00010092 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O t 60 L( p�
CITY OF CUPERTINO .. BUILDING-ELECTRICAL PERMIT NO.
BUILDING DP71SI9N APPLICATION/PERMIT • PLUMBING-MECHANICAL
i BUILDING PROJECT IDENTIFICATION•
BUILDIW*,ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT[
qq vet o o
OWNI
S NAME: NHONF,. WNTRACTOR'S NAME: LIC NO
r A-n �• �Y^I II� G; i, NIC CONTROL#
CHITECT/ENGINBER: LIC NO: AUUk-�51�` �77� � rn,yll ❑
CONTACT: PHONE:
1 . /p������L E] Consultant Pages Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
�K 5,; II 4 ' ❑ ❑ ❑
LICENSED CONtftACTORS DECLARATION QTy ELECTRIC PERMIT' .'IFEE`.
rn by.ffr 6.1 la licensed udcp .of chapter 9(eonme ng ) , t .." 1 .t ... t. r,, JOB DESCRIPTION
y0Z aims i 701D 3.f thBusiness dProfessions Code,andmy license w RESIDENTIAL:
l- OA is fall fronandel I. PERMIT ISSUANCE L1SFDWL [_1 KITCHEN REMODEL
aU U Licel Cl.s #
F w Date C I _. APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING REPIPE
N� ARCHITECT S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z C)an Z I understand my plan,shall M uced es public records PANELS MODIFICATION
O Z r UP TO 200 AMPS
w ZI'-Q Licensed Profwsioval ❑INTERIOR [I CHIMNEY REPAIR
qq 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
X 2 Oat I am
DECLARATION OVER 1000 AMPS ❑BA H REMODEL/REPAIR ❑DEMOLITION
C4 I hereby affirm that 1 am exvmpL from me Connudnr'x Lice caw for the
3 04 U lollnwing rwxon.(Sutiou IlU 1.5,Business slid Professions GNe: y city or aunty SIGNS ELECTRICAL THER ;SOD WIAsT'Imu AFYM f
w md which requires a peril m construct,alter,improve,demolish repair any srmdure
yiy d, princto its issuance,alsorequites the uppll...IPorxachpe oBlea ,taxlsturemem SPECIAL CIRCUIT/MIS
rf"dy rhm he is licensed pursmnuo the provLLms nF the Cont ofsl•icwse Lowncho"u9
a00 (commencing with Section 9110Am Division Sof in ,inessaud Profession,Code)., TEMP.METER OR LEINST. M R -
G p�o eG that he is exempt lherefmm and the basis Car th Ingest exemption.Any violation of - NEW BLDO/ADDITION ❑DEMOLITION
iC 4i
Section 70315 byaay apfactor fur.peril jects the applicant n a civil penally of POWER DEVI ,S
W^'rn ENANT ❑FOOD SERVICE
not more than live hundred dollars $500
Ey�p" ( IMPROVEMENT
�5C ❑ Lo thewomd IM1e prommendrmy loyees wilM1 wages as their sole cnmpensminn, SWIMM PWLELECfRIC
0.I. will dathesirms Codec st[narured ar'sLicensorossdoesonot apply 9044, wnmws OTHER
3 and Pm sell.b Cade:The C rector's License w Law does not apply tem owner of O 'TS-SWITCHES-FIXTURES
property who builds or imp es Ihercon,and who does such work himself or Through
his awn employees,pm ed Ihm such improvements are not ImendW nr offered for 8W RESIDENTIAL ELBCTk SQ PI'.
auto owns-midevewthe the bur en of
fpnncnlisat he iid non orad.,improve to, the
SQ.IT.FLOOR AREA $ISQ.FT.
ufarlder wit ave the burden of.mving that he did not bond.,impmvamrpui-
E I,of sa1cJ. -
❑a as ow t of the properly,am exclusively contracting with licensed Contractor's
f- 'TOTAL.
censhu a#ruled p 9044 Business d P f.. C de 7 The Canheac r.Li .,
can .aw does not.pplyln owner fp p ny h builds or improves Ihercon and Q{CY i .PLUMBING'PERMIT, s y' a}FEE.1
wcontracts for such corrects with a eoutracmgs)licensed pursuant o the Contractors E• r•+
c
se,Law.
