S 0232 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '//�I�(�
CITY OF CUPERTINO BUILD IS -BLECTRICAt•, PE5IT NO, O L J Z
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAI. ``J
• IIUILDINGPROJECTIDEN'1'11+[CATION
BUILDING ADDRESS - - SANITARY NO. APPLICATION SUBMITTAL DATE
10g00 i or ( �2'��
OWNS 'CjJAME^ �,� PHONE: CONTRACTOR'S NAME: LIC NO:
PP I/eR� NIC COfN$'OLp
PMCHITECT/ENGINIiIiN: LIC NO: )I ESSrr ❑ r/ S 00
W G, W YV
CONTACT: •PHONE: BUILDING PERMITINFO
`{M ❑ Consultant Fees Paid by Applicant(Initial) BLDG P.rl ecT PLUMB MECH
-VW MCI&LOg LICENSED CONTRACTOR'S DEC LARATION QTY. ELECTRIC PERMIT FEE aB DESCRIPTION
1 hereby affirm[hut 1 am licensed under provisions of Chapter 9(commencng JOB DESCRIPTION
Owith Section 7")of Division 3 of the Business and Professions Code,and ny license is RESIDENTIAL:
p PENMIT ISSUANCE
ty� in full force and eRect. ❑SPDWL ❑KITCHF,N RIiMODEI.
�U Lmcn.n Class 1.ILM gVPLIANCIiS-RESIDI3NTIAL ❑ADDI'TION ❑PLUMNING RIiI'IPE ,
Y1 Dem Commemr
F.<7 c. ARCHITECTS DECLARATION PANELS
❑MULTI-UNI',' ❑STRUCTURAL
ZO'p2z !understand anytime,shall b;uodaspublic meant, UPTO 200 AMPS MODIFICATION
oz—Q Licensed Professional ❑INTERIOR s ❑CHIMNEY REPAIR
201.10100AMPS IMPROVEMINT []SWIMMINGPOOI.S
OWNEk-BUR.DH.R DECLARATION OVER[INN,AMPS ❑IIATIi REMODEL/RETAIN DF.MOL1'1'ION
I hereby a87rr that,am exempt from the Cnntmemr's License Law for the
KO W U following reason(Section 7031.5,Busine,s and Professions Code:Any city or county SIGNS 1i1.ECfRICAL ❑OTHER
3
0 which requires a permit to construct, In,improve,demolish,in retain any.vacua
prison its i........l.vo regaims the upplicant Foramen l ormil m file a,,du Latmemeat SPECIALCIRCUIT/MISC,
that he is licensed punwmno the provisions ofthe Ctmmacmr:,License Law(Chapter9
W 0700 (commencing with Section 70hadifDivisin i Sof the Bu,iness.nd Professions Code)nr TEMP.METER OR POLE INS','. P
6 y Y that he is exempt therefrom it the basis for Ne alleged exemption.Any violation of N' IA DDITION ❑DEMOLITION
LLXl 4y Section 7031.5 byanyntplicant far.permitodijoem thic.ppliumn tu.,Oil penthyol POWER DAVICES ANT ❑FOODSERVICE
not moa than rive hundred hunts,(S5001.
z6 E] 1,as owneraf Nepropeny,er anycomoyces with w.ga,ue their sole compensation, SWIMMING LELECTR,C PROVCh11ENT
Q will dmthevemic,and themombae is no,imendedoroffercl fmrxnle(So,7044,Busines, ❑OTHER
m and Rofessiens Code:The Cmil acmr's Liconse Law dues not apply m an owner of OU'I'I.]:PSTS HES- URES
pmNny whit builds or improves thereon,and who does such work himself or through
his own employees,pmvideol that such improvements as not intended or offered far NEW RIS DEN .F.1.'CTR SQ ET.
sale.IL however,the buildmIlm improvementk sold withition.ycarormmphapm,the SQ.FT.FLOOR AREA $/SQ,ET.
