S 1912&PPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDINGwtOJEC'r IDENTIFICATION
PESIT NO, 1912
BUILDING ADDRESS AADyDD��RESS� y �py� p ��y� ,f,�..._ C ' f�—��yO
B�,�. Go
SANITARY NO.
APPLICAION SUBMI PIAL DATE
T
�...r PHONE:
O�.W-•{N,�ER'�S�NAMii:
' le-WI�"I c \t ,�
CONT RAM OR'S NAME: LIC NO'.
NIC
❑
7
CON'IAOLN
ARCIUTEC TNGINEER: LIC NO'.
ADDRESS:
CONTACT: PHONE
T¢_ lAZ:6) Zl:!,Z
EDConsullanl Fees Paid by Applicant (Initial)
BUILDING PERD r INFO
BLDG ELECT LUMB MIiC1I
LICENSED CONTRAC'TOR'S DECLARATION
I hereby affirm that I am licensed ander previsions of chapter 9 (commencing
with Section 9X11) of Division 3 of the Business and Professions Cube, and my license isRi
in fullforce an Ie 11 •tea
LicursveC Lee, 1 ,V _
Date ---Ls Cnmmcmr'TQIA�'T ¢
Q'PY ELECI'RIC PERMIT PEE
JO ESCRIPTION
❑KITCHEN REMODEL
❑ PLUMBING
/[:]ADDppI
❑STRUCTURAhI
MODIFICATION
❑CHIMNEY kISPAIR
NT E]SWIMMING POOLS
DE ITAIR ❑ D' LITION
❑MIER
PERMI'1'ISSUANCC:
APPLIANCES — RESIDENTIAL.
ARCHITECTS DECLARATION
underssoad my plans shall he used as public records
PANELS
UP'TO ^_1x1 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION1 hereby affirm thin 1 :un exempt from the Commonnes License Law Liu the
billowing waste (Section 7031 5, Business and Pron%sionc Code. Any city or county
which requires n petioli to construct..ltcq improve, dramlish, or mTer any smmmre
prior In it, roamer, also requirsstheatinived hasn't permit m file. oicad ntntement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Icnmmeneing wilM1 Srxtion llNN))of OivixinnJof the l{wines. wW Pnrfesaioas Ctsle)nr
That he is osetnin Nercfrnm toad the hosis fur the alleged exemptionAny violation ah
Section 00315 by any applicant lore perntit subjects lbs applicant to a civil penalty of
na more dam rive hundred dellun ($500).
I] I, as owner of the property, or my employees with wages as their sole compensation,
t will do the work. and the structure is not intended ordered forsule diec.](N4, Business
and Professions Cade: 'rhe Co mantorx License Law dnex not I,ify to an owner of
property who builds or improves thereon, and who dotes such work himself or Enough
his own employees, provided that such improvements am not intended or offered for
sale. If. however, the builbingorimprovcomnt issold within one year ofcompledmir the
,amerbuilder will have the burden of proving thal he did not heild or improve I'or pur-
-oFsele.).
FI 1. as owner of the property, am exclusively contracting with licensent
d cnmemts toall
mamet the project (Sec. AWA, Business and Professions Cade:) The Contractors Li-
hocnmmi.aw docs iia apply man ownernf funpeny who hadd. or improves thereon. anan,[QTY
nfore.clt lonjomaogs) licenced puns::::, tolbe Cnmmutnr�s
tas
License Law.
I am exempt under Sec. . B & P C oar Ills reason
201-1000AMPS
OVER IU00AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT MISC.
'TEMP. MEI'EROR POLE INST
COMMERCIAL:
❑ NB . G/ADDITION ❑ DEMOLITION
AHTNANIT ❑ FOOD SERVICE
IMPROVEMENT
C3 OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLH'IS—SWITCIIIiS—I'IX'IVRIiS
NEW RESIDENTIAL EI.ECTR Fr
SQ. IT, FLOOR AREA
P � 1
AII���S'D
JUL 24 F111
$/SQ. Er.
�
TOTAL:
PLUMBING P MIT .FEE
PERMIT' ISSUANCE
Owner Date
ALTER — DRAIN & !NT—WA'TER(EYO
GII Y Ur uUmOlUillm
WORKER:SCOMI'E?NSATIONDIiCI.ARA'I'ION
1 hereby affirm under penalty of Perjury one of the following declaration..:
(] I have and will maintain a Ccnifcam of Consent n seR-inure for Workers Compen-
.sadme, as provided For by Section 3901 of the Taber Code, for the Performance of the
work for wltieh this Per:nb ---red.
1 have and will mainmin Workers Compensation Insurance, as renamed by Suction
37OOofthe Lnlsu Cede, forthe farfonnunwufthe work Intoner this permit is issued.
