S 1161 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
4,%R
TY OF CUPERTINO BUILDING-ELRCTRICAL PERMIT NO.
UILDING DIVISION APPLICATION/PERMIT PLUMBING-MFICHANICAI, n
BUILDING PROJECT IDENTIFICATION J
1161
LDING ADDRESS: SANITARY NO APPLICATION SUBM1'TI'A L UATI
I 30 llgd�
NwSIL�I NAME Nh. CONTRACTOR'S NAME: :LIC N2
NIC CON'fROl.p
IQ IIT 7C/ENGINEER: LIC i Z& ADDRESS:NTACP:/v16`-1Y/+GSV PHONE: BUILDING PERMTI'INFO
,,�L�'�.,1 1�.y�g W 47&,-5-a �j ❑ Consultant Fees Paid by Applicant(initial) Bl.n� EL PLUMB MEeu
1_1 vY LICENNSElDCCONIT`RIACC OOWSS DECLARATION �`jo QTY. 'ELECTRIC PERMIT- 'FEE fD`{�' ❑ ❑
I hereby nlinn than I nm licctamd under provisions of Chu ,r 9(uotnmaming
JOB DESCRIPTION
y�jp- win Section]00Bpafplvinion3 of am Business and PmPo.ians code.ana my hams is RESIDENTIAL:
F lye in full force and eRect. PERMIT ISSUANCE.
�F.UFkJ l.icens.Cluss I.ic.#. .3�E,31�so/ 36 ❑SFDWL ❑KITCH17N REMODEL
;ZH Dare ConOacurz -"6J CD APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING BEPIPE
ARCHITECPS DECLARATION ppNlilS
,z O z I understood my plans shall he used as public records ❑MULTI-UNIT El STRUCTURAL
vr) MODIFICATION
OZ-- 20iTU 200AMP$ _J
�4�B1 Licensed!Profession.) `ItIMP LIOROVE ❑SWCHIMNEY
MINGPOOL
E54d, OVERX1SX)AM 1IMI'ROVEAfEN'f WIMMING POOLS
.Gd OWNER-BUILDER DECLARATION ❑
I M1erchy ul'lirm Ihm 1 oto exanpt from the Cuntrudnr'a License Law(or Om OVER IIXIOAMP$ ❑pA'fli RE DEEB' If 101."
(i15 6 U following reason.(Section]0315.Rosiness nnJ Profnvinnn Caalc:Any city or county SIGNS ELECTRICALOOTHER
F m1¢•" which requirepe
s a rmit an cnmtmct,aloe,impnwe,demolish,or repair any'ma lme
prior o its issuance,also requires the applicant for such permit to l i to a signed nmtement SPEC I Al.CIRCUIT'/MISC. ss
2�y that he is licensed puramen to the provisions of the Commene's Liecone Low(Chapter 9
W aCQO (commencing with Section 7000)at Division 3 of the Business and Professions Coact)or TEMP.METER OR POLE INST -OMMF.R -IA
6 y M C that he i.v exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^4N. Seeion 7031.5 by any applicant for a serum,'ahjectnhe applicant to a civil penalty of POWI?R pEVICf?S
t more than five hundmd notion,(final, ❑TENANT ❑FOOD SERVICE
FZO1-] 1.as owner of the property,or my employees with wages as their sole compensation, SWIM M LNG POOL ELECTRIC IMPROVEMENT
will do thework.and the structure is not intended ormanal forsnle(Six.7N4.nosiness" ❑OTI LER
'3 and Professions Code:The Contractors License Law does not apply to an owner of 0G3IETS-$WITCHIiS-FIXTUR
progeny who builds or improves Ihercon,and who does such work himself or through
his own employees,provided(hut such impmvc.ems ore mol Intended nT offered fnr NEW R17SID17N'TIAL HLECTR V S I'
solo.If,howeve,(hebuilding mimpnncmcnl is sold withinone ymarnfcnnsfiction,the Sp.FT FLOOR AREA S/SQ,Pr
owner-builder will have the buMen of proving that he did not build or improve fnr put-
,,e of sale.).
❑ 1,as owner ol'the property,am exel novely contracting with licensed contractors to
construct the pmjat(Sec.](}W,Business unJ Professions CadeO'fhe CommnoYs Li-
seLaw does not apply it)an owner of property who builds or haproxesthereon,and QTY. PLUMBfNG PER FF.E
who contracts for such projects with a amanclons)licensed pursuant in(lie Contractor's
Licence Us .
❑I am exempt unda-Sx. ,B&PCfarthisremnn PERMITISSUANCE
AurER-DRAIN&VENT'-WA'fiat CA)
Owner Dale - VALUATION
WORKER'Sndep COMPENSATION DE CLARA'DON
�. BACK[;LOW PROTECT.UF.VICIi � O�
1 hereby N1irm under penally al perjury one of the following declnrminns:
❑Ihavc andwill malmahaaCertilicatcof Cmasennnyclf-in.ra fnr WorAcr's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
.tion,as provided for by Sulinn 37(X)of the Labor Code.bathe wifomtanre of the STORIES TYPE CONSTRUCTION
w k 1 Inch this permit is issued FIXTURES-PER TRAP
m ave trod will nmintnin Worker's Compeu.ation Insmamce,a.required by Section -
W of the LaMnSgda,forthmm�ana allhe work fnr which this pemtit is issucA. CAS-EA.SYS'fEh1-IINC.60UTLE'1S OCC GROUP APN
My
Workers C JG,J7/, y{i ce artier and PolicyCn
Girrier: M Policy Nn.. Jarp GAS-IiA.5Y5'I'EM-OVIiR4(f?N
CERTIFICATE OF HXIiMPf10N
COMPENSATIONINSUg(HG \ hI� GREASE/INDUSTRL WASTE INTIiRCF.PD�R HUILI [VISION FBBS
Ohis,ection need nal hewmplcmd itlM permit in foment 115 dullnrs($IIXi GREASETRAP
or less.) PLANCHECK FEE?
1certify that on in any
t)as t work for which this permitisers Con shall
ax
not employ an SEWIiR-SANIq'ARY-STORM I'A.2fU I'I'.
p y of
in any lnanner'aana become subject Workers IeNERGY FE
-FV lows of Cailitrnia.Dote
z 0 Applicant WATER HEATER W/VIiNTIELEC'1'R
.. NOTICE TO APPLICANT:IL after making this Certificate of Exemption, GRADING FFP.
aFN-t Cyouxhnow WA'TFR SYST1?M/fREATING
7 become cuhjeel m the Workers Cnngronseum pmvisinns ul'the Label Cal.,you Inunt SOILS f
� forthwith comply with such pmvisinns or this permit,hull beJeened revoked. WATERSERVICE
Q
� zCONSTRUCTION LENDING AGENCY NEW It ISSIDENfIALPLMN. SQ.FT. PAID III � I vim, �;•,"rJ
U t7 work for
that there issued Scednn le,Cis,agency fnr the pedortnance of Itaeiplp
� F m<wnrl for ehich this permit is icvnN(Sec.ITN],Civ.C.)
C..1 lander',Name
Lender's Ami 'I'O'1'AL: TOTAL:
y1 certify that I have read this application and slate that the abuse inLnmation is BUILDING EG incl _p
VI cors l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
V buildingemwuuatian,and hereby amunizetcpre.madvcvof this city,macrupnn the SEISMIC I 'E
i dwee nientional progeny for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of CLlat against PERMIT ISSUANCE. ELECTRIC -F.
liabilities.judgments,costs and expenses which may in any way accrue against said City ALT ER OR ADD TO M ITCH,
in 'sequence of the gnating of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(X)CFM)
SOURCP EGULATIONS. MECHANICAL FUE
/ I:q•Vq 1'1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION'TAX
Sagmwrcof ApplmanVCommnor _�Dolle"1EXHAUST FOOD(W/DUCO HOUSING MITIGATION PEE.
HAZARDOUS MAT I,S DISCLOSURE
Will the applicant or future building motion store or handle haunlnu.v material HEATING UNIT(TO 1(X),(1(I0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
District? 4T
ode.Section 25 i32CH i HEA'I'INO UNIT(OVER l,p,0,p I1'TU)
❑Yes 0 N sa-
PAID .�
} ( VENTILATION PAN(SINGLE RI?,SID) Dom Receipt#
Will the air comm in future building by the B yA ea Air Qu or devices which
mus air contuminanrs as dehnal by the Bay Area Air Quality Management BOILER-COMP(311P OR IfX1,INX)B'I'U)BOILER-COMP(OVER I 00,01(s)BTU)
C]Y. E]No
'I have read the hnnewous materials myuiremem under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC DATE
fomio Health&Safety Code,Saaamnv 25505,25533 and 25511.I understand that if he NEW HF.SIpF.NI'IAL M[CH. SQ.FT. F, ( Alauldingdna,not currently have.wran,dalt it k my rexlamxibilily to ramify the occupant EI\J ��
If the requirements be mor m which must et prior insu mm of a Certifies,of(,,ppmwy. -
Owner nT aurbonaed.gent Date 'I'D'EAL: r1s•J'��-j`y�\/y`F�I]J
ISSUIiD By.
OFFICE