S 0805 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT I'LEM ROJECT:DENTIFIC S 0805
BUILpINO PROJECT IUEYI'Ib'ICAT108 U
SANITARY NO. N'PLICA'I'ION SUBMITTAL UA
BUILDING ADDRESS:
(,I q,� si�i92) e)v,c Rr d 2n v a
OW f�;yJ'S NAAP�MM\\L: ( C I'HO(�[J/L�: CONTRACTOR'S NAME:(7 LIC NO'.
R LI JU` e2 ( /�0--3)01 / �I , /7 /BOJ NIC CONTROL#
ARS/f/fIIT�EfCTIEU (NEER: LICNO, ADDRESS: /'l ❑
4X4 el
✓ i N
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG' ELECT PLUM- MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm mat I on licensed made,proviaurro nfehapter v(enm:ncncing JOB DESCRIPTION
O�Z with Seaivn]IX3)of Divisiun3of the Business and Profe,,imm Code.ond my license is RESIDENTIAL:
LL1 O O I'13RMIT ISSl1ANCE
CSF LiceneClassnd cOcvl. ❑SFDWI. ❑KITCHEN kF.MODEI
<UU Li«mac Close Lica APPLIANCES-RESIDENTIAL (TION [:1 PLUMBING RE-PIPE
6+Z W DartCom racn..
rn G G. 1:1'1-UNIT ❑SD UC URAL
F.],f ARCH]"rECTS DECLARATION PANELS
Z O a,`Z 1 understand my plana shall be used as public records MODIFICATION
OZ -� UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
�4t:W Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I0(3AMPS ❑BATH REMODEUREPAIR ❑DEMOLD'ION
W 6 I hereby air,.mat 1 am exempt from the Contmorms,License Law for tee
3 W F lidlevia,mrson Nee in r]131.5,Bu,mcss and Pnrt'e—onv Cole:Any city or county SIGNS ELEC fRICAL ❑(1fHlik
which n,9 Permit t c t t II improve.J 1:h P ) t eine,
O� pro t I .. 1. 4 fl ppl tf suchp bt TI asigned tteme , SPECIN.CIRCUIT/MISC.
fy�Ythat he licensed pursuant t theproionic,of the Contractor's License La (Chapter 9
ICC, brominemgwrth Section70(finof Division 3oftha Bosme,,and Pmfesaom Ctde)nr TEMP.MF.TIiR OR POLO INS'f. COMMERCIAL'
Q.=c C that he is exempt therefrom end the basin for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C3 DEMOLITION
X�y
Section]031.5 by any applicantfor a trait subjects the applicant to a civil Penalty of POWER DEVICES 'TENANT FOOD SERVICE
n mate than live hundred dolled($500). Le IMPROVEMENT
SO Q Las owner of the propery.onny employees with xagc az their,ole compenmtinn, SWIMMING POOL ELECTRIC
p. will dedevork.and the otmuctum' not imendedmollered b:rsale(Sec.]I144.13usincsr 11 OTHER
a 3 °nJ Pndessions Code:The Coinractor's License law does not apply to an owbe,rd OUTLISrS-SWITCHES-FI%TURES
property who build,or improve%Iherced and who does such work himself or through
his own employees,provided that such improvements sure not intended or offered for NEW RESIDENTIAL ELELTR SQ FT.
edr,If,cowers the building or improvement issold within one year of completion,the SQ.Flo. 01�AR&\ SJSQ.IT
caner-hui lder will have the burden of proving that he did not build or improve Iia put-
v"orsale.). �r en
n r of the property tan exclusively contracting with license cmo racnm m TOTAL: �� Ur V
m Ne project(Sec.]DLI.Business and Professions Code)The Commctnrs Li-
neLaw does not apply it)an raw net of pro,b,is to bit Idsm improve,derecn,and QTY. PLUMBI sP 2MIT FEP-
who contracts for such projects with a contractors)licensed pursuum m the Comtanor's
License Law. I'IiRMI'r ISSUANCE
1 am exem t under Sec. .B A,P C for this r
on, ANTER-DRAINk VEMr-WATER( ) VALUAI ION
mer Dum J
IRI M1t .A 10 D[CLARATION BACK FLOW PROTECT.DEVICE ♦ D O O O
thereby offrn:under penalty of lxTjmr rte nl the Hollowing dmlmrution,:
I have and will maintain a Cromer ofCo setnmulf-insum for Wn kch Compcn- DRAINS-FLOOR.ROOF.AREA.COND. STOHIhS TYPECONSTRIICrI
svtinn,a%provided lie by Seddon 371 of Ih�lube,Cede,fan ou perfrnmnrec of the
work for mhlch this permit is issued EI XTURFS-PER TRAP
1 have and will maintain Worker's Compcmation Insurance,as required by Section
3700oflbe Llxn Code,for the performance of the work for which this permit is issued GAS-17A.SYSTEM-I INC.4 OUTLETS r 01 GROUP APN
My Worker's Compensation Insurance currier and Policy number am:
Carrier. Palley Nv.: GAS-IiA.SYSTEM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUS'I RI,WASTE,INTERCEPTOR
BUILDING DIVISION FEES
("this section need pot becompleted dean permit is Htnme hunNeddollars($TOX) GREA$Ii TRAP
or le".) PLANCHECK PCI a 21 ZO
l verify not in lheperfmmanceolthewmk forwbich thispennit isiswed,Ishall ST:WER-SANITARY-STORM EA.200 FT.
not employ any perm in any manner w as to become subject m the Workero'Compen- CNIiNGY FEE IV cn� Gs
ZZ moan laws of California.DateWATER BEATER W/VENT/ELECEN
O Applicant GRADINGS
F-' ; NOTICE TO APPLICANT'.If,alter finking th'w Cer ificam of Exemption,you should WATER SYS"I EM/rNEATING
become subject ionic Wode!%Compensation provision,of the Labor Cale,you must SOILS
fethwim overfly withsudt poeworbe,this peemit.ball be decmWmvolae. WATER SERVICE
a.
aZ CONSTRUCTION LENDING AGENCY NEW RESIUIiNTIAI.DhMN. SQ,F1'. PAID
U Ifo, hoffirrat ih,hithzube,e isaco (Sew.3nlendingagency lar the perfomtanve of Dam Receipt
the work for which this permit is issued(Sew.3M],Civ.C.)
ULenders Name
{U I<nJeVI AJdrtss TOTAL
I cartily mat I M1wc fwd thi%applicvuon and.aune mal the above information is BUILDING 'EE
F' h correct.l agree to comply with all city and county ordinance%and sate laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and ficrebyamhoriw mpre,savativesof lM1uaity In cmm�tpen the SEISMIC IT
above-mentioned pro,wry for inspection purposes. PERMIT ISSUANCE
(We)vgrec m wvc,indemnify and keep battles the Goy of Cupertino against ELECIRI
Iiabildiccjudgmetns,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of me graining of is permit PLUMBING FEG
APPLI UNDsER/STf/ S \ND WILL COMPLY WITH ALL NON)-POINT AIR HANDLING UNIT(TO 10.x3 CFM) MECHANICAL FEE
7//
C AIR HANDLING UNIT(OVER 10,033 CTM) CONSTRUCTION TAX
Sign are of Applicane/Contmcaor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAT RIALS DISCLOSURE
Will thcapplimmorman bmIdingoceufum,bar or handle hirmshes material HEATING UNG(TO I don(m)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321e)Y HEATING UNIT(OVER 100,M)BTU)
❑Yes El No
VENTILATION FAN(SINGLE RESID) PAID
�� Will me applicant fir lumre building acnipanl use examines,or device%which D:uc Receipt a
hazardous air contaminant, as de fined by the Bay Area Air Quality Management ItOILER-COMP(IHPOR 100.(X3BTU)
d4 T(l rel.:
❑Yes FlNo BOILER-COMP(OVER 1000)(0 BTU)
I have read the hswdums materials requirements under Chapter 695 or the Cali- At CONDITIONER ISSUANC. TE
fordo Health k Safety Cede.Section,25505,25533 and 25534.1 underated teal if the NEW RESIDENTIAL MECH. SQ.17,
building does nm currently have a morn,data k my rwrymsibillf.m notify the o,,,pam
of the requirements which most be met sm,W ismance of a Cerifierw of Occupancy.
Owner or authormed agent Data TOTAL: ISSUED BY:
OFFICE