S 0347 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '— BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION' APPLICATIONIPERMIT PLUMBING-MECHANICAL. S 0347
.BUIT,DIN(;PROJFCT IDENTIFICATION
BUILDING ADDRESS', SANITARY NO, APPLICATION SUBMITTAL DATE
�gg92 �2oDR\GVES bole,
gWER'SNAMq' P ONE CO ACTOR', NAMB'. LIC NO:
�V\\U(�ei�41�CWn 1r�MI� 405 $ I-,).Ov 4K "- �JJ�IIIm��$ \N1.0 e�c4113 N/C - CONTROL#
ARCHITECfIF.NOINE R: LI NO: ADDRESS - ❑ me
a a6 S;,) 2 %-t 9440
CONTACT: '1 PHONE: / BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MELD
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE ❑ ❑
1 hereby affirm ata,l.In licensed under I...icons of chapter 9(c,mmenetg , JOB DESCRIPTION
�04Z with of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL'
100 wt PGRMII'ISSUANCE -
in full(orae and effect.
W F, (0417.3 0 ❑SFDWL El KITCHEN REMODFI.
�UU LicenseLlvss Contractor
A APPLIANCES—RESIDENTIAL ❑ADDITION [_1 PLUMBING RE-PIPE
yZL DamConva
p,Om ARCHITECT'SDECLARATION.SkJlo* Oµ PANELS ❑MULTI-UNIT ❑STRUCTURAL
Ooinz I understand myplansaholl he us ed as puMicruords MODIFICATION
UP TO MODIFICATION
REPAIR
FCS,CIOiI Licensed Prnrenioml 201-IIp0AMPS IMPROVEMENT E]SWIMMINGPOOLS
AR
OWNER-BUILDER un de Contractors
OVER Idy P ❑BATH REMODEL/REPAIR El OLMOLITION
a 1 hereby,jSanffirm that 1 1. exempt firm Ilio Cessions o License city
o fm the
G`z following rwwn.permit
to
A13 Business and vet de ions Code:Any°ity nr manly SIGNS CIL ❑OTHER
WLLOE' wh h t, prmII construct, h p h or repair anystructure
Ari , t a s y the appl amt hp n flea:geed(Chapter
SPECIAL CIRCO IMISC.
,> he is ed pursuant thep fth Contractors L L ICh.pter9
p (commencingwithSection]000)efDivision 3 ofthe Buninennand Pro,si n Code)or TEMP.METER OR OLEINS'T. COMMERCIAL:
4y o that he is exempt th°refrom and,he hunts for the alleged exemption.Any violation or ❑NEW BLDG/ADD I'1'ION ❑DEMOLITION
WAN
Section 7031.5 by any applicant for a permit subjects he applicant o a civil penalty df POWER DEVICES ❑TENANT ❑FOOD SERVICE
no,mora than five hundred dollars($5 W).
F Z Y IMPROVEMENT
6 01,as owner of the propeny,or my employees with wages as their solo compensa,ian, SWIMMING POOL ELECT RIC
�rq will doth¢work.and the structure is nalintended or offered to...to lXv.7044,Bacons ❑OTHER
�am and Professions Code:The Contmclor's License Law does a..,apply m an owner of OUTLETS—SWITCHES—FIXTURES
property who holds or improves thereon,add who does such work himself or through
his own employees,provided,hat such improvements am not intended dr olfered for NEW RF,SIDENUAL ELECPR SQ Ff.
sale.If,however,the building orimprovemem is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ,FT.
ner-builder will have the burden of proving that be did not build or improve for par- _
pone of aalu).
