B 0363 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N/o�flq 0 3 6 3
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL _ 50001 /�"
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'. NAME: PHONE: COMRACId )I ir ^OR'S NAMF � - LIC NO:
//44TTrr ,,IIJJTTJJ NIC CONTROL%
��ARCHITECT/ENGINEER LIC NO: ADUR SS: / r n ❑
Xtlt�fZe
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coNTAc'I` D g PPHHONE:(� BUILDING PERMIT INTO
d -/Q Q ❑ Gmsultant Fees Paid by Applicant(Initial) RI,DG ELECT PLUMB MECH
Svc v � G 3 7 O
E4!0- ED 0--- o
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby rffirla mm 1 am Recnaw ander proviaione or enapter 9(alnmmang 10H DP,SCRIPTION
Czzwith Seminn 90110)of Uivisinn3 o[thn Business Una Professions Code,mrd my license is RESIDENTIAL:
won v p PERM[T ISSUANCE
Fw� in toll force unit off ec �JZJ �J [I SCOWL El KITCHEN REMODEL
lUZrj License Ivss Licks N-T/' APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F Q W Date- Contract U S F
m m ❑MULTI-UNIT ❑STRUC'rURAI.
F D yz ARCHITECT'S DECLARATION PANELS
ZOv�i la l understand my plans shall he used as public records UP TO 2(111AMPS MODIFICATION
O Z.. ❑INTERIOR ❑CHIMNEY REPAIR
(:.N.F'E Licensed Professional 201-IMOAMPS IMPROVEMENT E]SWIMMING POOLS
C ', OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000AMPS F1 BATH REMODEWREPAIIi El DEMOLITION
X a(may F following Nei(Sectinn 7031.5,Business and Pmfessiens Code:Any city memory SIGNS ELECTRICAL []OTHER
Ed O which requires a permit o coronad,alter,improve,demolish,or repair any structure p�
Priorm its iamence,also re9mmslho appliant formeh permil to file aeigneA sbleread SPECIAL CI RCDIT/MISC. /V
reL� that he is licensed.....an I to lbe provisions ofthe Cennactels License Low(Chapter 9
F100 (commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP.MBTP.R OR POLE INS'1'. CTOMMFRCIAL'
d y m pd that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDI TION ❑DEMOLITION
SY7E f+y Section 9031.5 by any applicant for a Owlnil subjects the applicant to a civil penalty of POWER DEVICES
[:1 TENANT ❑FOOD SERVICE
Fy not more than five handled dollars($500), IMPROVEMENT
AQ ❑ has owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC _
El OTHER
one dothe work,and theonetilre isom intendedom[tared rustle(Sce.7044,Business _
1 ' uad Pndeoions Code The Connector's License Law does not apply te an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELEC'1'R Ff.
sale If however,the building or intprovelneat is bold within one year orcompletiomthe QrMAYO
AREA $ISQ.PT.
wnerbEiRder will have the burden ofproving Thalhedid not build or improve fmpur- ---111poseursale.).ucownererthe n y con 6 'fO'I'AL:pope Eoresinesan fessins wlihlieTheeCurner's ,-use La the ergot[(Sea o air Boniness and rty wh bui Cdr t Tho es Cu ora Li-
cense Law dcee nm applyman owner of property who builds or improves thereon,and QTY. PLUMBINGPERMIT /�/'� 1License law PERMIT ISSUANCE r VL7I am exempt under Sec. ,B&P C for thiorcaoonALTER-DRAIN&VENT-WATER(EA) sowner Dam
WORKER'SCOMPENSATION DECLARATIONbugle RACK FLOW PROTECT.DEVICE,
I hereby alfimt under penalty of perjury one of theeE
following Work,aticns:
'c Ihoveand will for by
of Cresco[to sodeiumfer Worker's Com pen- DRAINS-FLOON,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
.anon,as provided for by Section 3]110 of the Labor Code,for Ore pafnrmancc o[the
work for which this permit is issued. FIXTURES-pP.R TRAP
1 have and will ode,fon Wmerfor ante ofth ew work
which
required t i Scotian
I 3900 of Labor Code,for the performance of the work for which ihie permit is issued GAS-EA.SYSTCM-I INCA OUTLETS OCC.GROUP APN
My Work / arrermd Policy
Carrier: mliksuvcecPolcyN �nu
rStry s'.�r CAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE , BUILDING NVISION FEES
(This section need not be completed ifthe permit is for one hundred dollars(Mciff GRPASL TRAP
m less.) PLANCHECK FEE
I cenifythat in the performance ofthe work for which this Permit is lssnad,I"all SEWER-SANI'T'ARY-STORM EA.200 FT.
not employ my person in any manner so as o subject become subjeco the Workers'Compen- -ENERGY PEE
z ,Z sateen Laws of Cali�ia.Dam WATER HEATER WNENT/ELP.CTR
O Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Cer ifiale of Exemption,you should WATER SYSTEM/TREATING
I--t Ix ceme a.bjcc,to the Worked,Compensation provisions of the Labor Code,you mint SOILS FEE
{alit Q forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERV ICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUND. SQ.FI'. PAID
I hereby nllfnn that m
them coronation landingagency fonha perforanceof —Dom iP1#
L) -s the-s the which this permit is issued(Sec.3097,Civ.C.)
0 F Lenders Name TOTAL:
W Lender's Address TA.:
1 certify that I have food this applialion and state that the aheve information is BUILDING FEE
fr rn mace[.l agree[,,comply nim all lily and cm only ordinancev and elate lawn relaBngm QTY. MECHANICAL PERMIT, FEE.
C.>
building construction,and hereby authorize reprasattativea crustily toemerupon the - SEISMIC FEE
abommcntional property for impecmon purposes. PERMIT ISSUANCE
(We)agree w save,indemnify and keep harmless the City of Colson agaiml CLEC'I'RIC WHA
liabilities.judgments,tostsand expenseswhich may many wllyaarveaginestabid City ALTER ORADD TO MECH. /-1
in consequence of the granting of this permit. PLUMBING EEE V
APPLICANT U 1 RSTANDS AND WILL COMPLY WITH ALL NONPOINT AIR HANDLING UNIT(TO 10.000CPM) MECHANICAL PE
SOURCE REG LA.yONS.
AIR HANDLING UNIT(OVER 10,000 CVM) CONSTRUC'fIONTAX
Signa—npliedMCo roto /Dora/ EXHAUST HOOD(W/DUC'fl HOUSING MITIGATION PBE
IIA ARD'eI MATERIALS DISCLOSURE'
Will the applicant or future[affluence upant smreor handle hazardous material HEATING UNIT G 0100,003 BTU)
as defined by the Cupertino Municipal Corp.Chapter 9.12,and the Health and Safety -
Code,Section 25514,)7 - / I]EATING UNIT(OVER 10pff0 BTU)
El Yel VENTILATI ON FAN(SINGLE RBSI D) PAID
Date Receipt
Will the appiiered or future hudding natural use equipment ordevlean which
emit Tamen ous air conmmin:ots as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,01 O BTU) O,T d1
District, BOILER-COMP(OVER 100,000 RTU) Cl
❑Yes
I have read the hazorAomemaleriols requimnee,t her Chapter 6.95 varied Cnli- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,EP. C�
building doe t currently have a ament,that it is my mipnnsihilf,o notify iheocca ma J
them ¢
, . mwhlcm
h the eIF romisancdofo Cenifiam nfOcca ancy.
Owner of o0' dcard t :are I TOTAL: ISSUED BY:
OFFICE