B 0162 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BGIhDING ELECTRICAI, PERMIT NO�Q
BUILDING DIVISION t APPLICATIONIPERMIT PLUMBING-MECHANICAL. SOOO 1 NU 1 6 2
BUILDING PROJECT IDENTIFICATION
13UILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
9733 b✓in LP4 een Dr i ve� 22
OWNERS :,�AaeA. ClON CONTRACTORS NAM13: LIC NO:
,na Jr p n n S-� NIC CONTROL.M
ARCHITECT/ENGINEER: C^L(n" LIC NO:/O ✓ ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
p�a� /U/ _H kr p"467 9] .p'� ❑ Consultant Fees Paid 6y Applicant(Initial) BLUC�� F.LE�' LUMn/t MECI�
�( LICENSED CONT ACI OR;S DECLARATION 7 Q QTY ELECTRICPERMIT FEE. Lrft�l�/
I hereby ci irn thin 1 um licensed under pmvisinns of Chapter 9(commencing JOB DESCRIPTION
Omz with Sedinn]IXX1)of Division3mf the Business and PmfexsionsCNe,and mylicenu is RESIDENTIAL:
W O I'13NM1'1'ISSUANCE
��� in full farce and,Deet t DSFDWI. C1 KITCHEN RI3MODE1.
Hz�
License Clas Lit.Contractor APPLIANCES-RESIDENTIAL ❑ADDITION DPLUMBING RE-PIPE
vnQ0. [IMULTFUNIT []STRUCTURAL
ARCHITECT$DECLARATION
p.,D m PANELS MODIFICATION
O tr�Z 1 malcontentmy plans shell be used as public recordsO
O z,+O UPT03W AMPS DINTI3RIOR El CHIMNEY REPAIR
1-:4)�tvl Licen.md l'mfossional 101-1000 AMPS MPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IBM AMPS �TH RP.MODEUREPAIR El DEMOLITION
n'Q I hereby infirm
that'I am exempt from the Contractor's License Law for the ((
O L U following recon.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECI RICAL D OTHER
which requires a permit to construct,alter,improve,demolish,or repair any immune
prior to its issuance.also requires Ne applicant for such permit o rte a signed statement SPECIAL CIRCULUMISC.
T that he is licensed parsunmt to the provisions oft he Contractors license Law(Chapter 9
(commencing wit Section](I(Xp of Division 3 of to Business and Professions CssdO or TEMP.METER OR POLE INST. COMMERCIAL;
mat he is esempt therel'mm and the basis for the alleged exemption.Any violation of - D NEW BLDO/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for u permit subjeats the applicant to a civil penalty of POWER DEVICES
t more than five hundred dollars(SSW), ❑IMPROV FOOD SERVICE
Z� IMPROVEMENT
p Q ❑ Lo the or ,the the my.or myut lactated
wit wages Bred fosthei(Sec.compensation, SWIMMING POOL ELECT RIC
20 wJl da the work,and theswcturo is notimended or oRcreJ formle(Sep.9M4,Business DOTHIiR _
Wand Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
3.. property who builds or improves tenon,and who does such work him ellor through
his own employees,provided that such impmvenems arc not intended or afood for NEW RESIDENTIAL ELECTR SQ 11P.
sale.If,however.the Wildman,impmvemem is sold wiminoneycarofomplctina,the SQ.IT.FLOOR AREA $/SQ.FF.