My WorkEEis,'�C�nm �nsmin�n lrt ryp� rand Palic r9(p
C.; It, oorif I CLX1r cum'Puhr, No. nu 'y6*6I(iL
CERTIFICATE OF E'X1iMFFION hROM WORKIIRS'
COMPENSATION INSURANCE
('(Tis salon neral notMcamPlacJ Hills,pemtit i. (crone hundred dollars (Mix))
or Its.)I'LANCHr:CK
I coolly that in the perlimnnnce ah the work for which Otis permit is issued, Ishul
not employ any person in any mmaner en as m become s.bjed In the Wnrkas' Contpe
..tion Taws of California. Date
Applicant
BACK FLOWP YI'ECT. DEVICE
DRAINS— "OOR, ROOF. AREA. COND.
STORIES
OCC. GROUP
TYPECONSTRUCrION
APN
FTXTII t4—PER 'I'RAP
GA EA. SYSTEM.] INC. 4 OUTLETS
AS-1?A. SYSTEM OVERA(EA7
GREAMIINDUSTRI. WASTEIN'TERCEPTOR
RETCHING DIVISION FEES
GRFASIiTRAP
FEE
SE EA.2WFI'.
ENERGY FEE
WATER HEATER W/VENT/ELECI'R
GRADING FEE
[world
bmume xnhjwt to the Wnrkcr's Compensation pnwlxiow of the Labor most
NOTICE TO APPLICANT. IL after staking this Certificate of Ex/mvol.
forthwith comply with such provisions (or this perntit shallM dmm
CONST RUC`T'ION LENDING AAbNCyccof
umsrucalnnletd:n•u•ene fo
the walk for which Nis rail is issued (Sec. 30G. Cis. C.)
Lenders Nanus
WNI1IR SYSTEM/I'BIAT INC,
WATER SERVICE
SOILS YET:
PAIDIbercbyaffirmmaldhemiv. Dam ReceiptN
NEW RESIDfil IAL PLMB. SR 14.
TOTAL:
TOTAL:
Lenders Address Of
BUILDING FEE
1 call fy that I have read this application and stale In c ahove infnnnvtinn is
correct. l agme rat comply with all city and county aNin.ncI an I'la laws mbning to
building constmaiomandherchy authnriu rcpresenmtives Nis city to enter upntthe
atone -mentioned property for inscedion puTnmx.
(We) ugrow m save, indemnify and k -p hannle the City eh Cupertino epoiwl
liabditiea,jndgmems, mtav nal ocore ,wltieh nuryi any way trene eguinxtsnid City
nsequcnee of gruel ing of this permit.
APPLICANT U )ERSTANDS AND W ILL C PLY WITH ALL NON -POINT
SOURCE `F ,TAV"NS.
Q'I'Y. MECHANICAL PERMIT PEE "
SEISMIC hili
PERMIT ISSUANCE.
ELECT RIC FEE
ALT ER ORADDTO MUCH.
PLUMBING FI3E
AIR HANDLING UNIT (TO IO,IMxI CFM)
MECHANICALFF.E
10,00iANDLING UNTIRIVER 1(L00
CONSTRuc (TON TAX
Sign. roof App scan nntmce" Hum
HA%ARDOUS MA'r IAT S DISCLOSURE
Will lbe.pplocamnrmwmbuildi occup.ot so reorhasdlela,midousnmmrial
C defined by the Cupenlnn Municipal rxle. Chapter 4.12, anA Thu Ileullh and Snfmy
Gxlc, Section 25532(x)1
❑ Ycs ❑ No
Will the applicant or frau building occulsw tone rn uiprnenl er devices which
c Imeardonsalrcemmnlnun as deOnrs by the Buy Am. Air Qrmal, Management
inial
❑Yes Nn
Ihuvemadlhe ..reruns nmwrial. I. under Chu ler fi.95 of the Cat-
rc. 255
ting 25505.2553] and 25534.1 i understand Nut if the
Ibmia Hulls &Safety Gyle. have
building docs m, currently have a tenet p that it is my responsibility ca notify the occupant
of the reyuirmtmms which must b<met prior issuance ma Cenihcam of Omnpanry.
EXHAUSTHOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT(IO I11B.ORBB'IV)
-
HEATING UNIT (OVER IlN1,INM1 11 TU)
PAID
Date Receipt N
VEN ILA'I'ION FAN (SINGLE RESID)
BOILER—COMPI9HP OR 100,(NIII BTU)
'IO'T'A L: w
BOIL(?R— COMP (OVER 100,000 BTU)
AIRCONDITIONER
ISSUANCE DATE
ISSUED try.,
NEW Bps IDENTIA I. MF.CH. SQ. Fr.
'TOTAL:
Owneror..il meed agent Date
OFFICE