ihm I an exi mvl from the Couracmr'x License Urea for the OVER 1003AMPS ❑HATH REMODEURITIOR ❑DEMOLITION
x 3 d U following reawn.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F^O which requires a PCrmn Io coke",alter,improve, m
deolish m repair any swmure
v�m prinnnid rssmncq also mmires the upplimun forwn
chpenittordeaxigoal smtcmem SPECIALCIRCUIT/MISC.
6'q0 That he is licensed,...anon thepo,isiumnl'the Committees License Low(Chapter 9
(commencing with Sation70110)rf Idvision3ofthe BusinesslandProfesxionsCodeprr THMP.MEpER OR POLE.I ST COMMERCIAL
S c e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLUO/ADDITION 1:1 DP.MOLI"f10N
Section 7101.5 by any applicant for a permit subjects the applicant to a civil penalryof POWE DEVICES
F Z i• not more than rine hundred dollars D150). ❑TENANT C1 FOOD SERVICE
G ❑I,mnwnendthe property,or my employees with wages as their sole mnlpereation, SWIMMING POOL ELECTRIC IMPROVIiMENT
wdl do the work,and thesuucmm n
is m amended oro0'cred for sale(See 7044.Business ❑OTHHR
and ve
Professions Code:The Contractors License law dres not apply no an owner of OUTLETS-SWITCHES-FIXTURES
�' •' progeny who builds or improves thereon and who dres such work himmlf or ttuough
Ili'own employees,provided that such impavcmenls arc not mended or ffined for NEW kHMDENTIAL HLECTR SQ PT.
sale.IL however,the building or improvement is sold within one yearnRontpletimn the SQ.PI'.FLOOR AREA VSQ.14.
owner-builder will have the burden of proving that he did oat build or improve for par-
pure of eaten.
1,asowner r the Sm.local,
am exclusively contracting with licensed dnmve16, i TOTAL &qs
construct the pajcct(Sec.]DW,Business and Professions Code:)The Comrac'or'Li
Cense la'w does not apply to an owner of property who huilds or improves thereon,ane QTY. .' PLUMBING PERMIT FEE
who contracts for such projects with a eonlraclor(s)licensed paramount to the Cant ors `
License Law.
❑lam exempt under Sec ,1{&PCfor this Mason PERMIT ISSUANCE r7 Al
OwnerDam ALTER-DRAIN&VL'NT-W A)
WORKER'S COMPENSATION DECLARATION VALUATION
I hereM1y ullirm under Penalty f BACK FLOW PROTECT.DEVICIi 3 a y I cob .
yo perjury one of the following Jednrndnns.
❑Ihaveandwill mairmin a Certificate of Consem m self-insure for Worker',s Compem DRAINS-FLOUR,ROOF,AREA,GOND.
cation,as provided for by Section 37W of the Labor Crah.for the performance of the STORIES TYPECONSTRUCPION
work for which this permit is issued, FIXTURES-PF.R TRAP
❑1 have and will maintain Worker's Compensation bvwrance,as requiem!by Section
3700 of the laImeamoto
,fmthe peif o arta of me rk for which this pc lis issued GAS-EA.SYSTEM-1 INCA OU ET
My Wnrkcr's 'inn Inco ter an tic nu arc:' OCC GROUP APN
Camey Po GAS-EA.SYSTEM-OVER4 UTA)
TA O UEMPT N ROM ORKERS'
URANCE GRF.ASEVIDUSTRL WASTE INTERCEPTOR
Cl his ten Ih Ilyyet rl ut'e I r un J II s(81011 'oo " WILDING DIVISION,FEIis
orless) sir rs ass nr GREASETRAPPI,canaaa'hat nt a aof w k m' pC a sissuee,Ish:Jl
not employ any Person in any manner xn as to become subject Iola,Workers'Con.Pem SEWER-SANITARY-STORM EA.21X1 FI'.
cation Laws of Catamenia.Dae C F Z_2Q
0 Applicant 1 WATT?R HEATER WNHNT/ELEC R
CR )ING FEE
NOTICE.10 APPLICANT:Work If,aper making his Cisions of of Exemption,you should WATER SYS'I'I?M/fREA'TING
become scomp to the Workers Compensation Parisians of the Labor Code,you most S 1 S FEE
2,W Aforthwith comply with such provisions rr Ibis pem'it shall od dcemN reeked.
WATER SERVICE
�Dz CONSTRUCIIONIENDINGAGENCY NEW RESIDENTIALPLMB. SQ.FL PAID
U0 1herbyafftm that here is.commuctom lendingagency far the aformanateof Dee Receipttt
W the work fo,which'his permh is issued(Sm.3097,Civ,C.)
Q U Lenders Name
LV Lenders Address TOTA1 a '10'TAL:
Q., I certify Nat 1 have read this application and sem that the above information is BUILDIN / Z
h mmecl. agree a comply with all city and county ordinances one sere atw.s relming m QTg,, s 'MECHANICAL PERMIT ° FEE s
V z building nmswnion,and hereby vmhnrire reprcsenmtivcs ohhis citymenmr uponthe SEES I
above-mentioned property for indemnify
on kee,hs.
(WTol,raeasave sindemnify and kaProulin any wyammCu ninon nal, PERMI'I'ISSUANCE - �
Pe 6 ELECT FBI?
mliaeilities,judg to Iticam rind ng Rhes parent,
tory in any way uame against said City ALTER OR
se era NDER-en'ANDSthis lD WILL
PLUM GFEIi
APP n {NT UNDF,RSTANDS AND WILL COMPLY WITH ALL UN-P INT AIR IIANDL G NITIT toy CFM) or
S Rt 1?ZEGULATIO C MECIIA (CAL FEE
f AIR HANDL - NIT(OVER 10.000 CIrM) CO.V'STRI ION'1'AX
Smmmrm AppllmmU Thba 1 Dee EXHAUST
HAZARDOUS MATERIA(S DISCLOSURE ( ) HOUSING MITIGATION FEG
Will the applicant or future building occupant store or handle hazardous macrial HEATINGU 1 '('TO 101,(1(10 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and SaIdy
Code Satirn 255321a)? ^ HEAI'INGU 1 OVER 100,000 BTU)
❑Yes `I/IPCya%atg`�•
VEMI'IfATI ' bh(RWGhInE 0 PAID
Will the upP)icanI, I'eare building occupant use equipment or devices which Do,, Receipt k
c.at hezardoas air mountainous as definod by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
r District? Tt 1.:
❑Yes HOILIIR-COM P(OV EIt 1010,000 11
I hai
d the hamMnus materials requirements under Ganger 6.95 of the Cali- AIR CONDITIONER
Iamla Hcaafety Codc,Sectiens 25505,25533 and 2534.1 mtdeerwnd tam if mo ISSUANCE DATE
haildirgdaurrently havealenantIlliFmresibiliifNEW RGSIDEM'IALMIiCII. SQ.F1'. � `enem,req 's iqi n9•,be ma to issuance ora e,
Owner addimn , U'e
,gem TOTAL: ISSUED HY:
OFFICE