50560 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL F PERMIT NO.
BUILDING:DIVISION APPLICA'TION/PERMIT PLUMB ING-MECHANICAI.
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS: n SANITARYNO. APPLICA'r10NSUHMI'Il'ALDAT'.
?.�3 3(G, R n air k Poles- Cup&-67 0
ON
SI -q
OW 121 'NAME PHONE CON'1'RACI OR'S NAME: C NO'.
/_jop d ! 5 N/C CON'TROL#
'ild "HITTECUEN I EE : .7 1.1 N : DDRESS: ❑
On )yes r s 05
CONTACT: PHONE: BUILDING PERMIT INFO
•
C qo,� g Iqlo,17*7 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
or ¢1 ED F-11,ICItNSED CON'TRACTOR'S DECLARATION Q9'y. ELECTRIC PERMIT NEE
1 hereby enim,that 1 am E,enred node.Prnviamne ter Chapter v aommenrmg JOB DESCRIPTION
Od'Z wish SaBion 7")of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
WOO PERMITISSUANCE
E in full force anJl force dfe ❑SFDWL C)KITCHEN REMODEL
aZW Linen..ClCla Conor gpP1.lANCE$-RIiSIDENTIAL )DITION ❑PLUMBING RE PIPE
NQL DllIC Contracnlr
A CtI1TECT$DEC ❑MULTI-0NIT El STRUCTURAL
1O. PANELS
Z O in Z I undcrsmnd my plans shall d used as puM1lic rccoNx MODIFICATION
CZ—Q UP T0200AMPS ❑INTERIOR E3 CHIMNEY REPAIR
W Licenmd Professional 201J0110AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER UECLARNI]ON OV17R 100DAMPS ❑BATH REMODELIREPNR (]DEMOLITION
C C Q 1 hereby affirm that 1 am exempt from the Conlraaor's License hew,for the
tXy 3 o.F following reawn.(Section 7871.5.Business and Professions Cade:Any city m seamy SIGNS ELECTRICAL ❑�} �' __
m which requires a permit to cnnsoum.alcor,improve,demolish,or repair any strvcturc
06 prior,its&,arose,alssrre,mar,mr—pplicant linsuch peanit to file u signed statement SPECIAL CIRCUTUMISC. -
}� that he is licensed pa thic,ravisions ollh Contraction s License Law(Chapter 9 ,
O
(Commencing withS , 70081 of Division J ftheB - dProfessionsCad)or 'TEMP METER OR PO .IN, I
a a o m that he p,oftentimesd theh ':f ,M1 alleged pt Any 1, n of ❑ �y E /`" TION F� EMOLI 0
X m_LLN
Sector]1131 5 h) Y applicant f pe d ht t 0 ppl' ,, pen❑y of POWER DEVICES ❑ ANT H�Ju f7 SP V 3
H Z Y
notation,,1 five headrest d II (5500) 1 ROVEMEN I'
ESC ❑ Les ownerof the pmpcnHor my employees with wages as thelr.solecompensatum. SWIMMING POOL ELEC7TROF ❑ HER
F• will dothe work.andfhe swemreis not intended m uffeml formic lStt.901.Business
all m_ and Minx,sions Cde The Conm,etoa License Law Onto not apply to an owner of OUTLETS-SWITCHES-FIXTU OJ
a'3 propeny who huilds or improver Ihcrcon,and who dues such work himself ar through
If,awn employee,p,nvi led that wcl,impnwemmnU are tow intended m nffered Int NI?W RI!SIUEN DAL ELECi'R SQ pT
sale.IL however,the building or improvement is said within one yearefcompletion.1he SO.Fr.FLOOR AREA S/SQ.IT.
owner.builoter will have the burden of proving that he did nut build or improve for pur-
po a of mlc.),
❑ I, a owner of the nn,cal um exclusively canteading with licensed anannetars ,, "f L / �Q
construct the project(Sac.9814.Business and Professions Gone)The Contraction Li.
