S 0591 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELEC rRICAL PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 059
" • ,BUILDING CT'PROJE11)ENTIFICATION
11LUING ADDRESS: SANITARY NfI. APPLICATION SUBMI'ITAI.DATEo ti a Z 0 _ a
WNtR'SNAME: \` O PHO E: N'ITtACfOR'S NAME: .,.,,:. CAO: `�
N�—IN Q NIC CONTROL#
• ARCIII .Cr/LN INEE \ , LICA A PM. RESS ` �� n ❑
CON'I'AGc ver PHONE: J - BUILDING PERMIT INFO
\\\
ED Consultant Fees Paid by Applicant(Initial) BLDG F, E['.r PLUM Mc
L
LICENSED CONTRAG'IOR'S DECLARATION QTY ELECTRIC PERMIT FEE
CWn ny ff nh rl nl' used pr i, n. od Chapter 9 unn ,euring JOB DESCRIPTION
W O z an ser, u v)00) rD 3 nue Ras and 14o re sena a,de and nry l remse d;
F W C nnfail t c d B t. PERMIT ISSUANCE RESIDENTIAL;
�UV Lte use CWss tic,» \ " ❑SFDWU . _ ❑KITCHEN REMODEL
NQL Dam Cmdmcma \ y APPLIANCE'S-RBSIDEN'I IAL ❑ADD]TION ❑PLUMBING RE-PIPE
ARCHITECCSDLCLARATION PANELS
F�'� ❑MULTI-UNIT ❑MODIFI1URAL
ZOy$ IunJer.;mnd my plans shall he used ns puMlc rccoNs MODIFICATION
OZ—O \ t, UPTO2(X)AMPS
Ha'n.t:W LccnseJ Pnefessmnal ❑INTERIOR ❑SWCHIMNEY
MINGREPAIR
OOL
CW�-`1j OWNER-BUILDER UECWRATIONa. �x 2111PR10AMPs IMPROVEMENT [:1 SWIMMING I'0(ILS
C ad Q 1 hereby anion that 1 am exempt from the Cumrucmr's License Law far the OVER Igg1AMPS ❑BATH REMODEURFPAIR ❑DEMOLITION
,tea 4 U fallowing renaon,(Section]W 1.5,Business and Prafdlsams Codr Any city or clmnE SIGNS ELIiC'IAIGL ❑OTIIIiH
FO yQ which require.a permit m wmstmct,alter,innprove,demolish,or repeu any stmature
HJ pnnn r e,also Tey thapplicantf M1pe ml file g In doment SPECIAL CIRCUM/MISC.
} nm he I' dpursuamt thep .In. nth C ,m coL l L '(Cliapmr9 AMMF
Wp;O� (eon g lir Sect 7uXR fDi rsno 3 frbeB ess dP f .t m,Cmhdor TEMR MET ER OR POLE INET. 7R IA
61y M y that he is exempt therefrom and Ne iasis for no alleged exemption.Any in]' of
fzXl LL Sore ino 7031.5 n a tient for NEW BLDG/ADDITION ❑DEMOLITION
w by pp pemrit suhjcros rM1c applicem Barium($pmmliy;dj POWER DEVICES �`; NT [I FOOD SERVICE
F-ZQnot mote than five hundred dollars($500). ik I PROVEMENT
❑1 aaownsd fNe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECI'kiC��J-.
b=.� wHhd.dWwo.k.and tiro sr memrc Lenatlale led m ull'rred to,sele(Sec.7%rL Busnms ❑ TIIIHt
3 and Professions Code:The Contractor's License Law does nor apply to an owner of OUTLETS-SWITCHES-F14YT RES
property who builds or imprtnes tierce.,and who dues suchwork himself or through
his own employers,provided that such improvements are not intended or offered liar TA NEW RESIDENTIAL F.LECB \ SQ Fr.
sule.ILhowever,the huilding arimpmvemem is snlJ within one year of cemplerion,the v Y SQ,FT.FLOOR AREA sd%W.