owner,builder will have the burden of poising that he did not Wild or improve torpor-
Pao,
or pur- ^
Fl
Pao,al'aide.). Ik I D
E]1.as owner of the property am exclusively contracting with licensed emmmcmrs to ' 'TOTAL: r
entrust the project(Sea 7041.Business and Professions Coder The Convector's Li-
cense Law does not apply ro an owner of property who builds or imp.,,,,thereon and QTY PLUM PERNIIT FEE 11
who commons for such projects with a contrations)licensed pursuant to the Contractor's - AUG 19 DC/fI
License Lew. PERMIT ISSUANCE R[{J
❑I ate exempt under Sec. ,B&P C fir llfl,mason
clu
Owner Date ALTER-DRAIN&VE - AT' ' ) NU
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEV[ If IA e V
I hereby vllirm under penalty of perjury one of the following declardions: �/ �Y(,
Ihuvn.nd will muinhninvCertif am of Conaennn self-Inanre for Wmrker'x Cotnpen- DRAINS-FLOOR.ROOF,AREA,COO STORIES 'TYPE CONS'fI1UC'PION
Ballon,us provided for by Seetion 37(X1 of Ne Labor Coda for the perfnrmmnce at he
work far which Nis permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Inmonce,as required by Section
37M of the LatwrCWe,far the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP MIN
MyW,;Or Cu)y�s�y&ryur p�_rpr omit Pali . her YJ 2- OAS-EA.SVSTEM OVIIH4(13A)
Currie!/Iu JM�N 1J/C MFSPIicy Nn..•
CERTIFICATE OF E,, 'ION FROM WORKERS' GREA51%INDUSTRL WASTii INTF.RCEI'I'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Guesecnion needmatecompletwl iOupemtit isforone humacldillans(SI(10) GREASETRAP
ar less.) VLANCHECK PIiIi V. 6
Icenifythal lathe urfamanceol the work forwhich nhi.spermit is issued.l shall SEWER-SANITARY-l FORM EA.2S)FI'.
Out employ any person in any munner,o as m hecomosuhjcno the Workers'Compen- ENERGY FET ' SG
O Z cation laws of California.Date WATER HHATER W/VBN'DI3LECTN Flit.:7 Q Applicant GRADING PIi
`7 NOTICE TO APPLICANT:If,after making this Cenifcme of Exemption,you should WATER SYSTEM REA'1'1NG
become subject to the Worker's Compensation pmvisionx of the Labor Code.you must SOILS FEE
lfJ fonhwhh comply with such provisions or this permit shall bodecamdavokcd. WATER SHRVICE
W Q
UO CONhTONLEND,NG9G,3NCY NEW NI.SIDENTIA1.PLMB. SQ.FC INI� I all's
I M1emby atiirm than then ere isisacnnxnrocainn lending agency for Ne terfnmanre of ❑a¢ ceipta
the work for which this permit is issued(Sec.3(57,Ci,C.)
Lender's Now TOTAL
:
U Lender's Address T(yI'AL:
1 cmify than I have read this application and same Nat ie above imnrnation is B111LD
rq tercet lagree mcomply with all cony and county ordinances and stage lows relating In QTY. MECHANICAL PERMIT FEE
(.) Z building contraction,and hereby authorize mpreuntutivesofihis city anenmrupmn the SHISMI FHP
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agrto save,indemnify and keep harmless the City Of Cupertino against d
ee .EcTR1 EL
Latin los,judgmentx,cod,and expen...which may In any way acema nodoo said City ALT L'R OR A DDTO M ECIL
in consequence of the grunting Of Ntis pvnniI'LI1M, GPE1i
APPLICANT UNDERSTASH12S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
5011RCE REGULATION MECHANI LITE
A (�//Z•]/ -7 AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCT[( 'LAX
Si...mrcof AE,hei ilCommm
cr ( `Data EXHAUSTHOOD(WIDIIC'T) HOUSING MUHG PION FBI.
HAZARDOUS MATERIALS DISCLOSURE
Will theitiad ind it!roam building wcupam xma it handle h...mom,traneinl HEATING UNIT(TO 100,018 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Qdc,Sedion 25532001 HEAPING ON IT(OVER I(lfk(I(1(I BTI[( -
Yes Na
F-)Yes - VENTILATION PAN SINGLE RES]Of PAID pate Rereiptp
Will the applicant or future Wilding occupant use equipment or devices which
\§hazandous air contaminants defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,000 BTU)
r(yl'AL
snxtncl
E3 yes -1 No BOILER-COMP(OVER 101.000 BTU)
-
I have road the havallous materials aqulmanems under Chapter 6.95 of the Cali- AiRCONDHIONER ISSUANCE DATE
fomin health&Safety Code,Sections 25505,25533 add 25534.I undersmnd that if to NEW RESIDENTIAL MEC,!. SQ.FT
Wilding does not currently have a tenant,that in is my responsibility no unify the occupant
of the vgaimments which must W met prior to issuance of v Comficam of Occupancy.
Owner nr amhorizeJ agent Date TOTAL' ISSUED BY:
OFFICE