ersbuilder will have the burden of proving that he did not build or improve for pur-
pyes oI'm asna TOTAL
$I,a owner of the property,ore eadunivdy mmmming with licensed comacmrs m
(k a a,,the project(Sec.NoW.Busincis and Proficei.m Cad,,no Cmr,mcm,a Li-
cerise Law hics not apply to an ownerofpraperty who builds or improves thereon,and QTY. PLUMB INC.PERMIT FEE
who comuads for such projects with a connotations)licensed pursuant to me Contractor's
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. .B&P C for this roaxd
ALTG'R-DRAIN&VHNT-WATBR(HAE VALGA'1'1(lN
O U
WORKER'S COMPENS NDECLARATION BACK FLOW PROFECP.DEVICE
1 hereby affirm under penalty of perjury one of the following decimations:
❑ Ihnve mWwillmnimainaCertifcae of Cnnsem to self-insure for Worker's Compere DRAINS-FLOOR,ROOF.AREA,COND. STORES TY PE CONSTR UCI'ION
,tion,as provided fur by Scene.37M of to Labor Code,home performance critic
work far which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this Tamil is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' MIN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS EA,SYSTEM-OVER 4(EA) r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
BE IILUING DIVES ION FEES _
ffhiasectiom need nm lrccnmplmod iflbe permit is foram,hundred dollars(SIM) GREASETRAP
m I..) PLANCH[CK FEE
Icend,mal in me pcournence ofthe work for nub flo,,mdt is issued,I shall SEWER-SANITARY-STORM EA.2111 FL
oany
at em Ploy any person in manner m its tat hecome subject In the Worked'Co.,.. F.NE G
0 z' saion laws of California.Da¢ WATER HEATER WNEMI'/F.LECfR Rgp1NG FEE
Applicant
NOTICE?TOAPPLICANT:If,after neking this Ccrtilicue of Hsemption,you should WATER SYSTENIGRF.ATING
a ' become subject to the Worker's Compensation provisions of the IaM+r Code,you must SO=
forthwith armpit with such Provisions.,,his famuit shall be deemed revoked. WATER SERVICE
A .J
U O CONSIatthe iso conNLENDINGngAGENCY NEW 1tESIDENTIAL PLh11t. SQ,FI. PAID Receipt
I hereby which
that issued Saa.30l. gency for the perfunnance of LI 3 Vs v11)a(e y
.a the work for which this permit is issued(Sec.9f19],Co.CIv.C.)
0 F Lenders NameT(ITAL:
Q) fender's Address TOTA
[r I certify that 1 have read this application and sem thatthe above information is
BUILDING FEL
V) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PHIL
V Z building construction,and hereby minimize representatives of this city to enter upon the SEISMIC PEE
above-mentioned pmEamy for inspection purposes. PERMIT ISSUANCE Im
(We)agree us save,indemnify and keep harmless the City of Cupeninm against ELECTRIC WE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MHCH.
in consequence of the gaming
of this permit — PLUMBING FEE Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 Crm)
SOURCE REGULATIONS. M13CNANICAI.FEC
agpjaw
AIR HANDLING UNIT(OVER In"CFM) CONST RUCTION TAX
'�" Signature of ApplicantaConuactor Data EXHAUST HOOD(W/DUCI') HOUSING MITIGATION FEE
(^� IIAZARDOUS MATERIALS DISCLOSURE
Willtheapplicam nr firm.building occ:pumsmre in handle hnzmdous r iul HEATING UNIT fro 100,000 BTU)
a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Sudan 2557200° HEATING UNIT(OVER 101 IB BTU)
❑Yes ❑Nu VENTILATION FAN(SINGLE RESIDE PAID Date RcceiptN
Will air contaminants
nrfumre building by the Buy Area
Air Quality
viceswbicu BOILER-COMP CHP OR 1X1,000 BTU)
'nit hazardous air comaminants ns defined by the Bay Area Air Quality Mamgemwt r
District9
❑Yes 0 N BOILER-COMP(0701 100,000 BTU)
AIR CONOI'I'IONER
1 have real lbc h ode,Se tions 2 5115,2 533 an under Chapter oma of the it the ISSUANCE DATE
building
g does ne Sdery Ely m Sections 255115,i,my and 25534.1 undersand that it the NEW RESIDENTIAL MECH. SQ.
ofthemgdireatetswititlyhavealenctpian rtoinnyceofa erdricmmifytua cy.. Q
of ie.qu'venents wldch must be met prier to issuance of a Cenif¢am of(kcupancy.
TOTA
Owner or aulhm
ned age. Date ISSUED RY
OFFICE