31208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. JQ 1 Z O H
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS'. SI SAVITARY NO. APPLICATION SUBMITTAL DATE
0 6 _ ° e�?tiFr vIL4AcC _ •
OV4NEIPSNAME: A PHONE' CONTRACTOR'S NAME: LIC NO:
h IJO ( HSf U-� +lea— C3 W.I 3 C. NEC CONTROL 00
ARC [ /ENGINEE LIC NO: ADI RESS: 'I• ❑ /Tlr.L—! 'r
lZCV 3b 2 01 0J Y R NN�
ory'ACT - PHONE: Pj, BUILDING PERMIT INFO
Lc_ Cbfy^P,6 Sp`l/ ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH
LICENS D CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed order provisions of Chapter 9 Broome ndng JOB ESCRIPTION
Qa'Z with Section70mo ofO,i,ma 3 of the Business and Rrfivio an Cade,and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE
F�.. in fullfarceand effect. ❑SFDWL O KITCHEN REMODEL
aUw License Class Lica APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE
rF P, Oats Contra r�r '�� *r+ryPJ7
RCHITECFS DECARATI N i14C , El MULTI-UNIT El STRUCTURAL
1 ,alH PANELS
ypy mmndmyplanssM1dlb useeasvubliarecords MODIFICATION
__4c) UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
rQ4�f".41 Licensed Profcs,exed 201-1000AMPS IMPROVEMENT
C a a Oat I am exempt
from
DECLARATION OVER 1000AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
I hereby affirm tont 1 am exempt&nm the Contractors License Law for the
pj 3 F following reasnn.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which mgmm,u pemm m concoct,al¢r, m
impmve,demolish,,or repair any suulme,
4 prim to it,iswnnee,also regwrcx the applicantmmirm
forch Perfile asignedsmmmeu SPECIALCIRCUI.1'
'J oekix
mothe is licensed pursuant to the provisions ofthe Commeors License Law(Chapter9
tj0 (coencing with Section71Sgl,nfDiv...on I ofthe Business and Professions Code)or TEMP.METER OR T. COMMERCIAL:
04
mm
ei.6 that he is exempt therefrom and the basis For the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
it�n
Section 7031,5 by any applicant for apohnin subjects the applicant to o civil penally of POWER DEVICES
ty^w ❑TENANT [:1 FOOD SERVICE
not more than five hundred dollop'y employers
FL+rZ'f,Q Las owner of the propmy,or my employees with wages as their role compensation. SWIMMING POOL ELECTRIC
OTHER
e"
e will do the work,and thesmmurc ix not in¢ndcd or offered Tarsale(Sec.]044,Business OTHER / � 'IRk-I
C/3 m nod Professions Gde:'the Contractors License Law docs not apply,,an owner of OU'i'LE'PS-SWITC -FIXTURES �� CmtQT Y�
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that,such improvements meant intended ar offered for NEW RCSID'NT SQ FT
sale If.however,the building or improvement is sold within one year ofrompletlon.the SQ FT.FLOOR AREA S/SQ.ET,
owner-builder will have the burden of proving that he did not build or improve for our-.pra .
