B 0196 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 11 PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 1'1.UMBINC-NIFCHANICAI, SOOOI 0196
BUILDING PROJECTIDENTIP'ICATION
BUILDING ADDRESS SAN I'I'ARV NO. APPLICATI(1N SUBMITTAI.DATE
1261311 Lv"'a/ S8
OW It'S E: P ONG: MIAAC OR'S NAME: LIC NO
_ C— NIC CONTROLp
7
ARCHITECT/EN INIHzR: hICNO I ADDRESS: ❑
2
CONTACT, PHONE: BUILDING PERMIT INFO
�-�+ • �Z/ ^ ❑ Coes P
Consultant F aid by Allpp-licant(lotting HL❑ E
UG LO f PLUMB MECII -
OY Lr-n7/
LICENSE CONTRACTOR'S DECLARATION Qty ELECTRIC PERMIT FETE
1 hereby ani.Them I am license under provision:of Chapter 9 m.noo ming JOB DESCRIPTION
"Z with Section 7000)of Division 3 ofhe Business and professions Code,and my liana is RESIDENTIAL:
tlIPERMIT ISSUANCE
X
I in full farce and alien. ❑SElI C
FDWL KI' HEN REMODEL.
W
�VU License Class Lic.# APPLIANCES-RESIDENTIAL ❑AUDI'I'[ON El PLUMBING RE-PITT:
F W Dale Common
W.
ARCHITECT'S DECLARATION PANELS ❑MUL'1'1-UNIT ❑S'fkI1CTURAI,
Z O tn z I understand my plans shall he use records
as public MODIFICATION
02-q UPTO 200AMPS C3 INTERIOR ❑CHIMNEY REPAIR
rfiW Licensed Professional 201-IOWAMPS IMPROVEMENT 0SWIMMING POOLS
yQ !-J OWNER-BIJILDER DECLARATION OVER 1000AMPS ❑BA'T'H REMODEL/Rlil'AIR EMOLITION-
OC a hereby
affirm Ihhl 1 am exempt from the Contractor's License Law for the
O y V followin Section]031.5,Business and Professions Care:An count ❑OTHER
x g ammo( Y ci Y or Y SIGNS ELECTRICAL
1+13 0 F' which roams n permit tai aonstrver,alter,improve,demolish,or repair any stmaum
on prior mslicemncgalso rsuainquiresthe
ovisiosof for ContrarmiuofileaeLaw(statement SPECIAL CIRCUIT/MISC.
C Qf temheiscingwiit pursuant 7 the provisions of the C Bminmr's License Law(Chapter IC)9
W�GO thanmmncixen with Seaborn ad of Then...Our
afthee,ed varn,, rsPirtAn siolode)ur TEMP.MET OR POLE INS F.
6 y o e• the Section
Is exempt therefrom ani the.psis lin the alleged applicant
I-Any violation of ❑IEN BLDG/ADDITION ❑FOOD LITION
SERI
YXI Is• Su romt7031.5 by hundred
lours D500mit subjects the applicant loacivil penahy of POWER DEVICES ❑'IMPROV El FOOD SERVICE
r� not marc then Eve hunJmA dollars(5500).
I-Z> OTHER IMPROVEMENT
Wi Lo the Work,the pnepeny,mmyemplended with wagescoheir sole 044.Business SWIMMING POOL ELECTRIC 9Q will dnthework,andthehe Contractor's
License Law ffered for
apply to at Business ❑OTHER
and Toy who b Code:The C es Chemo License Lew i such w apply s Bn owner of OUTLET SWI'I'CHBS-Irl%'IURP.S
his,,..who builds or viproves thereon,ani who does such work intended
Lir through
his own weveares,building fiau,Owhor improvement
scarems arc not iyearefJ or neared for NEW RESIDEN'1'IAI.F.LEC'IR SQ PI'.