❑ 1,as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL. p p
construct the project(Sec 7044,Business and Professions Codu)'Ihe Contractors Li. - /'�ry
cense Law does nm apply or an owner of property who builds or improve thereon,and QTY: s PLUMBING PERMIT
who contracts for such projects with a commeloda)licensed pdrsnam to the Connectors evJ(/��
License Law. PERMIT'ISSUANCE. IG 8
I am exempt under Sec. .B&P C for this reason
ALTER—DRAIN&VEIN T—WATE(EAI VALUATIO
owner Dole
following
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
_ i hereby affirm under penally of orrJory one of the following Workerts Co
sat'have andwillmaintain of the Labor
Core,for
Worker DRAINS—FLOOR,ROOF,AREA,GOND. STORIES PB CONS'1'RUC'I'ION
aaidn,as provided for by Section 3]00 of the Lnhor Gtde,for the performance of We
w
(ave and
thispairmin oro,,' PIXTURF.S—PER TRAP
t have end will ode a r Wmeomn Compensation Insurance, h required by Section -
3901nfthe Labor Cede,(ogre pedormuncen(rhe work l'or which his permit is issued GAS—EA.SVSTP.M-I INC.40i]TLEfS . OCC.GROUP APN
My We G cation omni¢catrierand Policy��nyy qq�� �Q
Carrier a` P°Ilcy No.:w "01% 7- \ GAS—F.A.SYSTEM OVER 4 PA)
CERTIFICATE OF EX MPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IN BRCF.PTOR
BUILDING D ISION Flt is
(This scanner need not be completed ifted permit Is rnnme hundred dollars($10ry GREASETRAP
or lcsx.l PLANCHECK FF.B
I certify tbm III pofermanceof the oak for which[his permit is issued,I fiall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in a y manner sn as m bec°rt�,v=jlt ^ eri Cmupen-
ENERGY AEC
O z stood Law s°fcae�qV�ppIq :^ In L WATER HEATER W/VENT/ELECTR GRADIN
7 O Applicant�Y.Y,
G � NOTICE TO APPLICANT:ILafmramking,os it" o, of Exemption,you.should WATER SYSTEMGKEATING VIkAX
hecrme nuhjecl In the Workers Compemmi a,masons of the Labor Code,you toast SOILS EXIM
tti fnnhwith comply with ouch provisions nnhia Aconin shall he deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U 0 I hereby affirm that there isamt(Sec.construction lending agency for the performance of me Reeaip,#
the work for which 1paput*y't"wued(See 31N],Cie CJ
0 U Lender's Namc AL/7 tG DOUG.
O V Lender's Address TOTAL: -
�^ BUILDING THE
F^ I certify Ilial I has°read This apPliulinn and nWle[hal Ibe¢hove Information is
V] crossed I.,me...comply wall cityand county ordinance4 and s(am laws rem,ing to QTY. MECHANICAL PERMIT FEE
C) Z
building conswmion,and hereby authorize representatives(if this city tenter upon the SEISMIC PEE
if
torose-mentioned pmpe,y for inspection purpnaen. PERMIT ISSUANCE
(We)agree to save,indemnify rand keep hornless the City(if Cupertino against ELECTRIC FE
liabilum.,.judgramna,ni,amad expenses which may inany way accmeagainst said CityALTER ORADD TO MECIL
PLUMBING F F.
in cnnccyvenm of the graining of thl permit.
APPLICANT UNDERSTANDS DWILI MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CPM) MECHANICAE
SOURCE REGULATJQt,W
�(j)(��� AIRHANI]hINOUNI"f(OVER I0,000 CFM) CONSI'RUC TIONT
Signature ofApplicaaUCo I 'I Date EXHAUST HOOD(W/DUCI) HOUSING MITIGATI< FEE
IIA AR S MATERIALS DISCLOSURE.
Will the applicant or future building occupant tore or handle hazardous material HEATING UNIT(TO IME00 B U)
as defined by the Cuperhnn Memo I Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(x)^ L�d/�/ Hf ArING UNIT(OVER 11111,0111 BTU)
El Yes VENTILATION CAN(SINGLE RESID) PAID
Dae, cell)[#
Will,he applicant or(utum IF occupant use equipment or devices which RAILER—COMP(311P OR IIXI,WO BTU)
F mit hazerd.ns airc urs mmains as defined by the Bay Area Air Quality Management TOTAL:
Uadria? BOILER—COMP(OVER I010,010 BTU)
❑Yes
I have real the hazardous materials lryuireenh under Chapter 6,95 AIR CONDITIONER 5 nl'Ihe Coll- ISSUANCE. ATE
Firma lietth&Safety Code,Sections 25505,25533 and 25534.[understand that if the NEW RESIDENTIAL MECH. SQ.FT,
building does not currently haven)no.,hit it iseryte......Mile I.nedify the marpard
..f the requirements ' mdpdo ,o vsuneeofa Ccatifi=m ofj�c-FytG( '
Owner or authorized aKcut Date TOTAL] ISSUED BY:
OFFICE