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B 0488
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO /f II BUILDING DIVISION APPLICA N . MIT - PLUMBING-MECHANICAL SOOOI �O T'88 BUILDING PROJECT IDENTIFICATIO l HUILDING�DHG55: �� - td- SANITARY NO. APPLICATION SUI{MITTAL DATE 06 �- 3 1� Q E WNER;S NAMOil PHONE: CONTRACTOR'S NAME: LIC NO: N/C CONTROL# AR ENGINEER: LIC NO: ADDRESS: ❑ 93S D O CONTACT': PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid 6y Applicant(Initial) BLDG, ELECT PLUMB MGC LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT FEE 1 Leahy initrm t k 1 am ueea ed under provisions of chapter 9(commencing ',; JOB DESCRIPTION Matz thS rion9(al)of D' tinn3ofthe lan,mesaand P useis pERMITISSUANCE i- i full Luce d eB t. 5WF SFDWI. ❑KITCHEN REMODEL <U' Lice a. I.ic.# F�W Dale Contrw, APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE. 1m„py ARCHITECTS DIEC PANELS ❑MULTI-UNIT ❑STRUCTURAL Z p n Z I denw d my plain shall he used es public records MODIFICATION O Z i-• UP10200AMP5 CHIMNEYREPATR r4tw Licensed Professional ❑INTIiR10R ❑SWIMMING POOLS 201-1B)OAMPS KBATH OVEMENT �, OWNER-BUILDER DECLARATION ❑ ry, W 6 I herehy ulfrtn that 1 am exempt front the Contractor's License Law for the OVER 10MAMPS REMODELIGHPAIR ❑DEMOLITION x 3 2 F followin,ecti nn.(Saban 0031.5,Nosiness and Profession,Code:Any city or county SIGNS ELECTRICAL LLT h. which requires a permit m custom,altta improve,demolish.rsr repair any swnarc F�O�J prior,.its issnuncc,almrcquiresthcnpplicmo fmsuch permitan flcasigncd statement SPECIAL CIRCUIT/MISC. 999p I!(y,3,, that be is licensed pursuant to the provisionsnf The Contactors Licence Law(Cheprer Y _ Till (commencing with Section 7001 Division J.fthe Busi.c.mid pmedsions Code)an TIME METER OR POLE INSY ! ' 6 6 ca that he is exempt therefrom end the firms fm the alleged exemption.Any violation of iCyLL Section by any applicant Turn permilxubjects the applicunuo a civil penally of POWERDEVICES ❑ 'W DITION ❑DEMOLITION W m nm more Nun five htntlrcJ J.Ilan 1551q). fIiNANT ❑FOODSERVICE FSD ❑Lasowneroftheproperty..any employces with wages as their soleeoria,mili.n, SWIMMING POOL ELECTRIC IfMft(TOVEM. b will do the work,and One structure is not intended(noticed Torodc(SecJ(M1q Business ❑ B% and Professions Gude:The Contactors License Law does not apply to on owner of OUTLETS._SWITCHES-FIXTURES property who builds or improves thereon.and who does such work himself or through his own cmploycea,provided that such improvements are no,intended or offered for NEW RESIDENTIAL ELECTR SQ ET. aide.IL however,the building or impowmai ais a.ld within.neycarof completion.The ©Q SQ.FT.FLOOR AREA $/SQ.IT. burden will have,he buen of proving thin he did not build or impmve for Fur- a posy of.vitrale.). ❑ 1,as owner of The property,,B exclusively contmeting with Recused e.ntraemn i- TOTAL: IT construct the es jot (Seo.o an Business aM Professions ds or imphe roves i mmon, Li- - T e mLew Joesnmchaptly famioas with ofpntperty whored of imp roves Contractor's QTY. PLUMBING PERMIT FEE C 34 who wntmeo for such pro�ats with a c.ntna,or(s)licensed pumnnm to the Commemr's v License 1ww. PERMIT ISSUANCE ❑lam exempt under Sec. ,B&PCfonhis conconsistn ALTER-DRAIN&VENT-WATER(EA) Owner Date �)VAI,UATION s WORKER'S vCOMPENSATION DECLARATION Effacing, BACK