S 0435 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION AI'PLICATION/I'ERMIT PLUXInING-MECHANICAI. S 0435
BUILDING PROJECT'IDF,NTIF'ICA'1'ION
BUILDING ADDRESS: - SANITARY NO. APPIJCA'I ION SUBMITTAL DATE
7-1 /o ti7 c/ ?4 l 69.�9.�a
OWNER'. NAME: PHONE: CONT ACfOR'S NAMIi: LIC NO:
t�Na 'jam (N / NIC CONTROL#
•ARCHITLCTAiNGINEER:•.} LIC NO: )D13F.SS:
� G Sgi.I SO W q
CONTACT: PHONL: IIUILDING PERMIT INFO
.�] Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MCCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
i Iterchy affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section?Dlorm'Division3ol'the Business and Precisions Cale,and my license is R CID NTIAL•
1- PERMIT ISSUANCE
CWF in force and enact q2 ?U ❑SFDWL F1 KITCHEN REMODEL
QUO 1.icena Cl s Lina—r APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
y Q W Da¢ Connector
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAI,
F.,D H PANELS MODIFICATION
z lundersumA my plans shall be used as pantie recent,
UP 1'021NIAMPS ❑INTP.RIOk ❑CHIMNEY REPAIR
r1tM Licensed Professional 701-1000AMP$ IMPROVEMENT E]SWIMMING POOLS
OWNER.BUILDER DECLARATION
C Q OVER It")AMPSTH REMOUF.IJREPAIR [I DEMOLITION
1 hereby affirm Thal 1 am exempt from the Contractor's License Law for the
0SO L O following mason,(Section 7031.5,nosiness and Professions Cade:Any city or county SIGNS ELECTRICAL [IHER
:W F' which requires a permit to construct,alter,improve,demolish,or repair any smtcture _
app priormid is mance,nlsor quiets the opplicum for inch prminn flcosignW stammudl SPECIA.CIItCUI'VMISC.
yThar he is license)pursuanvnlhe provisions of Ne Camra rand License Law lChvpter9
W�G�O (commencing with Seninn 711!1(11 of DividionJ nflhe Business and Professions Cade)nr TEMP.MISIRR OR POLL INST.
6 Q.c eG that he is exempt therefrom end the basis far the alleged exemption.Any violation of ❑NEW BLINGIADDITION ❑DEMOLITION
stn Section 7031.5 by any applicant for a permit mnjeats the applicant to a civil penalty of POWER DEVICES ❑TBNANT ❑FOOD SERVICE
y not more than fee hundred dollars($500). IMPROVEMENT
Q ❑I,as owner(if the propeny,or my employees with wages as their sale mmpensatidn, SWIMM ING POOL ELECT RI
won do Ilio work,and the structure Is not intended or carried for sale(See.7194,Business ❑OTHER
W and Professions Cade:The Contractor's License Law does nm apply m un owner of OUTLETS-SWITCHES-PIXY L
property who builds or improves thereon,and who does such wank himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL ELECI'R
sale.if.however.the building or Improvement issold within one year ofeompinlon,IM SQ.FT.FLOOR AREA SISO.IT.
