00020045 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 1-170 7J
CITY OF CUPERTINO BUDDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUXiBIiC-MECHANICAL.
ItUILDING PROIF,CTiDE3I'IF VATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL.DAl
ao -7 SDmrpe25eT l�rL . a-io - o0
S NAME: PHONE: CO.saAMOR'SsNAly I 16, LIC NO:
p yyl 6° e SR. 996-0870 IID S CVY't NIC GDNTRDI.k
nRCHITEC'1'/ENGINEER: IAC NO: A DRESS' ❑
. O ,box 362. -5 J1m4yv /t
CONT'AC'T: PHONEII,DING PERMIT INFO
! O�� ❑ Conmliant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECO
O / b ❑ ❑ 50 ❑
LICENSED CONTRACTORS DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby alarm Inas I.In Eecaaed under phwialom of Online,9 mommencing JOB DESCRIPTION
ad'Z with Section 700prof Division 3 eflhe Busimss andPmfga.ianx Code,amdmy license is PERMIT ISSUANCE RESIDENTIAL'
�0,OF h alllmiceamlefle . Lick j?I ( �/ ❑SFDWL ❑KITCHEN REMODEI
Q U LL.. -- o APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
m<W Dale---Oy Comlacmr
ARCHITECTS DE CIL AUDN ❑MUCI'I-UNIT' ❑STRUCTURAL.
F 7 w PANELS
ZOyz I malentand my plamshall he used republic..N, MODIFICATION
OZ—Q UP To 2W AMPS ❑IN'TERIOR ❑CHIMNEYREPAIR
F,_FLLI Licensed Profcssinerl 201-E)WAMPS IMPROVEMENT 0SWIMMING POOLS
C C C Q I hereby alf ism Out I um Bsxmnpt Gao'he CommOors License Law Gn Inc OVER 1004 AMPS ❑BATH REMODEIIREPAIR DEh101.I1ION
L O a U following (Section 90315.Euxineca and Mn(cesinns Code An t I (OTHER Cj `� G�O.V1 M t A.
reason y vit,or county SIGNS ELECTRICAL
3 LL y which"ams a Permit to coustrvol,alter,improve,demolish,or repair any structure I I
.Io -,n• p) w a.� Fa._
F`k or m prior its issuance,also requires the applicant for such Perming file a signed.statement SPECIAL CIRCUIT/M ISC
f. r_l tha he is licensed poo-tato the provisions of the Courtrai License Law(Chapter 9
(commeneingwilh Section]Iq(bnf Divisioo3nfthe Businessnnd Profceinns Cnde)or TEMPMETER OR POLE INSI COMMERCIAL'
61 c C that he is exempt therefrom and the basis for the alleged exemption.Any violaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Section 7011.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
mol more than Fee l oadmd doll...155110).
SSC ❑ I,asowneroflhcpnpe
tny,ormyalmplhyecs with wllgw es their chic wanpens.Eon, SWIMMINGPOOLELECTRIC �OIHER
C F-e willdothe work.andlhestmcture is nut intended mattered for sale(See7044.Ifusiness I?MEN'I'
'1'HER
W 3 m and Professium Cale The Character's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTDRPS
ho,woy who hailds or tmpmvgs Hereon,and who doer rush work house I or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ IT
sale.IL however,the building or improvement is said within one year ofeompletion.the SQ IT FLOOR ARBA S/.SQ.FL
owner-builder will have the burden of proving that he did not build or improve for put-
Now of sale.).
1,as owner of the propeny.am exclusively contracting with licensed contractors to DOTAL
construct the project(Sec.9041,Business and Professions Calc)The CommeorS Li-
cense Law does ngtapplytounowner of property who builds or improves'hereon.and qm PLUMBING PERMIT FEE
whoconm eli for such projects with a comme nd licensed pursuant m the Count
L14O.Law' PERMIT ISSUANCE
❑ I no,exempt under Sec. .E&P C for Nis Tea
Date wn ALTER-DRAIN&VENT-WATER(EA)weer VALUATION
WORKER'S COM PCNSA['[ON DECI.ARA'I'ION BACK FLOW PRCTEI ..DEVICE
1 hereby affirm under penalty of Perjury one of the following dedumtherc:
I haveand will mammies Cenificamof Conscnnoself-ir,am for Workers Compen- DRAINS-FLOOR,ROOF AREA.COND.
