S 0303 APP J ICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
nUILDING DIVISION APPLICATIONIPERMIT PLUMBING,-MECHANICAL S 0303
.
BUILDING PROJEETY IDRNFrIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION�SUUAfI?
(® /7 / �!C#a)o0_0 ORt ✓"P yNMITTAh
OWNER$.N (7.YV PHONE: CONTRACTORS NAME. LIC NO'. NIC /1J /JCOONIRUL#
oi f�FUT/ENGINEER: LIC NO: AUDkESS: ❑ 1:/!\ `�
CONTACT PHONE: BUILDING PERMIT INFO
ItaaiA
RP9 /� ,� ,` ❑ Consultant Fees Paid by Applicant(Initial) JIG E PL MECH
LICENSED CONrRACrORS DECLARATION QTY ELECTRIC PERMIT FEE JOR DESCRIPTION
1 hereby affirm that I am Immoad under provisions of Orderly(commencing
"Z with Section]00Bof Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
WOO PERMIT ISSUANCIi
F-�F in full force and effect. ❑SFDWI, ❑KITCHEN REMODEL
�uu Lioense Class Lie.#_ APPLIANCES-RBSIDEN'I'[A], ❑ADDI[[ON ❑PI.UMHING RIbI'B'E
F Z Yl Dam Comrmum
NQ6
ARCH rr ECI"S DECLARATION ❑MU1T1-UNIT []STRUCTURAL
F Z 1 understand n I h II be used as blit rccnNs YANL[S MODIFICATION
OZ- rypansa UP TO 200 AMPS
[I INTERIOR CHIMNEY REPAIR
Ha(rd Eq"W Licensed Professional 201.1000AMP5 IMPROVEMENT SWIMMING 1'001.5
OWNER-BUILDER DECLARATION OVER 000AMPS El PATH REMODEL/REPAIR ❑UEMOI.I TION
C OG Q 1 hereby affirm that 1 am exempt from the Cmnrnemr's License Law for the
xy 06 V following reason(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTNEH
t+l yO P" which"at.Cr permit on construct alter.Improve,demolish,or repair any suucmrc
r/r/��' prior m its issuance,also requires the applicant for such permit File a signed statement SPECIAL CIRCUI I'IMISC.
�y that be is I cenam pursuant to the provisions of the Contractor's License Law(Chapter 9
400 nonumnoingwitb Scotion]00U)af Division 3 ofthe Businessund Prml'csouns Code)ol '!EMI's METER OR P0I.H INST. COMMERCIAL,
aye
that he is exempt therefrom and the basis for the alleged exemption.Nry violation of ❑NRW HLDGIAUDI'I'ION ❑UIEMOLITION
Section 7031.5 by any applicant for a'norit subjects the applicant)a civil Penalty of POWER 1)F.VICES ❑TENANT ❑TOO[)SERVICE
W not more than five hundred dollars(55110).
� 6 I.as owner of the norm mloees with wages thcinnlc Com atinn. SWI MM ING POOL ELECTRIC IMPROVEMENT
❑ Property, Yc P i gas ns ,Bos ❑OTHIiR
Woo willAothewons node; he Carola pals License
Low ferru
pply it1H4, wner or
a 3� and Professions Coria The Cnmtamor'a Limine Law ices not apply m an owner of OU'T'LETS-500 I'I GILLS-Is1X'1'URES
property who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvements are not intended or odcred for NEW RESIDENTIAL ELECTS SQ 1'I'.
sada I hoover,the building or improvement is sold within one year of completion,the SQ.FI.FLOORA SISQ.FT.
owner builder will have rho buNmr of proving that he did not build or dnprove for Pnr-
pose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to P p
cauuum the project(Sec.7044.Hilliness and Pnsfessions Ca cl rhe Contractor's Li- - /1
nm Law macs not apply to an owner of property who builds or improves thereon,and QTT. PLUMBING PERMIT FEE
whssammats for such pmjecawitlt aamtmemes)licevsel pursuant n the Contractors ' RE
License law. PERMIT ISSUANCE AUG 2 2 RCCI
❑1 ton exempt under Sec. .B&1'C lin this reason
Aid ER-DRAIN&VENT-WATER IEA) VALUATION
Dwner Dan-
WORKERIO
'S COMPENSATION DECLARATION HACK Ill-OW PROfECI'.UEVICP.
