00010175 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY , - e no 0 1 ® 1
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT Cleadatl
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDIN PROJECT IDENTIFICATION
BUILDING ADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATE
- .1
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OWNER'S NAME HWLI E: ON CTOR'SNAM�: LIC NO:
U NIC gN'rItOL#
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RCHITECT/ENGINEER: LIC NO ADDRESS: ❑
FCj , 1.(_,;Heg c-f90� 5o SiIWZI�ac� er.
CONTACT: PHONE: BUlLU1NG PER INFO
.I Cr,J t�/lA SId 6s6 y7�{ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTORS DECLARATION QTY . �a ELECrTRIC PERMIT FEE' -
I herehy affirm that I am decriedadd,, ,,,visions of Chapter (commencing ,3 JOB DESCRIPTION
Oat ib SedbnOWB) fDvtson 3aGhe Bos sand Prate non CA and nyiee i
l 0o wt PERMITISSUANCE
RESIDENTIAL,
caor mfail force an t o ❑SFDWL [D KITCHEN RF.MODEI.
QUU License Class Lia# APPLIANCES-RESIDENT']AL .ADDITION ❑PLUMBING RE-PIPE
tF�ul Dwe��Gmtranm
F'vWW As shall iCT'S DF.CLA 1'I - ❑MULTI-UNIT ❑STRUCTURAL.
Z lundersmndmy plana shall beused as public recti � `/' PANELS MOIIIPICA'fION
OZ-, n UP DO 200 AMPS El INTERIOR El CHIMNEY REPAIR
I-+..4"M Licensed Professional • 201-I0)(OAMPS IMPROVEMENT E]SWIMMING POOLS
C6 OWNER-BUTLDF,R DECLARATION OVER 100DAMPS ❑BATH REMOOEUREPAIR (]DEMOLITION
6 I hereby affirm that 1 am exempt from the Contractor's License Law Car the _
3 O U following reason.(Section]0315.Business end Transitions Code:Any city cr,cam, SIGNS ELECTRICAL D OTHER
Fy' which requires.permit to asmano d,alter,improve,demolish or repair any,tradurre _
E"�06 prior de its issuance,also requires the applicant for such permit to file a-signedstatemem SPEC IAL CIRCO IT/MISC.
that he is licensed p.cannot 1.he provisions of Ibe Contractors License Law(Chapter 9 _
(commencing wird Section 9(g10)of Division 3 of the Business and Professions Code)or TEMPMETER OR POLE INST. COMMERCIAL:
F y y 'he,he is exempt therefrom and the Fasts far the alleged exemption.Aoy violation of D NEW BLDG/ADDITION D DEMOLITION
Section 9031.5 by any applicant fora permit subject,the applicantma civil penollyof POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than rive hundred dollars($500). IMPROVEMENT
6 I,m nwnm of the SWIMMING POOL ELECTRIC
❑ pmperctur myemntended withwages r taleirenle compemm�om
pr will duthewons aide: he Contractors
License Law doesed of apply to
an,Business ❑OTHER
^w and ac,who fi Code:The Contractor',License Law doe,not apply hi to un owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improver thereon,and who dnc such work himself or IM1mugh v �
his own employees,provided that such improvements are not intended or offered for ^ NEW RESIDENTIAL ULECTR , SQ UT.
sale.If,however the facilitator impmvemcnt N alld wiNinone yconofarmplAiar,the SQ.FT.FLUOR AREA $/SQ.FT
caner-builder will bare the burden of proving that he did not build or improve for pur-
po,eofsale,).
D 1,as owner of the property,am exclusively contracting with licensed contractors to OTAL:
co etract the project(Sec.7GUL Buttner,and Phfic,lions Code)no Cnntfa cm,U- - -
cause Law does not apply to an owner of property who builds or improves thereon,anJQTY PLUME( ER FEE,
who contracts for such projects with a contracma,)licensed pursuant to the contractors t
License Law PERMIT ISSUANCE111 W .
