B 0188 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL11 PERMIT NO.X01 8 8
IJUII,DING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL SOOOk I
BUILDING PROJECI'IDENTIFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l oo5� LT, < G-23-9C
O N:R'Sl AMI:: "f PHONE: COy{RACfOR'�NAME: Cly_,4LIC 9 SIC 1 // X �,j NIC CONfROLp
ARCHIII?CI 'NGIM.ER: LIC NO: ADDRE S: e^ ^, f ❑
aky�
CONTACT: PHONE i: (\l lW/, BUILDING PERMIT INFO
3-d6 I ❑ Consultant Fees Paid by Applicant(Initial) BO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT 17EE LJ
I herehy a1Rrm thin 1 am lie..sd title,provisb.s of Chapter 9(commencing JOB DESCRIPTION
W d'Z infailforce a00p).f)tvasiom 3oNIm Rdeinmse nod PmNosier,Code.and my liccnw is RESIDENTIAL
PERMIT ISSUANCE
g u i- ' ❑SPDwL ❑KI"TCHEN REMODEL
QUU Littme Class Lie. APPLIANCES-RESIDENTIAL. ❑ADDHION BPCTM1BING RE-PIPE
2LDale C..orm,r
F,OH ARCHITECTS DECLARATION PANELS
❑MULTI-UNIT ❑SlRUCfURAL"
Z p m Z I understand my plans shall he used as public records hfODIFICA'f10N
OZN- UP TO 200 AMPS ❑INTERIOR ❑CHIMNEYREPAIR
F-on W Licensed Pratevionol 2111-IINNIAMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-RUILDER DECLARATION OVER IINVAMPS ❑BATA REMODEUREPAIR El DEMOLITION
tY C Q 1 hereby affmn that l am exempt from the Comacmrs License Low far dm
K0
a U following reason.Section?031.5.Hueiness and Professions CMe:Any city or county SIGNS ELECTRICAL ❑OTHEk
W LL N which rcquir.s a permit nr con4mct.cher,improve Jcmalinh,nr rep:rrt any smcture
_LLo� prior to its issuancm,abe requires theapplicant for such permit it)file a signed statement SPECIAL CIRCUI UMISC.
ythat be is licensed pursuant to the provisinm ofthe Contractor's Licerw Law(Chapter 9
C p�Q� R'onunnmingwilh Satin 91NIU),I Oivixion9of the Business and Professions GaleJnr TEMP.MIETERORPOLEINST. COMMERCIAL' -
'
cal a:o a, that he is eumpt themfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑IENANT [I FOOD SERVICIE
F_
I."nwrc'him five hundred doll...($500).Z} I
MPROVEMENT
Q 01.as owner of the pmpcny,nr my employees with wages as their sole emnpensaion, SWIMMING POOL ELECTRIC
cods do the work.and thrmnxlme is nor mumdedorotfcred for-in(Set.➢44,Basiress Lm and profe..Zonc Cade:'FIN C mea m's Liecnsc Low docs not apply m tet owner of OU'I LETS-SWITCHES-FIXTURES
roperty who builds or improves themon,and who dues such work himself or throughbis own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ Fr.sale.if.htwcver.the building or improvement is sold within ane year.fcompletiun.the OOR AREA YSQ.FT.cr-builder will have rhe burden of proving that he did act build or improve for pur-
,avac1,as owner ofthe property,am c.elmi,ely nsmading with INm,,d rNcmaors rn 9U1AL /1
construct the project(Sec.9144,Business and Professions Code)The Commuur's U-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE (.lX
who contacts for such projects with a eommnnrls)licensed pursuant to the Contnemr'c
License Law. PERMIT ISSUANCE r�
I ten exempt under Sea .B&P C for this reason
Owner Dmlc ALTER-DRAIN&VENT-WATER(EA) VALDAf10N
WORKER
under
COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penuhy of perjury one of the following declarations
�Ihave and will maintain aCenificae of the Labor
Cody,for
Workersccof the
DRAINS-FLOOR,ROOF AREA,GOND.