,ldl.—I hereby ulRnn under penalty nl perjury one nl the fnlhswing dedumtions:
I huveand will maintain aCerlilieale of Consent it,self-insure far Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. 5'I'OIHES I'YPI,CONSTRl1C'I'I)N
sation,as provide!for by Section 3]1x1 of the Labor Code,for the limmanencen of the
work fm which this Permit is issued Ir1X'r URES-PER"TRAP
0 1 have and will maintain Worket's Compensation Insurance,in required by Section
3]1X1 of the Lamm Code.fam tM1e perfimnance of the work for which thus permit is issued. GAS-13A.SYSTIiM-I INC.40UILL-I'S OCC.GROUT' APN
My Worker's Conrpenxndon lasanmec currier and Policy number arc:
Currier: Policy No, OAS-LA.SYS'I'EMd)VLR4(EA)
CEWNFICATE 01'EXEMPTION FROM WORKERS' GREASFYINDUSTRL WASTE IN'IERCEPfOR
COMPENSATION INSURANCE UI NliDIVISION FEES
(This section need not bu completed Him pemrit is for one hundred dollars CS lip) GRHASETRAP
or IcssJ PLANCHIiCQR�C,
I"
I mrtity thathdic,prfxtraosvofthe work tor which thi,,Cr I is issued,[,fail SEWER-SANITANY-STORM EA.200 Ff.
not employ any person in any manncf sit.1 m 1weare subject to the Worker:;Comma ENERGY PIiIi
Z anion laws of California.Duro WAI ER ItETER WNENT/EL.ECI'R
O Applicant GRADING IgiI?
NOTICE TO APPLICAN9:If,aficr nalkiog this Ccnilicam of F.xcnsption.you should WATER SYSTEMnKEATING
a� hecomc subject to the Workers Cuntpenxation provisions of the I,oMm Coda you must SOILS PI?I3
forthwith comply with such provisions or this permit shall he leemal revoked. WAI ER SERVICE
�z CONSTRUCHONLENDINGAGENCY NEW RESIDENIIAL PLMB. SQ.FL PAID Data
V 0 Thereby affirm that them is a construction lending agency for the performance of
Els r the work for which this permit is issued(Sec.3097,Co.C.)
O Lenders Name TOTAL:
WLcndcrs Addmss TOTAL:
0. 1 certify that 1 have read this application and state that the above information is BUILDING FEE
correct.l agree to comply with all city and county oninances and.state laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC PEE
V Z building construction,and hereby authoriae repreanmtives of this city to enter upon the
obovoomntioocd pml,alty for inspection pugsacs. PERM I r ISS UANCI! ELECTRIC FRE
(We).,,an to save,indetnuily and keep honnlCss the City of'Cupenina against
Ithatitics,judgmmns.cons and expenses which may in any way acerae against said City AITERORADDTOMECL PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,000 CFM) MECIIANICALPEE
SOURCE REGULATIONS.
AIR HANDLING UNI'I(OVER 111.000 CPM) CONSTRUCTION TAX
Si...trice of AppliclmlCmdrncen, Date EXHAUST HOOD(WIDUCT) HOUSING MITIGATION VEP
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicum or futare building occupant smre or handle husmme,mumdill HEATING UNIT(1011X1.0000'I'U)
to dented by the Cupertino Municipal Crde,Chapter 9.12,Card the Health and Safety IIhAfINO UNIT(OVERIIXI,[ItXI BTU)
Coca Section 25532(^)'!
Yes ❑No VENTILATION FAN(SINGLE RISID) PAID Date Receipt#
Will me applic nt or future building occupant use eyuipmem nr devices which BOILER (3HP OR 100.000 HI U)
,it la rammes air contaminants as damned by by the Bay Area Air Quality Management TOTAL:
Javier BOILER-COMP(OVER 100,000 If'I'U)
E3 Yes 0 N
I have mad the foundation,dancing L male,Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
hard.Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have n Nnanl.thin it is my mc,ensibilay it,notify the occupant
of that rcgchamems which mus ha tact pdo,to Isaaunm al'a Cenillur¢of Ocmpuncy.
Owner or xurhorixcd agent Date TOTAL: ISSUE[)BY:�
OFFICE