er-builder will have the burden of proving that he did not build or improve for par-
P^ A ' ID
pose err salo)
❑ 1 as owner of Ne propcny amexclusively conamcong uilh liceii.W rontmcm:br ti t ` ( 'TOTAL
' m m d the project(Site 70,14,Bdsireos and Profession,Code:)The Contractors Li. sF�4'
cense law does not apply to owner' fp pony h build:or improves thenen d QTY. d} RLUMBWCr PERMIT EAT �1�/sZ �•a�
who contracts forsuch pmiects with a conuacta(s)Icensed pursuant the Comnct,rs - t1 iT IV•
ElIindLnw \� � coUr
❑ Tom exempt under Sec. ,B&1'C fonbis reason PERMIT ISSUANCEx v\S\ ' ^+
LUT,114 riA'
Owner Dae ALTER-DRAIN&_VENT'-WATRR(BA a;3'% VARA
110
WORKER'S COMPENSATIONDECLARATION BACK FLO j 9
• IWorhy affirm under penalty of penury oneafthe folbnving Jecladlium, a v� ,
Iha {
❑ veondwlllmainraina Ceniric;ne Of Consennnself-insumfor Worker's Compen- DRAINS-PI,OOk.ROOF.ARCA,COAD. ) ,
sation,as provided for by Section 3700 of the LnMn Code.Our perfommnce of the �•��� STORIES TYI'li CONSTROC'1lON
work for which this pemen is issued. FIST'ORE JIQue Ipnor to Plan c eCk coat Aefilon
❑ 1 nave and will maintain Warkers Compensation Insurance,as rehired by Section 8 Can Or
37(Ml ofthe labor Code,for the perRnmance ofthe work for which this permit is issued. GAS-EA. er ecce p ApN
My Walker' nrion 'e o- d Pulley n rb - '
/ Garvie= � yNd, " GAg EA so cor ectin ad ftlom
C TFIC TP.OF EX� IP110N FROM WO K RS'
COMPENSATION INSURANCE GR17ASFJIQryp� 'and'a isi ns on - BUILDING DIVISION FEES(Thkxerrimumedrad bernmpleredifthepe,mirisfnrnnehundmJ dollars(SI(g0 GREASE et Blsue Pri
or leu.) • PLANCHECK ME
loyalty psorhat othe permy murder sit
thebecomr which his tpermit he Wise.;snedishn- �•a %10r
not employ any perxm in any manner ser a'In become xubjM to the Warken'Compcn- SEWER- �N��I1I1N� r
O ,Z smion Laws of California.[)aid ' HNERG.PEE
z0 Applicaor ' WATER HEATER WOVEN r ,IR ¢ GRADING FLU
W NOTICE TO APPLICANT:If,after making this Cerofeae of Exemption,you should WATER S ,
ah become;abhor to the Workers Compensation provisions of the Labor Cale,you must SOILS FEE
!Ta Iti forthwith comply with such provisions or this permit shall W deemed revoked. WATERS; ICE S
0. Q
.�. Z CONS'rRUC'flON hliNU1NG AGENCY - NEW RE , 4.0
U O Ihemby affirmthat them iso conswniort lenJingagency for the performance of 4. Re
the work far which his permit is issued(Sec.3097,Civ,C.) t'
0 V Lender's Name Ar
W Lenders Address TOTAL:
Okilocnifythat 1 have r<ad this applicainn and sat¢rim the atone infommtion is BUILDING FEE
uFa v1 artrccnlagrcymw,mply with all city one roomy onfnonsns and smm laws mlaring to QTY. MECHANICAL PERMIT PEE
UZ building eonsm,nion,and hembyaurhoriu repmsemarives oflikeeiiy to wrOtipontbe SEISMIC..o above-mentioned property far inspection purposes. PERMIT ISSUANCE(We)agree to...Inm
denify and keep ld rnlcss the City of Cupertino against ELECTRIC PHE
liabiliries,judgments,costs and eapcnses which nw yin eery way devote against said City' ALTI7R OR ADD TO MECIL
or nm' l enceldthegrantin efthis permit. PLUMBING FEES
API', CET UNATIO AN S LD WILL C MPLY WITH ALL N !-POINT AIR HANDLING UNIT(TO 10,001 CFM)
SOU CL EG TIO MECHANICAL DEG
/ AIR HANDLING UNIT(OVLR 10,00lCPM) u
i CONSTRUCTION TAX
Signmu Appliemi/Ccnrmctr re EXHAUST HOOD(WMUCr) HOUSING MITIGATION FEE
MATER ALS DISCLOSURE
Will the applicant or future building excursion score or handle hirearmus mamri HEATING UNIT(TO 100.000 BTU)
as refined by the Cupemar,Municipal Code.Chapter 9.12,and the Death and So[ y
Code,Section 25532(#)? HEATING UNIT(OVER 100.000 B I U)
F1 Yes ❑No
VENTILATION FAN(SINGER RES[DO PAID
.Will the applicant ur future huilding trcupaHi use equipment err Devices which Data Receipt b
Dmost t'hadzardoua air mmaminams as defined by the Noy A.Air Quality Management BOILER-CUMPIJHP Ok I(q,gMI RTU)
Disuia?
TOTAL:
[I Yes -❑No BOILP,R-COMP(OVER IINI,[gNI H'11U)
I have mud rbc horurdous materiels desryndarvois.Ddu Chaper fi95 of the Cali- AIR CONDI"I TONER ISSIIANCL'DATIi
forme Heath&Salidy Code,Sections 255115.25533 and 25534.I understand drat if the NEW RESIDENTIAL MECH. SQ.FT.
building dors;not currently have a tenant,that it is my rexpensihiliry to ratify the occupant
of the"ulramenrs which must he met prior In issuance of a Cenifeure"I Occupancy.
Owner or outhlrzed agent Date 'IOTA L: ISSUED BY:
OFFICE