ccome Law does not apply to an owner of properly who build$or improves thereon.and QTY. PLUMBI 'G PERMIT FEE
who enmmns for such projects with a coannewass)licensed pursuant to the Contracmr's
Liceme Law. PERMIT ISSUANCE
❑ Ixm exempt mtder See ,B de P C for this manna
ALTER-DRA IN&V ER(EA) VALUATION
Date &6,000
^ i
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT.UAhe W 6} 00 0
Thereby affirm under Cnaltyof per jury ime the ire fte Winamsom: `TI a Q/
I have and wllDmai nminuCordlicatco(Cnnncmmoll-inxurc fm Worker'sGmf he DRAINS-FLOOR.ROOF,ARIiA. $'TDk .S 'TYPBCONS'TItUCT10N
moan, ,ohich d for i Section 3]00 of the Latx,r Cale,for,he performance of,he
work fsn and Nis pcmtii is issued. FlXTl1RE5-PIiR
❑ I have and will oxic.maintain Worker's Compensation work
ac,as inquired by Section
771X1 nfihc Lahnr Cala furthe p,rinrmunauJ'thcwrrk(or which this permit is issued, GAS-P.A.SY$T[h1-I LNG 4QUTLET$ OCC.GROUP APN
My Worker Cnmpcnsal ,n Insu t c'pier and Policy number are:
Canicr:C'1��^l�2n pvBcy Na.:o2FunnWj_ 3. GAS-EA.SYS'TIiM OVER 41EA)
'CERTIFICATE OP EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION ICES
(Fri—cooerd not M:complrual it he permit a forma,hundred dollars($I(M) GRIiASETRAI'
less) PhANCtIECK FEE �~
Icemyfhal inch,petformanceoflhc work for which this permit isissued,lshall SEWER-SANITARY-STORM EA.200 FT.
ancon
F•Q
cmplay any person in any mannerom
r season M1ee xuhlect to the Warkenc Compete- ENERGY FEE -5'0
Z nation Laws of Calif nein,Dura WATER HEATER WNENTIELECTR
zAppllcaul GRADING FEE
Z) NOTICE TO APPLICANT:If,after making his Cenificme of Exemption,yea should WATER SYS'FEwrREATING
became.bloc,1.the Windwe,Compenmtinn P.vi,ioms of the Labor Cde,you mmt SOILS FEE
farmout,comply wflh,.eh provisions to,this pemnit shall he reversed rcvnked. WATER SERVICE
Q
7z CONS'TRUGITON LENDING AGENCY NIiW ItGSIDIiMI'IAh PLMB. SQ,FT. I ) Mare Rcceiptp
V 0 Ihercby affirm the„hare iso row
nection lending agency for nn
he perfoance of to
It ,he work for which this Permit is i...d(Sec.3097.Civ.C.) TOTAL:
C) "TOTAL'
U LenJcrs Name
R.1 I,,a&,,Address
d I remB that I essential in,application and emir that tuc above infumernan Is Ul IlqW10
Fen ncorrect l agree.comply with all city and county ordinances and shite laws mlatingm QTY. MECHANICAL PERMIT' FEE
)Z building construction.and hereby authorize representatives of this city to enter upon the x E IC ME
above mentioned pra,ary for inspection PUHw.e PERMIT ISSUANCE
(Wr)agree of)rove,indenmify and keep harmless the City of Cupertino spitedE 'CI'RIC FEE
Iiuhilitlee.judgnmms,costs and expenses which may in any way assn again.a said City ALI 17R OR ADD'TO MECH. P.UMBING PRE
in nu9uenre of the&ranting of this pennil.
APPLICAN' UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10,001 CFM) M HANICAL M-H 0
SOURC s R. ULATIONS.,{ YF
( //nA� �J. A AIR HANDLING UNIT(OVER 10,00Y)CPM) CON, UC'1'ION TAX
tgwm`74fXppf pplica NCnOmmnorl 6 Date EXHAUST HGOD(W/DUCT) HOUSING MITIGATION FEE
BAZ RDOUS MATERIALS DISCLOSURE
Will lh,appli,maer future huildingmcupamt,¢me or handle hazrnlous material HEATING UNIT(TO 100,0B)BTU) I u. 'n q
as did ned by the Cupcnian Municipal Code,Chapter 9.12,and the Health and Safety T
Cade,Section 25532(a), HEADED UNIT(OVER 1M.0110 BTU)
❑Yes ❑Nu NTI
VELATION PAN(SINGLE RFSID) PAID 9 r U
Dat /
e eaip, I
Will the ap,kran,er future building sccupant one egdipmenter devices which BOILIiR-COMP(JHP OR 10,00013TU)
V
hazardous air conmtnmo ms as defined by the Bay Arca Air Quality Munaremenl
Di.nrict9 BOILER-COMP(OVER III OM BTU)
❑Yes Nor
I have read the he,f,ans nutcrials is under Chafer ts95 of me Cali- AI R CONDI'I IONER ISSUANCE DATE
�gmmmcn P
iirmia Ilcehh&Sviny Cdc,$cations 25505,25533 and 25934.i understand the it the NEW RF_SIUEN"TIAL MIiCH. SU.FT
huildmild nm Gummy have a tenant,Nal it is my respansibillty,to notify the occupant
of dTe _no, m,h me poor ur'�mancc of a CmlBcme o Occupancy.
i
ag.v Dam 'TOTAL: ISSUED BY.T n
OFFICE