❑ 1 an exempt under Sea ,B&P C far this reannn '
err Date
ALTER-DRAIN&VENT-;ATE VALUATION
can WORKER'S COMPENSATION DECLARATION RAC%FLOW PROTECT.DEVICE \ O ®O^^
1 hereby aff on under penalty of perjury one of Nu fallowing declarations: `
❑I have and will maintain v Certificate ofComent m self-maum for Workura Compom DRAINS-FLOOR,ROOF,AREA,CONE. at, V
..tion,as provided far by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONS'TRUCT10N
work fit,which this permit is issued. FIXTURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance,as required by Section -
3900ofthe"hot Code,for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GROUP Ny ry
My Worker's Compensation Insurance tartlet and Policy number aro'. J C�
Carrier: Palley No.: OAS-BA.SYSTEM-OVER4(EA)
CERTIFICATEOFEXEMPTION FROM WORKERS' Q
COMPENSATION INSURANCE GREASE5N_DUSTRL WASTE INTERCEPTOR ,
(this section achimbecontpleted ifthepemnitisforonehundmdd,,11.($IMI ` ,BUI4DINO I�IVISiON IfE65 =/
or less.) 1 GRF.ASF.TRAP PLANCHECK FEE
t I certify that in Nepertnrmance ofthe work forwhich this permit is issued,)shall SEWER-SANITARY-STORM EA.200 FIT..,it employ any person in any manner to as to become subject to the Workers'Canadian- ENERGY FEE
Oz station Laws of California,Data o
WATER HEATER WNENT/ELECTR
z Applicant ) GRADING FEE ,
h NOTICE TO APPLICANT:If,after making this Car ficut,of Exemption,you should WATER SYSTEM/TREATING
ai breis schrost nt the Worker's Campencmion provision,of the Labor Cale,you mast _ SOILS PEE
{7) forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAIU
UQ I herwhich thi that there iisuen(wmi0 lending agency for porfommnwat D01e Receipt#
Hhe work for which this permit i,issued(Sse.3099,Civ.CJ -.
O U Lender's Name - - TOTAL:
Gia Center,ATOTALS.
a 1 certify
rt'ry th he,1 have reed this application ad late that the move mountitoo is ., - BUILDING PEE
f-t (A correct I agree to comply with all city and cromy,ordinances and ante laws honing lot QTY. '..MECHANICAL,PERMIT I .FEE.
U Z building cntruction and hereby unitarian representatives of lhit city to enter upon the SEISMIC PEE
shove-mentioned property for inspection potposes. PERMIT ISSUANCE
(We)agree m save,indemnify sad keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way reame against said City ALTER FRAUD TO MECH.
in wnsequenceA the gmming of this permit I PLUMBING PEE
APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 COM) MECHANICAL GEE
SOURCUREGUL S.
D(' AIR HANDLING UNIT(OVER 111,000 CFM) CONSfkUC'IION TAX
Signa of Apdira VoCinumem, Dote EXHAUST HOOD(W/DUC1) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
nllthevpplic.A.,famrc hadming ecc.pow,dreor handle luxurious material HEATING UNIT(TO 100,000 RTU)
as defined by the Cupertino Municipal Cods,Chapter 9.12,and the Health and Safety
Cade,Section 25532(v)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ONa PAID
VENTILATION PAN(SINGLE RESIU) -- -
Will the applicant or furors building occupant use equipment or device,which Date - Receipt#
'unit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) '
Da'Inctp TOTAL.
❑Yes, 17]No BOILER-COMP(OVER 100,000 BTU)
I have read the hazardom
us materials requireent,under Chapter 6,95 of the Cali- ATRCONDI'f10NER ISSUANCE DATE
Contin Heallh&S.fety Cads,Sickens 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT,
building does not currently ha atennnh that it is my respnncihility to natty Ne mcupant /� /^
11 regA eat In A temetpriomolssuaavenfa Certificate ofOvanoy. I / r._J JFK)
Ow r ra or ed of Dote TOTAL', ISSUED BY:
OFFICE