S 1323APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO - . BUILDING. RLECTRICAL PE I'I'No.
BUILDING DI VISION APPLICATION/PERMIT PLUMBING-listNICAL 1323
OFFICE
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OWNER'S NAME; PHONE:
CO7 &AA,•CCT--OR'S NAME: LIC NO:
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ARCHITECT/L'NGINIiI?N; LIC NO: ^ O
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BUILDING PIiRMI'I' INFO
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❑ Consultant Fees Paid by A plicant (Initial)
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LIC ENSIIDCONI IFACT DIES
rprovDECLARATION
1 hereby ullirm thus 1 am licensed under provisions of Chapter sl (nnnmrncing
�th Secdinn](XXp of Division7af the Businav unit l'mfessions Cade, cod my license is
sur n
`v �GL iU-•/
Liccm'c Class w Licp CU /
'�
Date s '- Co.motor
QTY ELECTRIC PERMIT PEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFOWE ❑KITCf11:N REMODEL
[]ADDITION ❑ PLUMBING RIiPIPE
C3 MULTI -UNIT ❑STRUCTURAL
[I INTERIOR ❑CHIMNEYRFPAIR
IMPROVEMENT 0SWIMMING POOLS
❑BATH RBh P.VI II' IH I ](iyIT10N
[I OTHER '1�1
PERMIT ISSUANCE
' ��
APPLIANCES - RESIDENTIAL
DECLARATION
1 undemanJ Iny plans shall he used as public alA10DII'ICA'TION
PANELS
UPT02MAMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am axcmPt tram the Cnmremoh License law fnr the
following reasr'on. ertion'7031.5, Business and Professions Cole: Any city or county
a permit construct, alter, improve, demolish, or repair any structure
m which
prior to its issuance, also requires the applicant for such permit o rile a signed statement
201-1000AMPS
OVER IfkIB AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M ISC.
icy
�aG�O
4 y 2,Y
it 4,
LLl
that he is licensed pursuant a, the provisions of the Conlmcter's License Law(Chapter9
(commencing with Section 90(RDof Division of he llusinax and Pofessions Code)01
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for apermit subjects the applicannn a civil penalty of
'TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW RLDG/ADDITION F1UFIOGFITION
❑TENANT❑FOOD SERVICE
POWER Oft"fis
ran
F Z Y
6
L=.O
,3 S
not muse th.n Eve hunJreddallurs(SSOO).
E]I, as owner of the property, or my employees with wagesm their sole compensaion,
wi11 dumc work, unit damatiusre is not intended or of lured far sale(SeeTW4,Business
and Prafessians Cole: no Comme no's License law Jars am apply to as owner of
property who builds or improves thereon, anti who does such work himself or though
his own employees, provided that .such ntprovenene are not imcnded or offered for
sale. It, however he bmiling or in:pawanent is sold withinone yeiasa out,letion,the
IMPROVEMENT
[I OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES 0
NEW RESIDENTIAL ELECT& Q FT.,
SQ. ER FLOOR AREA
E/SQ. FL
own,loollder will have the burden of proving that he did not build or improve or pur-
Ease of soca.
I, as owner, al the prnpeny, ain elusively contracting will, licensed cn aracmrs to
TAI' D
caribou the Project Rec,7044.Business and Plefessions Ccdc:) MeContrces,I Li.
umw Law does not apply it) an owner of property who huRiN or imposts thermn, unit
QTY.Y—r PLUMBING PERMIT FEE
who aauriats fu.... iproiccu, wit h a et tmcmr(s)licmrxttl no rsuout so lha Canlmcmrs
'I
PIV IS. CE
License Low.
❑ 1 am excirm under Stu ,B& P C for This reason
- oma
'RAIN -W R(EA)
ICIER - D -
VALUATION
/si
.owner
WORKIRIS COMPHNSXI ION DECLARATION
RACK FLOW PROTECT. DRV
'I leach, ofMn under penaltyof per at, ono it he I'ol lnwi ngdeclnruies,
k_JL0%
9'1'Oklli
'I'Y,F CONS' I' RUCTION
f
❑ HoseunJwillmaintuinnCenlfemc nfCnnxcnnn scl Gln,wre fnr Worker's Coo,er.
setinn, as provided for by Section ]ARI ol'the labor Cade, form p,,lo...mor of the
DRAINS- FLOOR, ROOF, AREA, GOND.
work for which this period ix issued.
