99070073 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL 1'E MIT N .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY IN r, UATI
X20�FZS S I A_VECA D� E pr�tt ri n�J GA 9 So k 4 7 z p
o Cori E,=c,-coERSNAME �FPC�'� (�u$���HONE"1 _C 3 CONTRACTOR:SNAM1Ow 13 LIC NO:
NIC IC�ON-TROLM
.dil
GIIITECH?:NGINEIiN: LIC NO ADDRESS: ❑ ` 2,
CON'1'AC'I': PHONE: HUILDING PERMIT INFO
-1_n Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
7' (.-S,09S [C,/ LK El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby.(lion that 1.a,licensed v.dcr provishms of Chapter a la,n,men hilt JOB DESCRIPTION
WHOwith Section]IXMgof Division 3of1he Businessand Professions CtNe.and my license is / PERMIT ISSUANCE s�..L TIAL,
FWD in full force and effect. WI, D KITCHEN REMODEL
M�UU License On" LIB# APPLIANCES-REMDEN'bU. ADDITION D PLUMBING RE PIPE
Q M Date Contractor
ae<w ARCHI'I ECI':S DECLARATION PANELS (� y1, DMULTI-UNIT CS'FRUCTURAIMODIFICAT1.
OZ=hZ IunJetstanJ my plans shall be used as public records , GPT0200AMPS Tr / 0INTERIOR CCHIMNEYR PAIR
O
FNF'W Licensedl'rdensm,tal 201.1000AMPS IMPROVEMENT DSWIMMING POOLS
OWNBR-BUILDER DECLARATION
C -I OVER] AMPS D BATH REMODEUREPAIR DD17MGLITIQN
Q 1 hereby.Ilion on 1 am exempt from the Cssions Co basest Law for the
W 3 M F following mason.(Seaton]03L0.Business and improve.
de Professions Calc Aoy city or aunty SIGNS ELECTRICAL ❑OTHER
W tL h which requires a permit m constrvn,alter,imprmc.demolish,ur Hepar any swewrt �' .f n
E"uJ o') prior its issuance,also accounts the uppliwm buixoh Permit fil...imedorcmem SPECIALCIRCUIT/MISC.
�'�y that he is licensed pursuant to the factitious oftheCommebasLicense lnw(Chaptcr9
Ia+1�QC) (comnencingwith S«tinn]IMMryol Division Jof the Business and Prnfvsxinnr Code)nt 'HEMP.M BIER OR POLE I NST. COMMERCIAL:
Q.ke M that he is exempt mocefmm toilette basis far the alleged exemption.Any violation of D NEW BLDG/AUDITION D DEMOLII[ON
_ Sectio 7031.5 by any applicant for a permit subjects the upplicunuo a civil Penalty of POWER DEVICES []TENANT DFOOD SERVICE
nt re than live h,mdneddullnn(S5W).
IMPROVEMENT
owner of the prnpeny.onny. employees with wages as thcir.wlecomtctmtion. SWIMMING POOL ELECTRIC
will an the work.and the suueture in not Intended mourned fur sale(S«J044,Business CQTHER
M 3 m and 1'rofensions Code Me Conmacaus,License Law does.,it apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who huilds or improves thereon,and who does such work himself or through _
hit own empmm
employees,provided that such in, veentx are not intended or offered for NEW RIS ENTIAL ELECTR SO PT.
sale.If,however the building or improvement is sold within one year ofcumpletion.the SQ.FT.FLOOR AREA LSQ.FT.
eoladder will have the barren of proving Ihat he did not build or improve For par-
Pioof sale.).
❑1,m owner of the property,am exclusively contracting with Incensed contractors it, TOTAL: ,z5
omunct the pr feet(Sec.11144,Business tntd Professions Cale:)The Contractor's Li-
cense Law does not apply to an owner of prolaiany who builds or iMpmVCS ffiracron,and QTY. 'LU INC E IT FEE
who contracts far such pnpccts with.aommttoas)licensed pursuant to the Contractor's
Licen .w. PERMIT ISSUANCE
DISon exempt under So
.B&1'C fonhis reason
It U l ALTER-DRAIN&VENT- ) VALUATION
WOR"' IJSATIONII; ,ARAGON t e BACK FLOW PROTECT.U CG O Q Q
I hcrehy.Harm under penalty of perjury one of the following declarations: 'V
L]I have and will maintain a Cenibcme of ConscdIn olf-insure far Worker s ContraDkAINS-I1,00R.ROOT'.AREA, OND. STORIES TYPE CONSTRUCTION
totian,a,Provided fur by Scetion 3](m of the Labor Cade,fimhe performance oldie
work for which this permit is issued. PIXTU RES-PER TRAP
D 1 have and will maintain Workers Comport......Im..nove,as required by Section
ITS)of the Lnhor Coic.for the performance ofthe work forwhich this Permit is issued. GAS-EA.SYSTEM-II .EI:S OCC.GROUP / 9A Pia s
My Worker's Compensation Insurance carrier and Policy number are
Currier: Policy Na: : GAS-ILA.SYSTEM OVER 41' li ti7 Tj
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINUUSIRL WASTE INTER[] T
COMPENSATION INSURANCE BUILDING DIVISION PEES
(lTis section need not he completed if
the permit is for one hundred dollars P$100) GREASETRAP
or lcsx.l PLANCHF.CK FEF,
I renify thal it)the performnace ofthe work for which this gemit is issued,l shall SEWER-SANI'T'ARY-STORM EA.203 ET.
not employ any Person in any manner m as usubject Corm
en-become subjeco the Workers'Coen- ENERGY \E ' O
Z .cation lswsol'California.Date WATER HEATER WNENTIIiLECIR
z Applicant GRADIJ 1'
lin NOTICE TO APPLICAN'E IL after making this Cenifcate of Exemption,you should WATER SYSTEM/TREAI'ING
Pbecome subject to the Workers Ciantan tenon provisions of the Labor Cala You at SOILS
forthwith comply with such provisions or tombs shall be,deemed revoked. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPhMB. SQ,1.7. PAI
V O Iherebyaffrm Ill., m
there iso cons ,cnou leach......cy for the wrlimnarwoof all Receipt#
U. F-' the work for which this pernit iS,Swed(Sec.3097,Civ.C.)
Lcnder'.t Name TOTAL'
WLender's Address TOTAL: O
y I certify thm I hme reed this application and stem that the ab ve information is BUILDIN FEE
F" to correct.Iagree it)comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
UgcMI SEt
Z buildino wlai,iou,unit hc,,1wm M1aiec representatives ofthisc9SEISE
y n,color upon the /�/<vO
aMrvc-mentioned property for inspection protests. P13RMIT ISSUANCE ELECTRICF'. C !O J 7
(We)agree u+sase.indemnity and keep harmless the City of Cupertino against
Iiabillticcjudgmentc,rosLs and expenses which may in any way income against said City ACTER OR ADD TO MECH. PLOMBING FE
of the griming of this pemdt.
APPLICANT tRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FE.
SOURCE REGUL ' ,.
-1 2q�49 AIR HANDLING 11Nii'(OVIiR 10,(NIn CPM) CONSTRUCTION TAN
Signature of�A gygavaC+me Dec I?%HAUST HOOU(WIDUCC) HOUSING MITIGATION 'EE
I IAZARIIOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hacradem material IIEAI'ING UNI T 1'IO 100.000 B'i'U)
as definW by the Cupertino Mmolitd Cmho.Chapter 9.12,and the I]catch and Safety
Cndc,9cctinn 25532(a)' IIP.ATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt# 2o&
taWill the applicant or future building occupant use equipment or devices which BOILER-CObfP(JHP OR It10,(Np OTU7
®r mit Icmdous air commiumants as ddlned by the Buy Arca Air Quality Manugenient TOTAL:
Ontam l BOILER-COMP(OVER 100,000 BTU)
0Ycs ❑No
I have a Emardtws materials rcquimmcnts male,Chaplor(.95 of the Cali- AI R CONDI'I ION ER ISSUANCE DATE
fomia Ilwlth&Silo C,+dc.S«tions 255115,23513 unJ 25534.1 unJcrntunJ the if the NEW RESIDENT'IM,MECH. SQ.ET.
olding Jens not cornu ly the it is my responsibility to notify the occupant — 2—
t
of -requiter n, ch musthm primmissuancc ala Cenilica¢ f<kc
Snt
Owner art uuthonmlagea D a TOTAL: ISSUIiD BY:
OFFICE