S 1793 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.C'1'RICAL PIISITNO. 1793
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V
BUII.IIING 1'ROJF.CT II)i:..N rIFIC,CDON
BUILDING ADDRISS: SANITARY NO, APPI//IC�A'I'ION HIINMI'I'TAL UA'll
7// 5-rF_N J
OWNERS AME PHONE: CONTRACTOR'S NAME
�p:j LICNO'.
�J 1 �� S N/G CDNfHIIL k
ARCHITECT/ENGINEER: LIC NO: AIL)RF,SS: f❑
Zs5-�-_ L ro ✓�
CONfACT: - PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(initial) BLDG I7LECIPLUMB MF.CH
Jose_ C) LAS—❑ ❑ ❑
LICENSED CONTRACfOR'S DECLARATION QTY. -LECfRIC PI3RMI'f FEE
I herchy dri n,Thal 1 mn licence ander prol"kns m Chapmr 9(commencing JOB DESCRIPTION
Z with Section 7000)of Division 3 ofthe Business and l'mf...ums Code,endmy license is RESIDENTIAL:
F+ in Gull foraenndet PERMIT ISSUANCIi
3p�rj'{ ' .may �I� 'Z,�p7 p ❑SFDWI, [I KITCHEN kIiMODEI.
F' License Class Lic.#
Q U APPLIANCES-RILSIDEN'I'IAL ❑ADDITION ❑PLUMBING kE-PIPIT
u, Dam CauracTSDEl,,r
Dy ARCHITECTS be use DECblieneON PANELS ❑MUCI'6UNIT ❑MODHFIURM CATI(
yZ IunJemmmJm plana shall M+weJ as puhlic recoN,. MDDII'IGA'fIGN
O �Q y UP TO 200 AMPS ❑INTERIOR ❑CHIMNEYREPAIR
W Licensed l'rnfexsionul 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOLS
OWNER-BUILDER DECLARATION
tuY1¢ I hereby.affirm that 1 am exempt from the Cnmmcdh/.License taw,battle OVER I(NX)AMPS [I BATH REMOI I? EI'AI MOLIT N
a.U fullnwiny rcm.nn.(Scemn 9131.5,Bunincra and I'mfcssinns Code:Any city or county SIGNS ELECTRICAL. (JEER,
W vFi which re9uims a permit to cann t alter,improve,demolish,or repair any.structure
tt
�g
print its issuance,also requires the applicant for such permit m Glen signed.mtement SPECIAL CI HCUIT/M ISC —1
,14 are,heisincensedpt..s arra a,,lheprovivionsorthe Cmnmm:n's Lice,,,Law(Clat,W,1)
kmnmencmg wattSection 7000hifDivision?elthc Unions ant Profe.. Code?nr TEMP.MIHl3k OR POLF.I NST. COMMFRCIA:
a c tG
'hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W 4•
Section 911.31.5 by any applicmn fora permit xubjeeln the applicam m a civil penalty ,I POWER DEVICES
y ❑'IHNAN I ❑FOOD SERVICE
not more limit five hundreddallan(SSBO. IMPROVEMENT
I= QElI,as owner of the property,or my employees with wages as their sole ahmpenaflam, SWIMMING POOL ELECTRIC IIMPROVEMENT
G will do Om stns,,anA themmemmis not imcndcdoToncrW forsale(See 7044,13mhuess / liew ❑OTHER
WW m and Pmfescions Code:no Cammcmr's License law does not apply m ua owner oI OUTLETS-SWITCHES-FIXTD i.
property who huildx ur impnrvcc thcreuq unJ wh,,Ascs such work hilnsolf nr through
his own emple,cec,provided that such iteprovemems are not intended or offered for NEW RESIDENTIAL ELHC'I'k SO ET
sale.Ir.howmrerthe building or improvement is sold within one year ofcompletion,the 7,7 Sp,R.FLOORAREA $/SQ.FT.
owner will have the buNon of proving that he did nm build or improve Paint,
,yosr
ri nr-
ry,m of sale.).
❑ I,as owner of the praenam exclusively contracting with licensed emnrucmn to TOTAL:
py,
n�cnnm III, now(Ses,7044,Buninms nnA Prate.slnns Ctxlc:)'1'he C,,nuenm's Li-
n.c Law does not apply to an owner of property who builds or improves mercon,and QTY. PLUMBING PERMIT 1°F.