Sala.If..eleven the building orimPmvcmaniz mid within one Ywr rf completion,the SQ.FT.FL(XIk AREA SISQ.FT.
owneolnuilder will have the burden of proving that he did not build or improve for pur-
po o of sale.).
f as owner of the property,am exclusively annmeting with licensed r loramo m 'TOTAL:
Construct the project(Sce.](94,Bmaness and Profepsions Come,ILie Contactors Li- - - -
reninl.aw does not apply ILL an owner of property who builds or improves daemon. it QTY PLUMBINGT FEE
who contracts for inch projects with a connotations)licensed Initiation to the Contractors
License Law. PERMIT ISSUANCE
I:un exmnpt undo Seo. ,B&P C fur this reason
ALTER-DRAIN&VENT'-WA'T'CH(EA) •� VALUATION
Owner DIOee, C
WORKER S on DECLARATION BACK FLOW PROTECT.DEVICE 9O Q
1 hereby as res under penalty of perjury one of the following declarations: o
ha,cmul parcidl for
SeclrtificmcufComenuo eN-insure for ifara Comp the DRAINS-PLOOR.ROOI:,AREA,COND.
svtion,ns provided 6r by Scniou J]W of the LnMr Code,for he performance of the TORIES 'TYPE CONSTRUCT[ON
Work for which this permit is Isnled. FIXTURES-VER TRAP
I have and will ne imain Worker's Cn r,ausatinn Ice ourac,as required by Section
37W ofthe Labor Code.for the performance ofthe work far which this pcmtit is issued. GAS-PA.SYSTEM-1INC.4 OUTLETS OCC.GROUT' APN
Fk My Workers Compensation Insurance carrier and Policy number art:
Cartier: Policy Nn: GAS-EA.SYSTEM-OVER J(CA)
CERi'I FICATE OF EXEMPTION FROM WORKERS' GREASFIINDIJSTRL WAS'1'EINI'ERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
fHas section need not be complete if he isamit is fnrane hundred dol tars($100) GREASETRAP
or less) PLANCIIIiCK FEE
I certify Na in the performance of the wnrk for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 IT.
not employ any Person in any manner so as to Navarra subject to the Workers'Compen- ENERGY FEE
Z anion Ltwaof California Dam WATER II EATER WNENT/HutCTR
Z Q AF,I,alm I 80
GRAVING PEE
It, NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should WATER SYSTEM/FREATING 'C,/r
a ; become subject to the Workers Compensation provisions of the Labor Cole,you most
SOILS ITE
W forthwith comply with such provisionsor this permit shall he deemed revoked. WATER SERVICE
wG
CONIme,isLTIONLBNDINGAGENCY NEW RESIDENTIAL PCMB. SQ F. PAID
1 hcrchyich this .it
isvad(Sec.ionlending agency for the perfnnnuncerf
- Date Recoipt#
OIr ths,wnrk for which this permit is issued(Sec.309].CIv,CJ
F" Lenders Name T(3'fA1.:
Lenders Address TOTAL:
I certify that 1 have read this application and state that the aWvc infnnnminn is BUILDING FEE
IG correct,I agree to Comply With Bit city and county ordinances Lind stain laws relating to QTY. ML'C}1ANiCAL PP.RMIT FEE
V Z building con,mietion,vM herebyautbnrlu representative,ofihis city menmr abrin me SEISMIC VISE
above-memioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree m,anperti
ve,indemnify and keep haaless the City of Cuno agaiml ELECTRIC FEE
liabilities,judgments,cost and expenses which may in any way access,against said City ALTER OR ADD TO MECH,
in amseyucate of the grunting of this permit PLUMBING FEE
APPLICANT'UNDERS'FA NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
MSCI IANICAI.Nlifi
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of ApplicaMConturmr Dee E AUST FOOD(WMUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplieuntor furore builiingiacopent smmou handle hazardous material HEATING UNI'I'('to miulf,BTU)
relefiocd by the Cupertino Municipal Code,Chapter 9.12,vnd the Iliatih ted Safety
Cole,Section 255320 t HEATING UNIT(OVER 100,10)BTU)
❑Yes El No VENTILATION FANS INGLE RESID) PAID
Date Receipt#
� Will the applicant Or future deflug occupant use equipment or devices which BOILER-COMP(311P Olt BHkIXO BTU)�emit Nvurdans air uimaminnms as Joined by the Bay Area Air Quality Management To IA '
District? BOILER-COMP(OVER HANX)8911)
[I Yes Fl No p�
Ihuve read the hazardous materials requirements under Chapterfi95 of the Cali- AIR CONDITIONER IFy ISSUANCE DATE
fomiu Health&Safety Cee,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECII, SQ.ILL
buildingdoes not currently have a torent,tlun it is lay re,liumiladgm notify thcoavpant
of die requirements which must be met prior to issuance of a Cerilicvte of Occupancy.
Owner Lir aulhoriud agent Date TOTAL: t O ISSUED HY. I ) VI'(
OFFICE