Ol am exempt under See. ,B&P C for this mason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dao �f
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE So
1 hereby affirm under penalty of perjury one of the fallowing declarations. f+
I have:mdwill maintainaCenificme of Cnnsenttn,elf-insure for Worker's Camper- DRAINS' FLOOR,ROOF.AREA,CONO STORIES TYPE CONSTRUCTION
tion,as provided for by Section 3900 of the Labor(bre,for the permanence ofine N
k��ttuu.which this permit is issued FIXTURES-PER'TRAP f 'T7
(3Thave and will maintain Worker's Compensation Insurance,as required by Section 1 �1�
3700.t the Labor Code,forle,cromaoceof the work for whichdo„ comply issued. GAS-EA.SYSTEM-1 INC.4o LETS OCC.GROUP —/ APK.�
My Worked,Cnmpensmion ln,urance canicr and Policy#p it .' (p
CanieC S'�ORfrRJ+b Policy No.:`�y�'l-9'7 GAS-EA.SYS'I EM-OVE (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
007
COMPENSATION INSURANCE GREASE/INDUST RL ASTE INTERCEPTOR F B � I S [I NE659 F$••
Thlssedionneed notlfe completed if mo.crmir is fame hundred dollars GREASETRAP
or low.) PLANCHECK FEE
I certify that in the performance of the work forwhich ter is issued,I shell SBWP.R-S 1'[ARY-STORM EA.200 Pp.
wt employ any person in any manner so as m bee . lcomme winor 'Compen- ENERGY FEE
,� ,Winn Laws nl Califnmia.Orate WATF ATER W/VENT(ELECTR
z
Applicant EGRADING FEE
y NOTICP,TO ADPL :IL atter m.kiug chis Cenific.m of Bxcmptian,you should W 'R SYSTBMRREATING
become s o rhe Worker's Compensation previsions of the Labor Code,you mun SOILS FEE
W4 u comply with such provisions or this peril shall bedeemed revoked. ATER SERVICE
Q
z CONSTRUCTION LENDING AG NEW RESIDENTIAL PLATE. SQ.IT. A PAL�TU D IM1ereby uffinn mW there i,ucnnsuuct,a, g.gencfor thepeformanw of ^Dote Nhe work Por which this pent i , ..09],Civ.C.)C) Lend N e /Lend Addre., TOTAL:
1 e rt h d this application and state that the above informaC y - IBUILU F”conecomply lh alllilyand countyore'neveas aneseem lawsrdai F I QTY " MECHANICAL'PERMIT
U built' ge .t tlnn a dh by.orhonze repmsenratives of this city to cruet upon the SEI F.E
n mentioned property for inspaetim purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way roman against said City -"
consequence of the ting of this permit. ALTER OR ADD'I'O MECH. E�IMBINGFF- H-_---' "
in gen
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,011f1 CFM)
SOURCE RE MECHANICAL FEE _
/ AIR HANDLING UNIT(OVER 10,0000 CONSTRUCTION TAX
Sigmamre of Apphrim/Conrraomr Uatu EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wollhe...from,or films huildiegoceupamsmrem handle hamohms material HEATING UNI'FTO 100.GW U)
Us defined by the Ce,whoo Municipal Code,Chapter,9.12,and tum Health and Safety
Cade,Section 255320)1 /' HEATING UNIT(OVER 0,000 BTU)
�Ve� lyre PAID VENTILATION (SWGLERESID) Dare Receipt#
Will the applicant or future building occupant use equipment or devices which
Di�M1aOMou,vir contaminants as deYned by the Bay Aren Air Quality Managmncia _ BOILER-CO 'THE OR 100,000 BTU)
bt1 BOILER OMP(OVER 100,OWBTU)
Yes '[I[Yo .
AIR NFFDONER
I reverential,homrdmw mummuls reuire
qments under Chapter 6.95 m rhe Call / IS LANCE DATE
fomiu Health&Sefuy Code,Sections 25505,25533 and 25534.1 understand that if the 'W RESIDENTIAL MECH. SQ.Fr.
not
building does I s lean,that h m
hne is y responsibility to notify me occupant L O O
orequi t.wbtrh t�yednr m.iaxaanee at a Cenifiea �foo parry. _ y�
,hot 0 '(7
owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE