S 0334 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE❑ALL POINT PEN ONLY R
CITY OF CUPERTINO BUILDING-ELECTRICAL Pli IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 0 '334
BUILDING PROJECT IDENTIFICATION
BUILDING ADDkESS: q SANITARY NO. APPLICATION SUBMITTAL DATE
I D SS ojoe1'i� e U
O NER:SNr:. /�� PH��_0S CI TNO
RACE R'S N 1QcG I A�^ NIC CONT L
VtCHITEC1Yy'NGINEER: C, LIC NO: -�rIR..V 1 �•�,! e�v�V L1/ ❑ CCVNN
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BIG ELECT PLUMB MECH
eieriS Ll7 -653p St ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Scmian 7000)of Division 3mfahe Business and fessions Code,and my license is RESIDENTIAL:
x700 PERMIT ISSUANCE
FUF Lnfulle Class
d18c,. / DSITJWL L1 KITCHEN REMODEL.
�UZO Licence Clnxx Contract
APPLIANCES-RESIDENTIAL []ADDITION D PLUMBING Bit PIPE
I 60. Data GamDECIL
AHCHI"fF.CTS DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL.
F m PANELS
ZOq IunderslnnJ my plans shoal he mad hs public records MODIFICATION
OZZ UP TO 20t)AMPS DIMrERIOR F1 CHIMNEY REPAIR
Licensed Pml'..c.innal 201.1011AMPS IMPROVEMENT C]SWIMMING POOLS
OWNIiR-BUILDER DECLARATION OVER IdIN1AMPg D BAT it REMODEUREPAIR ❑DEMOLITION
I hereby uRrm that I am exemia from the Cantmctors License l.aw for the
1L,1�C)L U following mrson.(Section 7031S.Business and Professions Code:Any city or county SIGNS HLCC RICAL D OTHER
F LL 0 y which requires u permit m consumer,ager,improve,demnlisb,or repair any structure
Prior to its issuance.also mquirts the applicant for such proton to file a signed statement SPECIAL.CIRCUIT C
EnEngthat he is licansed personal mthe prasnionenf NC Communes License law(Chup,mr)
g (commencing with Section 7000)of Division 3 ofrhe Business and Professions Csde)ar TBMRMET-ROR 0 S COMMERCIAL'
Q.q C that he is exempt therefrom and the basis for the alleged exemption.Any viol-ainn of D NEW BLDGIADUITION D DEMOLITION
aXl 4• Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of POWER DEVICES NANT ❑FOODSERVICE.
�' not more than five hundred dollars INi OTHER MOVEMENT
< 0 La,revnerrahhe property,samet re imy snotemployees llairrhw.gesar their sole compensation, SWIMMING POOL ELECT
O will Professions
Code:
The Creisnorr Lkeedoro0eredforsale(Sa.7044,Busincu ❑OTHER
13 and Professions CNe:The Contrecrofs License law does not apply to an owner of 3 OUT(.f;TS-SWITCHES-I:IXTGRES
prapeny who builds ter improves whereon,and who does such work himself rr,hrmgh
his own employees,provided that such improvements art not intended or offered for NI?W RESIDENTIAL ELEC R. SQ Fr.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.AD AREA $ISQ.IT.
owner-builder will have the burden of proving that he did not build or improve for par- /(ft
❑ 1,as owner nl she property,um exclusively contracting with licensed contractors,o T
construct the project(Sec.7014.Business and Professions Code:)The Commeam's Li- Z}
se Law does nu apply to an owner of property who builds or improves thereon,and QTY, PLUG
MB PERMIT FEF, f,/' I' U
who cmuamn far such projects with a contractions)licensed pursuant to the Commetor's I vh �VNEI'r/Ar/1
License Law. PERMIT ISSUANC �1'V
D lino exempt tinder Sm. ,B&P C for(his reason
AM17K-DRAIN.k VB ATE (HA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PRDTF. T.DEV � r
1 hereby affirm under penaltyof perjury one of the following declarm a,:
❑I have and will maintain.CcniGcme of Consent to self-insure for Worker's Compen. DRAINS-FLOOR OPOREA, STORIES YPECONSTRUCTION
,.,Iran,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this lemur is issued. FIXTURES-PER TRAP
I have and will maintain Woecr's Compensation Insurance,as required by Section ,
GOD oflhe Lauar Cd .pesdIoe,{fWormw1he peroftaC�monce of,h.woefftor which this peomi,is issued. GAS-IIA.SYSTEM-1 INCA�i S OCC.GROUP APN
MyWo .CJV)T�111/( J/(/r//Al�l�.iry Nne`u.�° zGy3Z GAS-EA.SYSTEM-OVER 4( )
Cartier LL(( )� L1 (/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPHNSAT10N INSURANCE GREASEIINDUSTRL WASTE.INTERCEPTOR
This sectionneed nm be completed ifthe permit is for..hmdoed dollars(SIM) LD (VISION
nr les,.) GREASE TRAP pLANC FI ,
I emify that in the performance afthe work for which rhispermi,is issued.l shall SEWER-SANITARY-STORM EA.200 FT.
nus employ any person in any manner so m m become subject to the Workers'Compen- CNE Y F
O zmica Laws of Culifomia.Data WATER HEATER WNENTIELECTR GHA 1 iF:
z 0 Applicant
L
NOTICE TO APPLICANT.IL afar making this Certifcam of Exemption,you should Wp'fHH SYSTCM/fkEATING
Ir become subject to the Worker's Compensation provisions of the Labor Code,you most
Wforthwith comply with such pro,Island or this permit shall be deemed revoked. WATER SERVICE
Q
Is CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ff. PAID
r7 z :nc Reccip,N
I here,y wh this
(here is sued(Ser.30 lending agency for the performnnec of
U Ran work lin which Ibis perrnil is lx,ucd Isco.3(197,Civ.CJ
P.
1^ Lender's Nnnm TOTAL:
Lender'sAsoyTO'fAl.
I :
cenilk'y rho I have renA this appllwtinn and,rote to.,the above information is II1111,I1IN IgiF.
ZL comer.I agree In comply with all city and county ordinances and state laws rdatin6 us QTY. MECHANICAL PERMIT FEE
IJ Wildingnsnn...lin.and herchymormim representatives afteisciry m enmI.Lon the SEISMIC FHG
above-memiomed pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino again.d CLCCT IC FEE �
Iiabildics.judgmenls,costs and expenses which may in any way eccme against said City ATTER OR ADD TO MECH.
in ansequcnce of the grandirgof this permit. PLUM LNG FBI:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UMT(TO 10,000 CFM)
M13CI ANICAL FF.F.
'AhREGULATIONS. 11 zjq�
1Lga�X`]II(uy` 1. 1/ AIR HANDLING UNIT(OVER IQ(I(p CFM) CON TRUCTIONTAX
K
Signature of ApplivaDate I100D(W/DULT7 HOU'ING MITIGATION FEE
HAZARDOUS
E%I
US MATERIALS DISCLOSURE
Will he applicant or future building ssccupan,sort or handle hazalloux material IIIiA'fING UNIT LTO IOO,IXIB BN7
az defined by the Cupertino Municipal Code.Chapter 9.12.and the Health mad Safety
Code.Section 25532(.)^ 1 BEATING UNIT(OVER I00,0M BTU)
❑Yes ❑No VENTILATION FAN(SINGL.B IIEMD) PAID
Uac Rece' IM
Will the applicant or furore building occupant use equipment or devices which
(nit havurdnus air rnmumiuunts ns defined by nbe Bay Area Air Quality Mnnugemenw ,N(IILER-COMP CHIP OR I W,I100 BTU) ,
Domim'!
❑Yes []No BOILIM-COMP(OVER IfNkMOBTU)
I hnvu renal the hazardous materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUAE DATE
(onto.Ilculth akSolely Gyle,Swoons 25505,25533 and 2553L I undmo:m l that it the NEW RESIDENTIAL.MECIL SQ.IT
building daec nm curren0y have u macn6 that'd is my m,,mo,ihR ay m naily the wecnpnnt
of the rv,mma cm,which must be mct pool n,issuance of a Cmd acme of Occupcy.
an
Owner or.dhorieW agent Dole TOTAL: ISSUED BY:
OFFICE