B 0177 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA], PF.Rhfl'P 00.X 0 1 7
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BUILDING DIVISION APPIACATION/PERMFP PLUM NG-MECHANICAL S0001 `Il{�J�l
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'T'ARY NO, APPLICATION SUBMIT'MAL DNIH
0 'S NAME 1 1 MUNE: O TRA 1GRS NA E: LICINU: O
l_II 1 i N/C CON'I'kOLp
ARCHITECT IENGINEER: LIC NO: AD 'SI , 1 ❑
1 - CGNTACI: PHONE: I TIS IlUILDINGPERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG FLEET PLUMB NIECH
❑ ❑ ❑
LIC17NSED CONTRAC70R'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm don l am licensed under provisions(if Chapter 9(commencing
QgZ isilh Section90(rom'Dieisien 3al,he Business and Professions Cud e.wtdmylicen.cis RESIDENTIAL:
W p O PERMIT ISSUANCI!
EL
W-i- in full force and eR — ❑SPDWL ❑PLKI UMBICHENG BE PIPE
QUU 1.k<n—,-F�--'�LicM APPLIANCIiS-RESIDENTIAL ❑ADDITION El PLUMBING RF:-PIPE
44
F Z W Dnd. -k-D—Conuaclo
m Q G ❑MULTI-UNIT' ❑S ODIFTURN.
Wet)
ARCH] DGC PION PANELS
F o Z I vaderasud my plans shall be used as public records MODIFICKIION
CZ4C UPTO200AMPS El INTERIOR ❑CHIMNEY REPAIR
I-41 License)l'rafessional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
J OWNER-BUILDER DECLARATION OVER I000AMPS ❑BATH REMODE'UREPAIR [I DEMOLITION
C C Q 1 hereby i ffime Phut I am exempt from the Cmilmalnr's License Law lir the
�6�d R F reason.L U Billion, n.(Section 7031.5.Business and Professions Gds:Any city orcaumy SIGNS ELECTRICAL ❑(YTIIER
1+1 O which require,a permit to Construe,,alter,improve,demn[ish,or repair any stoomm
priena it,I...vnce, korcyvires'he applicant lar such permit to filo a signed statement SPECIAL CIRCUIT MISC.
men>. that he is,,,used pursuem to the grovisions of the Cnmmceer,license law(chapter9
�a GAO (commencing with Section 7")of Division3of,he Business and Professions Cole)or TEAM METER OR POLE INS'1'. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/AUDITION ❑DIi4101.i'fION
ISXI LL• Scctiba7031.5 by any upplicam lirupcmdt suhjcros the nppllcnunn a civil gentry of POWER DEVICES ❑IHNANT ❑FOOD SERVICE,
FZY not more than five hundred dollars($5(10). IMPROVEMENT
SSC ❑1,as owner of 0e progeny,or my employees with wages nnheirsokcompensminn, SWIMMING POOLELECfRIC []OTHER
will do the work,and the ntrudure is urn imendedoroRercA for sale(Sec 70W,Business
se roil Professions Code Tire Conuuctors Ween,Law does no,apply to an Owner of OUTLETS-SWITCH ES-FIX'1'URES
Progeny who build,or improves thereon,and who does such work onnalf m Ihnmgh
his own employees,provided that such improvements art no,intended or offered for NEW Rf SIDENTIAL ELECT SQ FT.
sale.If.he,ase,the building or improvement is sold ouldrane year(if completion,the SQ.Ell FLOOR AREA LSQ.ET.
owner-buildcr,will have the burden of proving that he did not hold nr'nnprove for pnr-
paxnl'sale.).