0 1,of sale). TOTAL'. /i
❑Lasowner ofthe See 704 .Business
volt'ronvueem,with:)To,,Cmrmehers to A # v
cense La the project(Sec.o an Business mJ rty who bei ds or internists
Contmdon, Li- �p i/
c Lawdocs nmapply rean with
aofpropeny wcense pminntoIne Co me and QTY. PLUMBING PERMIT FEE
who wntmces fnrsuch Dmjeots with acummemr(s)heenxeU pupnnnnnlM1e Cnnwcnrh
License Law. PERMIT ISSUANCE �CYf
1 am exempt under Sec. ,B&P C for this mason (ff
ALTER-DRAIN&VENT-WATER(EA) ilulq,OAT ON
Owner _ Dam I Gn
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
x: 2O�noo.�
1 hereby affirm under penalty of perjury one of the following declaratimn �'
I 14
have and will maintain a Certiticale of Cmnsentto self-insure for Wader's Gsmpen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES q'YPE CONSTRUCTION
IM Limn,a provide)for by Ser'-tion 3700.1 rho Labor Calc,for the performance of the
k which this permit is issued. FIXTURES-PER I RAI' sS Tj N
- war hove and will maintain Worker's Compensation Inmmnee,as obtained by Section N 1
3 Oil of the Labor Cade.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My WorkaLs Componmtion Insurnn d Policy number are:
Carrier. lit,pj,d b1[l.Z` oe carrier
No.:11"e'- M
GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS' ,-r l
COMPENSATION INSURANCE - GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ttiES
(This section need not be completed Him permit is for one hundred dollarsI$ran GRFASL'TRAP
or less)(This
FEE lop
Loy any that in the anymnnero the work as
subjech ct
to Enothe Wisl,sued,I shall'Comon- SEWER-SANITARY-STORM EA. FT. V
not employ any person in any manner so as m heads subjed m the Wnrken'Cnmpen- ENERGY FEE
OZ cation Laws of Califomia.Doc WATER HEATER W/VENT/ELECTR GRADING FEE
Z 2 Applicant
NOTICE TO APPLICANT:If,after making this Certificate M Exemption,you should WATER SYS'TEMTREATING SOILS PEE
h r become subject m k
the Worer's Compunv..too provision,of the Luhar Code,you muu
a [,r forthwith comply with such provisions or this permit shall be decmal revoked. WATER SERVICE
Jam+ J^q I
Lis CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID , ,
UC I hereby affirm that is a construction lending agency for the performance of Dobe Re ptp
f� the work for which this Permit siwmrd(See.3097,Civ.C.)
u' Lenders Name TOTAL
U Lcndu's Ambess TOTAL:
W I certify that 1 have read this applicat m and stale that the above information Is BUIL .G
V0.2 sanest.I agrce to comply with all city and c nasty ordinances and,nate lows remGng nr QTY. MECHANICAL PERMIT FEE
U � building construction,and hereby authorize prusemahos"of thiseitytoenmrupnnthe sets Pa `
above-mentioned property for inspection per ones PERMIT ISSUANCE
(We)ugrce to save,indemnify and k 'p harmless the City of Cupcnim against ELECTRI6 'E
liabilincx,judgmema,cos lx and expenses wh h may in any way revive ag,imd,rid City ALTER OR ADDTO MECH.
in omxaquence of the granting of this Decant. PLUMBINs �E
APPLICANT UNDERSTANDS AND WI COMP ITH ALL NUN-POINT AIR HANDLING UNIT(1010.(Xk CFM) MECHANICAL NN
SOURCE REGULATIONS.
A- p AIR HANDLING UNIT(OVER IRWII CPM) CONSTRUCTION'
Signature of Appliv,rmCmr ' ,S DIc EXHAUST HOOD(WMUCO HOUSING MITI GATIO FEE
HAZARDOUS MAT LS DISCLOSURE
WilltM1capplicammfmure building spam store or handle hazardous material HEATING UNIT(10 IW.OW BTU)
as defined by the Cupertino Municipal Code, apter 9.12,and the Health and Safety
Code Section 25532(a)R HEATING UNIT(OVER 100.1N)BTU)
E]Yes VENTILATION PAN(SINGLE RESID) PAID
Dobe Fecipl a
Will the applicant or future building occupant use equipment or devices which
'mit hazemlous air cttuou I Ps as def rf by the Bay Area Air Quality Manngcmcm BOILER-COMP UHP OR I00.000 BTU) TOTAL.
's °y ,.,,,/ BOILER-COME(OVER iW,M)BTU)
[J Yes t�^'
I have road the hazard,11 mot ri is is under Chapter 6,95 of the Cali- AIR CON DITIONER ISSUANCE DATE
uin
fmmia Hcalih&Safely Code Samson SUS.2553 en 25514,1 understand that it the NEW RESIDENTIAL MECH. SQ.FT
build,ng Arws not eurtently hove area t hn i ' yrcsponsibilily la nmify the nccupom
of the mquircments which most mcc of a Coni ficme of r7tuncy.
Owner or unmanned agent I Date TOTAL: ISSUEDBY:
OFFICE __ _ _�-
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