dwnerhuilder will have the named of proving that he did not build or improve for pur-
pose.f,alo,),
❑I,as owner of the property,ant exclusively comneling with accused contractors u, ,YTAL:
condoned the project(Sec 7014,Biomes and Professions CWe:)'Ihe ComructoYs Li. pp
cense Law docs not apply to an owner of property who builds or imposes themon,and QTY. PLUMBING PERMIT FEF, A Y D
who commcu for such projects with a contracvo6)licensed personal o the Contracto(s
License Law. PERMIT ISSUANCE S�P
❑I am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRA IN&VEN'I'-WA'I'fit(EA VAI,
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE ���� 'j
affirm r
I hereby arm under penalty of perjury one of the following declarations:
❑I have and will maintain oCcuilicatco'ConsenucsdGinsurt for Workers Compen- DRAINS-FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCTION
section,as provided for by Section 37M of the Lmxn Code,for the incontinence of the FV
work for which this Permit ix isstmd. FIXTURES-PER TRAP
Fl have and will maintain Worker's Compcnmlion Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My WarkK.s Compensation Insurance carrier and Policy number arc:
Cartier Policy No.: GAS-EA,SYSTEM-OVER 4 DZA)
CERTIFICATE OF EXEMPTION 17ROM WORKERS'
COMPENSATION INSURANCE GRI3ASMNDIISTRL WASTE INTERCEPTOR
BUILDING DIVISION PEGS
This.wnion realnot he completed if the Perot i tax forme hundreddeffors($100) GREASI?TRAP
nr lens,) PLANCHIeCK PEP.
I certify that in lheperfonnanceofthe work forwhich this permit %armed,IshAI SEWER-SANITARY-STORM EA.2W FT.
nal employ any perso any moaner so as 1. m
becoe subject Io the Workm'Comped- ENERGY WE
Z smion Isws mf Culifomla.DaJP WATER HEATER WNENDELCCTR
ant �,�J��rQh -( GRADING ITE
NOTICE TO APPLICANT:If,ofrer m t ing this Certificate of Exemption,you should WATER SYS'1'IiMOTEATING SOILS Flit.
[r r>i become saincer m the Workers Compensation provisions of the Labor Code,you muss
s„1 forthwith comply with such provisions or this permit short be deemed revoked. WATER S17RVICE
aQ
L) p CONSen isac ONLENDINGAGENCY NEW RGSIUENTIA1.PLh1B. SQ.PC PAID Date Receipt0
Iherebyich thithat Them istued(Sec.3nlending agency for the p,tfotmancc of
f~° the wok for which this permit is issue)(Sec.31N7,Civ.CJ
W Inndcra Nunte TOTAL: �•
> Lender's AJdre.ss TOTAL: BUILDING FEE
F 6. L certify that I have read this application and state that he above information is
Vi correct.I agree to comply with all city and county ordinances and state lows relating to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby authoress representativesafthis city menterupon lire SEISMIC FEE
` above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep limitless the City of Cupertino against ELECTRIC ME
liabilities,judgments,costs and expenses which may in tiny way scene,against said City AIA ER OR ADD TO MECI{.
n consequence of the granting of this permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WLl'H AL1.NON-POINT AIR HANDLING UNIT ITO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
Ls//i 1 exZ-4 ��,��9� AIR HANDLING UNIT(OVER Iff"CFM) CONSTRUCT ION TAX
Signature ol'AAp�plic rdUConlmchor Nvle EXHAUST HOOD(WMUC) HOUSING'MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will tmoopplieent nr future building occupant storenf handle mountains material HF.AI'I NO UNIT(TO 1110,000[]TO)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cof Section 25532(x)? HEATING UNIT(OVER 100,001)BTU)
E3 Yon, ❑Nn ENTILATION FAN(SINGLE.RESID) PAID
Date Rcceipl p
Will Thr applicant or future handing occupant use equipment of(devices Which
emit haxumnus air conmminams as defined by the Buy Ared Air QmA'ny Mvnvgemenl BOILER-CDMP(3HI'OR I(Nl,gkI BTU) TOTAL:
District? BOILER-COM('(OVER 100,0001111i
❑Yes C]No
I have readthe fomrddus materialsHoots under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
regoim
Bsmiu gdoes&Safe,,rre Coktry have
Sections 255(15,is ary and 25534.1 it)many the
that if the NEW RESIDENTIAL MIiCI{, Sp.def.
of tldmgdorsnot currently irtothen .(hal it isuaceof.Ccritymeolttytheoccupant
of the requirements which man be ran prim m issuance of.v Cenifcvtc of Occupancy.
(honer or authatima agent Date TOTAL: ISSUED BY:
OFFICE