El h as owner of the pmpert am exclusively enduacting with licensed contractors to TOTAL:
construct the project(Sec.91144,Business and Professions Codo)The Contactors Li-
cense Law does no,
i-seLawdoesnot apply to an owner of property who beads or improves thereon,and QTY, PLUMBING PERMIT FEE:
who contracts for such Projects with a contractor(,)licensed pursuant I, Contractor'I -
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
Owner Data
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following Jedamtions:
I have and will ummona CenifiemeafConseotfo self-inmre for Workers Conifen- DRAINS-FLOOR,ROOF,AREA,COND, i) I YPIq18UCTION
nation,as provided for by Section 3900 of due Labor Cada,far be poli or ante or the
work for which this Permit is issued. FIXTURES-PER TRAP
11 have and will maintain Warkerx Compensation Insurance,as required by Section
N,ofthe labor Code,for the Noomtaree of the work fur which this permit is issued GAS-EA.SYSTEM-I INC 4 OLUTIT'S II OCCGROUPP
My Warku.',Cam asgoon) w+ ,mdPoli. fir! -S
A1ov
Cartiee ` km lrMn�11S��Policy No.y' ^�I)Ib„J''( GAS-EA.SYS'THM-OVER 4 U3,AI �P�17
CERTIFICATE OP EXEMPTION FROM WORKERS' CREAST%1NUUSTHI,WASTPINTERCEI-F
COMPENSATION INSURANCE IIUILDING DIYISION FEES
(fhis section need oat be annplaed inti,permit is loom,hundrcAdollen($11X) GREASHTRAPm less) I'1. NCHF,CK IrHEI certify that in the permundanceaf,he work far which this permit is issued.Ishii[] SEWI!R-SANITARY-SIOnot employ any aean in any manor,so as to becomenuhjcat to the WmkeriQnngcte- ENERGY FEE
z .lion Law,nl Califnrnin.Dam WATI!1t 1 HATER WIVE ZApplicant I OIIADING i'I!liNOTHCE'I0 APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTF. SOILS FEE
haeme subject to the Worker's Campcn,vtion prosmonsal,he Lahr Code,yoummo
Ienhwi,h comply wllh such provisions or do,permit shell he deemed invoked. WA'THR S- ICONSTRUCTION LENDING AGENCY N I 1'IA .18. PAID
VQ I hereby affirm that here is a construction lending agency for the perfommmceof Game Receipt It
u+ the work 1'nr which Illi,permit is'Inmed(Sec.7099,Civ.C.) Jr X
O U
IGIAI,
Landers Name .
r {LI Lender,Address TOl'AI,:
I certify that I have read this application and rude that the elrwc information is B
UILDING Plili
cored.Iagree mcon,d,with all oily suit entry ardlnmcesmd,tule hoinoongm QTY, IANICAI:PERMIT PEIi
(,) Z badinage mshucdurmal hereby radiator representatives ofthis city to itineration the SEISMIC FEII
above-mentioned prapcny far in,pcaion purryrses. PER SUANCii
(Wel agme to soon,indemnify and keep harmless be Cily of Cupertino vgninst Iiabihnr,.jodgmenlu.m.1,andexpcn,m wbidnny in airy way accma uguinnt,aALTER OR ADD'I()MSCI i. LUM ❑Ilinacqucnce of the grantingof this Permit.dAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,100 CFM) r C FEII5 URUhATIONS, AIR IIANDLINC UNIT(OVER fO,INNICPM) ONSTR CT'IONTAX
5numofAliplicaa,Coa OurDal EXHAUSTHOOD(WIDUCf) GNITTIGATIONFER
HAZARDOUS MATEHIAIS SCLOSWill theupplivan(orfumrebnlldingoccup store or handle hitardousnuderal HEATING UNITTO 100.(00RTU)as deOW by the Cupertino Municipal Code.Chapter 9.12,modthe Plealm and Safety
Coda Secban 25532(0)9 HEATING UNIT(OVER 110,0X1 ET U)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) AID Date Receipt
Will the applicant or furore building occupanl use 0gropment or devices which BOILCk-COMP'OHP OR 10U,fX1U BTU)
coif bacialms air contaminants us defined by the Bay Arca Air Quality Mamagensnl TUI'
�District? BOILER-COMP(OVER 100,1X0 BTU)
❑Ye, 0 N C
I leave mad the haradous arsenals requiremmu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC )AT/IG
frod.Health&Safe,y Code,Sections M505,25533 and 25534.I ondcrstand th a If 0e NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have it moral.thin i,is my responsibility in notify thurccepant
of the requiremerns which mus,Na met prior In i.amsuce of a Certificate of Oracularly, ll
T51Q q0
Owneror rmhariud agent Dem TOTAL ISSUED BY:
OFFICE
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