wh,contracts for such projectswith acom ucmr(d licenced puna an tothe Contractor's
Lic....c Law. PERMIT ISSUANCE
❑I am exempt under See. ,B&1'C for this reason
Owner Dmc ACTFir-DRAIN&VENT-WN1 HH(EA) VALUATION
WORKER COMPENSATION DECLARATION BACK FLOW PROTEC(.DEVICE
1 hereby at firm under penalty of perjury one of the following declaration,
❑ I have and will lnuinuinaCeniliealc of Consennnsdf-in.aure for Worker's Compcn- IIRAINS-I�LOOR,ROO17,A1tEA,C'UN'6.'t ' salt cmIT 111 Id STORIES TYPE CONS I'NUC'1'[ON
sation,as pr vidVd far by Section 1700 of the LaMn Code,for the performance of the
yk for whicM1,M1ic permit ie'issued FIXI'URIES-PERT RAP
1$I have and will maintain Worker's Compensation Inmranee,as required by Seclinn
.)of the labor Cede,fonhe pcfimmanenfthe work for which this pe earn is issued. GAS-EA.SYSTEM-1 INC.4011TLITS OCC.GROUP MIN
Ca Wnrkere Cox smuyll uul ecB Policy Nand o: -(�-!2—/g GAS-HA.SYSTFM,OVFlt 4 CA)
Cartier: S-1 ' k. FV'/J L
CIiRTIFICApB OF UXEMFI ION FROM WORKERS' G GREASFJINWS'1'HI.WAS'It IMIEHCBPIOk
COMPENSATION INSURANCE UNIT Zg8 IIHILDING DIVISION F'iS _
(T his section need not IN completed tithe permit is Drone fairness!dollars(SHNq GREASETRAP
or Is,,.) PLANCHIiCK FEE
Icerthy that in the pert tmuncaofine work lia,Inhlhis pcnni(is issued,1,1nll SEWER-SANITARY-S'IOItM ITA.200 FP.
not employ any person in any manner z as,,become subject m the Worker'Compcn- ENERGY FEECk
Oz sation Lawnof California.Dmc WATIER HEM Ell W/VENI'/ELECTR
Z Applicant GRADING FEE
y
NOTICE 11)APPLICANT:If,at,.,making this Ccnificam of Exemption,you should WADER SYSTEMhTREAI'ING SOILS HEa become suhject m the Worker's Campearat provisions of the Labor Code,you mitt
W r-u lonluwlth comply wi,Ih such provininnx or this pemtil shall he Acenu'A revoked. WA'I'ER SERVICECONS'TRiNLENDINOAGIENCY N1iW RESIDEM'IAI.PLMIi. SQ.FI'. PAID
Z Ihcrcby al'Grm that there isa conconsnuginn lending agency fonM1e performance of DateHmviptX
the work for which this permit is issued(Sees 31NG,Civ.Cy
1"' Isndcrs Nuunc TOTAL
nd :
U Leer's Address TOTAL
1 certify thin 1 have oad,his applicaion and stere thn the above informmion is - BUILDING P'
�i 0 amad.l agree ,,c..... whh un city and county ordinanws IuhA rite laws rdming ns Q'I•Y. MF.CHANICALPERMIT FEE
U Z building constructinn,and hereby commii,representatives of this city m enter upon the SEISMIC FId
a eve-mentioned progeny for inspection purposes. PBNMI'P ISSUANCI3
(Wc)ngrea In save,indemnity and keep han..Irc the City ol'Cupertino against ELECTRIC PGG
Iiabili,ies,judgmems.costs and expenses which mayinany way aceruea,most said City AMER OR ADDTU MECEL
to consequence tithe grunting of,hic pennon. PLUMBING FEE
APPLICANT(UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING IINIT,11O I00h)CFM)
SOURCE RBGULA'I'IONS, MIiCHANICAL FEE
AIR HAN DLING UNIT(OVER I B,(XX)CFM) CONS1 RUCTIONTAX
Signature of Applicant/Con,mc,or Date EXHAUST How(W/DUCT HOUSING MITIGATION ITE
HAZARDOUS MAT17RIALS DISCLOSURE
Will mcir,,licam or mum,buildlngnccupartemre or handle haxanlnm material HEATING UNT,('11)I q,IXX)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I lealth and Safety
Code,Swti,,r 25532(c)7 _ I IHAING UNIT(OVER 10d,000 BT U)
E3 Yes Fl No VENTILATION FAN(SINGLE RP_SID) PAID
s Date Receipt X
Will,he app ore m nr nos a huiMing occupant use Area
Air Quality
ter devices which
�1 Dillict? ouc air cnnwminant.e.JefnW by the Ory Area Air Qmlity Mnnagemrnl ROILIiR-COMI'(BHP OI2100,INN)BTU)
'I'OTA 1.: �
UlslrinP
3 y
C]yes E]No BOILER-COMPfOVER 100,0001317U)100,0001317U)
AIR CONDITIONER
I have reuA Ne hne:mlous nmmrialr requirements..odor Chapmr n 95 of,he Culi- I SUANCE DATE
barrio Health&Safety Code.Sections 25505,25533 and 25534.1 undemmid Ili,it the NEW RESIDENTIAL MUCH. SQ.IT. \ •11 �, T
building docs not currently have a mnam,that it is my responsibility to notify the accurym
of l harequiremenu'which nom,tante,prim'ah issuance of a Certificate of(heupancy.
Owner or umhocoat ages lime "TOTAL: ISSUED HY.
OFFICE