FIX 'I'ORES -E'ER TRAP
r�t{�y,,nave 41will maintain Worker's Compensun Insurance, as required by Section
nld W
3900 of the .uhor@,de, fnr the ptrlbrtons, ol'the work for whleb this petit is issued,
OCC. GROUP
MIN
GAS-EA.SYST'EM-I INC.4OUTLETS
My Wmr 's'Com cnxalin Insumn o carrier and l'nllcy
Camer:� Policy Na:
fA5-F.A.SYSTEM-OVER4(EA)
GREASIVINDUSTRI. WAS TE INTERCEPTOR
CERI'IFI A'TE OP EXIiMI'1'10N PROM WORKIiRS'
COMPENSATION INSURANCE
It DING DIVISION FEES _
(Thlnsectimmeed nut be completed if the permit islimmt hundred dollars is I did
nr less.)
GREASE TRAP
PLANCI :' P
SEWER- SANITARY -STORM EA. 200 FT
Ryr3 C 12 .
I certify that in the performance of the work for which this permit is issued, I shall
e Workers' Caper-
- to revenue subject thm
not employ any person in any manner so mmm
WATER HEATER WJV N /ELECTR
G DIN 'C[
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sodium Laws of California. Date
Applicant
NOTICE. TO APPLICANT: If, after making this Cenifcate of Exemption. you should
become suhject to the Worker's Compensation provisions of the labor Cale, you must
forthwith comply with such pmvisionsor this pcmnii,hnll be deemed revoked.
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a construction lending agency for the performance of
the work far which this permit is issue) (Sec. 3097. Co. C.)
the
Name
WATER SYSTRIG IREATING
WATER SERVICE
I S 1 sE
PAID Date Receip x
NEW RESIDENTIAL. PLMB. SQ. FT
TOTAL"'
1 \ TOTAL'
Lenders Address
BUILD 'PEC
I verify that 1 have mad this application and state that the above immoralum is
correct. I agree to comply with all city and county orthmumesand state laws mbaingm
building construction, and hereby audamic repreantaives of Nis City m enter upon the
above-mentioned perfectly for inspection purposes.
(We) agree to save, indemnify and keep hamiles the City of Cupertino against
Iiabilidies,judgmems, amsandexpenses which mayinany wayaccom againsdsxiJCay
in comequenceo thegmnting of this Num"
QTY. MECHANICAL PERMIT 'C
SEISMIC FEL:
PERMIT ISSUANCE
ELECTRIC FEC Z O
ALTER OR ADD TO MECH. GAIT
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL. IEE
APPI.IC ,NDERSTANOS AND WILL COMPLY lV I'fH AL1, NON -POINT
SOU 'F iGLAI'IONS.
•t7 �L`..
7J
ALR HANDLING UNIT(OVER It"CFAU
CONSTRUCT ION TAX
n reo pplieanoCome—tor Date
EXHAUST HOOD(W/DUC)
HOUSING MI' I'IGATION PHI?
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100.000 BTU)
WIIlthe applicant or future budbigoceupantstore or handle hueaNausmaenal
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the [Icahn and Safety
Cale, Section 255720)7
HEATING UNIT (OVER 1(10.(100 RTU)
VEN'T'ILATION PAN (SINGI.6 RESIDE
❑Yes E) No
Will
..tthe air'untnlorallot building aacupumluse aAir im Dumbly Marawhich
ecoid hnznnlous air cnmumin:uns nx JeOnal by the Ihry Arun Air Uualily Mnnagcmem
PAID
Date Ree M .�
TOL'
BOILER- COMP(3HP OR 100.011) BTU)
DlsalnP
El Yet r-] No
BOILER-COMP(OVER I00.00OBTU)
AIR CONDITIONER
I IS1$ll�jpNCH D HE
I hove read rho boardonsonnenals ruluimusenti, ft, Chapter(i Lha Cali
NEW RESIDENTIAL. MECH, SQ. HT.
tomia Iumll i & Snitly Coil, Salinas 255115, 2557] n al 85594. 1 anda,b d that it the
/�
bu lit ng Jacsnacnrranly hnvwr tennntiduo 11 ix cry rcxpnnvihillly In noify de usnpum
VVV (, V
of the rquiremene which onus no sect prior m iI'mrole of a Cerlilicale ol'Ocnmuncy.
I ISSUED fly.
TOTAL^
Ownenu.nduc urd client Dalt
OFFICE