FLOW PROTECT.DEVICE 3 [["11 I hereby aRrm under penuhy of perjury one of the following dalma,ions: ❑ Uuweandwillinuintuimt Cenifcumofpmsent(os.lf-insurefer Worker's C.mpen- DRAINS-FLOOR,ROUP,AREA,COND. STORIES, 'fYP8 CONSTRUCT ION n, statioas provided for by Section 9900 of,he Lobo,Cede,fm rfom The performance of,he work fur which this Fermi,N issued FIXTURES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3900ol the Labor Code for The pe '.r lthu wnrkf rwIt In th unissued, GAS-EA.SYSTEM. INC.40UTLETS OCC.OkOUP APN C or Ins c r is •• ➢ Cartier: na i. men ( ./y GAS B-BA.SYSTF.M-OVEN4(HA) TIFIC O PE SATION'ION FR( 1 WORKERS' COMPENSATION INSURANCE GREASE7INUUSTRL WASTE INTERCGI'I'Ok (This section need no `GTYfn�T^')ry',1/y'}y�/pr/`d//y I/Llan(blWl IIILDING DIVISION FEES _ or less.'cettify Nat in the pe10 rform cee ftheW�C folxMcRthR�c KRsued,lshull GREASETRAP I'L CI Fz— Zp nn,employanylamo,inunynamou, soas,o hec.me suhjemmthe W.rken.'Compen- SEWER-SANITARY-STORM HA.200 FT. EN FE Q Z satin I.e.,of Cob fomin.Date WATER HEATIiN WNIiNT/ELECT'# 1 z 2 Applicial G DING FEC H NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTIEMeTREATING alec.nm subject to the Workers Compensation provisions of the Lubar Calc,you mus, S LS FEE forthwith comply with such provtou,n,the,permit shall he deemedrevokeJ, WATER SERVICE d z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Us Q lforherwhich this thanhcreissue (Sec.inn lending agency par The Performance of kaeiptN � F the work for whidnhis Fermi,is issued(Sec.3097,Civ.CJ OU Lenders Name TOTAL: F yLcnder'.a Address TOTAL: 1 certify that I have read dal applicminn end state that the above information is BUH P ? �"- UJ contract.I agree m comply with all city and county ordinances and state laws relating tat QTY. MECHANICALPERMIT FEE building construction,and hereby authorizetepresemativesofthiscitytoenteruponthe SEISh11LI' E 7 0 abovocracntioned properly for inspection purposes. PERMIT ISSUANCE TWO)agree m save,indemnify and keep harmless the City of Cupertino against ELECT C FEE Q ,S liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH. nsegtmnce of the gnawing of thiopermit. PLUM li 'G FEF, APPLICANT UNDERSTANDS ANlQ WILL COMPLY WITH ALL ON- INT AIR HANDLING ON]r(TO I uR0 CFM) SOUR L TIONS MECHANI NAL FE AIR HANDLING UNIT(OVER 0.0(X)CFM) ONST RUCTION TAX Signet ApplicenUGm, D e EXHAUST HOOD OVIDUCT} USING MITIGATION IFE HAZARDOUS MATERIALS DISCLOSUREWill the applicant or furore building occupant store s handle hazardous mtamflol HEATING UNIT'ITO 100J)IO BTU) as defined by,he Cupetinn Municipal Code.Chapter 9.12,and Ne Health and SafetyGide.Section 25522(x)! HEATING UNIT(OVER 100,000 BT ❑Yes Nn PAID VENTILATION BAN(SINGLE RIESIU) Date Receipt# Will the applicant or future building occupant use equipment or devices which emit hazardous all mmaminanJefined by the Bay Area Air Quality Management BOILER-COMI'(JHI'OR If10,(IIN)BTU) )AI 3 t Uistrin'.'❑Ycs BOILER-COMP(OVER 100.000BIV) have mail the hamodist mmcrials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER I SUANCE DATE fomin Heal Suf'Y CnJe,Saiimw 25505,25533 end 25534.1 ani, 1 Nm i ,hc NEW RESIDENTIAL MECIL SQ.FT. M1uiWing ncunemly have ten thatd is my marytnsibilitymn a 'm V of The ul 'ch t m issuance ofa CcnlEru Owner umhnriz agent Ua¢ 9'OTAL: G SUED BY: OFFICE