sminn,os provided far by Scaion 3?W of the labor Code,[or the Ixrfnrmmmc of the STORM'S '1'YI'li CONS'TRUCBIOP
wok for which this Permit is issued. FIXTURES-PER TRAP /D
&TS�vcand will maintain Worker's Compensation Insurance,as required by Section
311111 ofthe Labor Code,for the performance of the work for which this permit is issued. GAS EA.SYSTI7M-I INC.4 OU ILEI:S OCC.GROUP APN
My workgp Campgnptio rv�ccr rand Policy nundrerae>9L�� GAS-EA.SYSTEM-OVER
Carrier:�f Policy OM AJ'9 � n p
CERTIPI EG Pr10N MOM WORKF,RS' P. P
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
eU1UIN
LG DTV IS 'EES
('Ihis section need ern hecompletd ifthe penrdl is Rn one handmaiden.,1$100) GREASE,TRAP
or less,) PLANCHEC T'
I cenify that in the performance offing work for which this permit is issued,Ishall SHWER-SANITARY-STORM EA.HN)FI'.
msubject ol employ any person in any manner so as to become subjeco the Workeri Camper- ENERGY M
z soli..Laws of California.Dae
WATER HEATER WNENT/ELT:CfR
Z Applicant ) GRADIN 'RyG v.
became, TO APPLICANT.11:Ciar makingthis Cc.im,of hExentplCudyoushuns, WATER SYSTEM/TREATING
bea..x subject In the Workers Gampeor this peninions of he aLabmed CMe,you must SOILS[ZEE,
� simhwith comply with such provisions or this permit shall bedumM revoked. WATER SERVICE
0. 0
UO CONSTRUCTION LENDING AGENCY NEW kESTD1iNT1A1.PLM B. SQ.Ff. PAID
1 hereby aflithi that There is sued(See.30 lending agency for the performance of Dam
frel lis
Osun the work For which this permit is issued[Sec.3139?,Civ.Cd
F' Lender's Name TOTAL:
} D.1 Lcnde,'s Address OT,
1 real,That L have red this application and.maN Oma the sN,ve information is BUILDING FlIfn a/
Fh correct.)agree to comply with all city and county ordinances and sum laws rdatingm QTY. MECHANICAL PERMIT FEE:
UZ buildingcamuuction,andhemby authorize representatives ofthiscily toenleruptm the SEISMIC FEE
above memiard pmpcmy for inspemmn purposes. PERMIT ISSUANCE
(we)agree to save,indemnify and keep harmless the City of Cupertino against (ELECTRIC FEE
liabilities,jmdgincess,costs and expenses which may in any way woman againwsaid City ALTER OR ADD TO MECIL
in .sequence of the granting of this permit. PLUMBING FE
APPLICANT UNDIERS'rANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO I0.000CEM)
SOURCE REGULATIONS. MECHANICALF iE
AIR HANDLING UNI'1'(OVER 10,00 CPM) CONSTRUCTION TAX
Signature of Applicanl/Comr¢ar Dam EXHAUST HOOD(W)DUCT) HOUSING MITICA'1'TON PE[
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant smmorhandle hazv,ous material HEATINN;71T(TO I00,000 BTU)
es demon,by the Cupertino Municipal Cola Chapter 9.12,and the Heol ,and Safety
CMC,Section 25532bm? HEATING UNIT(OVER 100EDIN1 BTU)
❑Yes ❑N. PAID
VBNTIhA'1'ION PAN(SINGLE RISID)
Will the applicant or future building axcuptnt use equipment or devices which Date Receipt If
imilk haeardous air contaminants as drained by the Bay Area Air Quality Management BOILER-COMP CUP OR 100.000 BTU)
OTAL:
D ectad?
EJ Yes ❑Nu BOILER-COMP(OVER IUU,00f)BTU)
1 have mad the heallom rsacmds a mods,Chapter 6.95 of the Cali- AIR CONDITIONER
requircmcn p eo ISSUANCE DATE
Not health&Safely CMB S lines 25505 5533 aM 25534.1 understand Lha if the NEW RESIDEM'LAt,MECH. SQ.Ff. l?^i 9
buiid,,dress y catcnant vmy reslmnsihilily to notify the occupant O
remc w nust bete of to is o nCc ificlllc of(tMZZ) Q n
EE
Owner uthoriaed agent Date TOTAL: ISSUED BY:��^ A��fz AA
OFFICE