S 0804 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PIi ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGROJECTECHANIFIC OHO 4
BUILDING PROJECT IIIRNTIPICATWN
BUILDING ADDRESS: SANITARY No. APPLICATION SUBMITTAL DATE,
a0
OWNER'S NAME; PHONE: CONTRACTOR'S NAMIi: 1 LIC NO:
O A Ta,uc on)
T/ ay9Sa. Nrc c)N' ol,x
•ARCHITUENGINEER: LIC NO: ADDREIS`: ❑
{V ✓
CONTACT: PHONE: BUILDING PERMIT INFO
6 n
9-91q-6763 ❑ Consultant Fees Paid by Applicant(Initial) ❑DG ELE�CI PLUMB MECIi
/• LI SED CONTRACT'OR'S DECLARATION QTY. ' ELECTRIC PERMIT FSE G/ ❑/
1 hereby ulnrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CaZ with Sectio.9flo(pof Division 3mf the Brvinessaod Profcseime,Cale,and my license isRENtIENTIAL
y100 t PERMIT ISSUANCE
F Iy m full force and eRect. `a FDWT. ❑KITCHEN REMODEL
�UyU License Ela Lic.» ••g APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
I7Qa, Date +`s T'qD CL �A-v (r'1 tML eJ
7,� ARCHITECTS DECLARATION PANE" E]MULTI-UNIT [I STRUCTURAL
,�,�vJ I understood my plane shall he used as public records CHIMNMODIFEY
TION
REP
i oy;4o uP T021X)AMPS C1 INTERIOR ❑CHIMNF;Y REPAIR
94
I,u Licensed Profa"m—1 201-10X0AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IfX10 AMPS El REMOD EPAIR ❑DEMOLITION
1 hereby ufOrin that I am exempt from the Contractor's License Low for the
ig5 OIL U following mason.(Section 7031A Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER E}�R,/��fj7j��
to E3O F which requi¢s o permit m conswct,eheq for
such
u demolish,m repair any swcmrc r r s r '
an.,heltx ervedgdsoregdhe thwistrasi for mchractor Liceo file sense Law(ned mtemcm SPECIALCIRCIIIT/MISC.
My that heincingwithSection7 parmant 0oofDivision ofthethe e ria ea, ndProfsaw(Chnpteavar9
BICC (cat he is exempt therefrom
](IDB)The Division oft he Business and Professions Any
Cadeof TEMP.METER OR POLE INST. COMMERCIAL:
dy a that io is exempt therefrom end the basis for the alleged exemption.Any violation of ❑NEW NLDGIADDITION ❑DEMOLITION
X�4 Scetion]BJlSby any appllcum for oVomit subjects the applicant mncivil penalty of POWER DEVICES NT
1-Z> notmure than five hundred dollars($5001. TE ROVEMEb El Fool)SERVICE
Q ❑1.as owner of The properly,or my employees with wages as fire'.le compensation, SWIMMING POOL ELF.CfRIC �y�I
will dmhe work,and the structure is nm imended proffered Imside(Sec.7094.Business q'0
W-' and Professions Code:The Contractor's License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES ll
6 3 properly who builds or improves thereon,and who does such work himself lir through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELGCIR SQ Ff.
Wvl If,however the building or improvement is sold within one year of completion,the
SQ.FT.FLOOR AREA USQ.IT.
er-Wilder will have the burden of proving that he did not Wild or improv,for pur-
pose of sole.).
The C
Business haul Profession,CaAL
cC]I,us owner of the properly.am exclusively convecting with licensed contrecmn to : T�
oasvuct the project(Sec.]M4. de:) Contractor's Li- Ey'
nu Law does not apply to con,owner of progeny who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contrachi s)licensed pursuant n the Counamor's NOV 1
License I. PERMIT ISSUANCE r ,9 7
❑l am exempt under Sao ,B&P C fonhis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE •_—�
1 hereby affirm under penally of perjury one of the following declarations:
•� Ihave and will maimain uCerlihcute nfConunvo self-insure for Workers Compcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCf10N
ration,as provldW for by Section 3700 of the Labor Code,for the pcHmmonce of the
weak for which this permit is issued. FIXTURES-PER TRAP
pb 1 have and will maintain Worker's Compensation Insurance,as required by Section
3]OO of the Lehr BCespJse,funhe performance of Ne work fnrwhich this pennir is issued. GAS-RA.SYSTEM.I INCA OUTLETS OCCGROUP APN
MY Work s[0.Bcpstio�uray,.dvnev it ley No:
9"l"11 Y GAS-HA,SYSTEM-OVER 41CraGI
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSPIINDUSTRL WASTE INTERCEPTERCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section aced not he completed if the permit is for one hundred dollars IS 100) GREME TRAP
or less.) PLANCHL'CK FEE
T certify that in Ne perfchrox of the work for which this permit is iaued,Isbell SEWER-SANITARY-STORM EA.200 FT.
not employ any pnson in any manner so as to become subject the Wodera Common. - ENERGY FEE
O �$ ,onion Laws of CuGfumio.Dare WATER HEATER WNENTIELECTR GRADING FEE
O Applicant
ti NOTICE TO APPLICANT.IL ofmr making this Cer ificute of Exemption.you should WATER SYSTF.M/I'REATING SOILS FEE
I" hecome subject to The Worker's Compensation pm em...of the Labor Cala,you most
W � f Ill comply with such provisions o1 This permit shall be deemed revoked WATER SERVICE
7z CONSTRUCTION Llending agency
NEW RESIDENTIAL PCMB. SQ.FC PAID Date ' in
U Q I hereby affirm that is sued(Ses.construction0 7.Cagency for the perl'ormnnce al
The work for which this permit is issued(Stt.31X],Civ.C.)
0 U Leddcra Name TOTAL:
Lender's Address A O BUILDING FEE
!C'^ I certify that 1 have mad this application and state that the above information ie
TaH correct l agree to comply with all city and county ordinances andstne laws relating toQTY, MECHANICAL PERMIT FEE
wmat
building consaion.and hereby authorize representatives of this city enter upon the SEISMIC HE
C� 2; at
1
above.mentioned property for inspection puryuses. PERMIT'ISSUANCE e 4
(We)agree to save,indemnify unit keep harmless the City of Cupertino against f O [LELTRIC FEE _
liabilities,judgments,cosaund exhatmeswhich mayin any way income agamstsuid City ALT ER ORADDTO MECH. PLUMBING FEE O
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0011 CFM) O
MECHANICAL
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCDONT
Signature ofApplic.msC7m.cmr Dote EXHAUST HOOD(WMUCD HOUSING MITI GATT FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous mamrril HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Safely
Code.Section 2553210)7 HEATING UNIT(OVER 100,0011 BTU)
Yes No
� � VENTILATION FAN(SINGLE RESID) PAID Dam Rtt<ipr N Z
kWill the applicant m fatter,building oecupant use eyuipmem or devices which
., ou
t hazards air conandrunts as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR IW,(XNI BTU)
TOTAL:
District? BOILER-COME(OVER 100,N)i
C]Yea Fl No
Ihave read the hvardnus mm,rials reyuiremcmx under Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
forma Health&Safcty Code,Sections 25505,25533 and 25534.T undersmn l that if the NEW RESIDENTIAL MECH. SQ.FE
building does not currently have a tenant,that it is my responsibility to notify The cecupant
of the nrachrente which must be met prior to iouonce of a Certificate of Occupancy.
Owner or authorized agent Data TAL I�ISSUED BY: i /,4
f 0
OFFICE