cation,us provided for by Section 37W of the Iain Code,for the performance of the STORIES 'TYPE CON$IBUC'I'1(
work for which This permit is issued FIXTURES-PER TRAP
I have and will unimmin Workers Compensation Insurance.as required by Section
3700ofthe LaborCode for'heNifnnwnce mf Nework forwhichtNs Permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC,GROUT' / PN�
My Warke(eGbrmpeaeorm,lavrommecanimmid Palicy.unberam: IQ Q
Currier: I'TA,,UVM Policy N., .0 GAS-EA.SYSTEM-OVER
CERTIFICATE OF EXEMI'1'ION FROM WORK;R.T O Q
COMPENSATION INSURANCE GREASFIINDUStRL WASTE INTERCEPTOR
This sediun need not be campmorl RNper
mitis mit is for one hundred dollars ISI W) BUILDING DIVISION FEES
gr less) GREASE'1'RAP PLANCHECK IEE
leanifytnd in Neperformance oflhework forwhich thispennit is issued,l shall SEWER-SANITARY-STORM EA.2E0 FT.
nal employ any petxm in any manner so as to become subject to the Workers Compcn- ENERGY 171TE
Z ealinn laws of Culifmi
oa.Date WATER HEATER WNENT/T:LECfR
z2 Applicant I GRADING IEE
ti NOTICE TO APPLICANT:If,after making this Ccnincnte of E.ch can,you rhgWd WATER SYS"I UMO REA)'ING
a > Mcome subject to'he Worker's Compensation provisions of the labor Code,you must SOILS FEE ,
(otnwilh wntply wilt,w,h provio s or this permit xhall be dec ned rcvnked. WATER S12RVICE
Q
U0 CONSTRUCTION LENDING AGENCY
agency NEW RGSIDF,NTIAI.I'LMR. SQ.FT'. PAID
UO lfareny anion errmm is acansweianlending.rgencY for the performance of �, _ Recciplk
FL (•-I the work fm which this permit is israal(Sec.31X1],Cos.C.) T�
O Lender"Name
U L eadeh Address TOTAL: _ r
Fy 1 emits that 1 have read Nis application and stale that Ne above informmion is BUILDING IEE s LI II I
h convet.l-,me to comply wish un dry and',,maymdimm",and atm law,miming m QTY. MECHANICAL PERMIT ]FEE
U Z building coneweion.and hereby uuNoriempresenlrlive.s ofihis city menmr upon the .ELf.IESE 1
aMwo-ameltuned Pntpeny for u spechim purposes. 1'ERMD'ISSUANCE
(We)agree to save,indemnify and keep hmmlesn the City of Cupertino agniasl ELECTRIC FEE
liubilities,judgmcnls,mst.and e,K es Which may in nay way ammo again sl amid City ALTERORADDTOMECH.
in,im"oem a of in,granting winds permit. IPLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONAIR HANDLING UNIT(TO 1(111(X1 CFM)
S. MCCBANICA6 .may
11 AIR HANDLING UNH(OVER IL000CFM)
� . 3,I,G L'1� C(INSTRl1CT1(IN'IAX
uStire(itA Iicant/Conlydctol' to EXHAUST HOLD(W/DUCH
�� HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will Ne.,bramorhome building accupamstoreor handle bferahms material HEATING UNI r(To 100.000 BTU)
as defined by the C.,hat.o Municipal Cole.Chapter vi.12,and the Health and Safety
Coale,Sectio 2553200/ HEA'1'INC UNIT(OVER IN).000 BTU)
El Yes F1 No
VENTILATION VAN(SINGLE RESID) PAID
Will the applietm ar hilum building cecmprnt mss equipment ar deeRes which Data Receipt k
emir hazardous air commotinanls as defined by the Buy Area Air Quality Management HOILF.R-COMI'fIIIPOR IfXI,(XO BTU]
Didner TOIA :
❑Yes C]No BOILER-COMP(OVER 100,000 BTU)
1 have read the hmardon.s materials Ic h under Chapter(�95 of the Cali- AIR CONDITIONER
.255 3 a p IShSIIANCIi DATE
fomia Heald&Safety Cale,Section..thin i 25533 and 25534.1 to notify h thou if the NEW RESIUEN'1'IAI.MECH. SQ.IT.
buildingfiiHcannlcmrcich have
mair,Por T.ismymspoosCertiytanotify he execution nl
ante mglilrememu which Ilmxt bo Imet pea m iss.ansx gra eenifigatc ar ocempanry. qq
Ownermatillnrrrcdagcm Date TOTAL: ISSUED BN �y
OFFICE