B 0654 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N
Rwr 190020
UII,IIING DIVISION APPLICATION/PERMIT PLUMBING MECxgNICAb. -�
If Ull,MNGPROJECTIDENrIFICATION '��I 04J40
IUILDINGADOHESS:,, ��/%T73 rn ��/ SANITARY NO. APPLICATION SUBMITTAL DATE
-�
IS E: PHO If:y(�q CONTRACTOR'S NAME LIC NO',
t N/C COMfHOLN
.rt HIT /ENG, E R: � LIC NO; / / ADDRESS: � �
CON'AC F PHONE: BllI1.I71NC PERMIT INFO
Ll � Consultant Fees Paid by Applicant(Initial) HLDG BUILDING
PLUMB I3 MF,CH
Iona pan
LICENSED CONTRACTORS DECLARATION QTY " ELECTRIC PERMIT FEE
I iou 7f 0)of nm,am fieemed anon.pruvitmns nr enapmr 9(mmm,encing JOR DESCRIPTION
Qaz "n Semdm nNNn nrin,lan,n3..nne naame.aa.,e vronxtmmta,de,ane trtr lxen,reis IA
00 in full farce and eR'ecl. PERMI'1'155UANCE
aF.,UU License Class Liv. WI. D KITCHEN REMODEL
NG4 Date Contract... APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE.
ARCHITECT'S DECLARATION PANELS SI
F.Om - MULTI-GNIT ❑MODIFIRUCTURAL
MODIFICATION Z O y Z I understand my plans shall he vsN as public records MODIFICATION.
Or'�Zzp^p I1PT02(NI AhrPS El INTERIOR El CHIMNEY REPAIR
e"SgMW LlcroseJ Pmfesslaml 2BI-1(NNIAMPS IMPROVEMENT'
ayf.j OWNER-BUILDER DECLARATION El SWIMMING POOLS
tX W6 I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IMOAMPS 0 BATH REMODIBJREPAIR D DEMOLITION
at1 F following reason (Section 7131.5,Business and Poufeasions Code:Any any In cnmdY SIGNS ELECTRICAL - D OTHER
u- which fequires u permit to nmsauet,alter,improve,demolish,ar repair any etuictute
�LL0 primrm its issuance,alsorequires the applicant forsmch piano to file asigned statement SPECIALCIRCUI'UMISC.
y thalhe is lnensedpumount In the provisions oftie Contractors License Law(Chopmr9
QDhimmcnclmgwlth Section Mod)of Divisim 3ca,the Bm1m,s mll•rofcssiom Cod0or TEMP.MITER OR POLE.INST. COMMERCIAL,
6 a c ty that he is exempt therefrom and the basis for the alleged exemption.Any violation of
-^„u• Section 7131.5 by it.,cep,licmn for.permit subjects fix., wamuo.civilElNE•W BLDG/ADDITION El DEMOLITION
w of mare than five hundred Jollms(8500). penalty or POWER DEVICES 1:1 TENANT DFOOD SERVICE
f=G ❑Las owner of the pmpeny,or my employeex with wages as their sole mmpen,oma, SWIMMING POOL.ELEC TRIC IMPROVEMENT
F will do the work,and the structure is not intended or mderell farsala(Sax.70,14,Business DOTHER
lam] and Profeevinns Cada:The Cart. a''c Lic ma Law dues not imply to an owmr of OUTLIffS-
L SWITCHES-hIXTUNIiS
propertys own who builds or improves thereon,and who Ices such work himself of through
his own employees,building that such menti, lld ate not intended or aRered for NEW RISIDENTIAL ELBCTR SQ IT.
aide.l[however,tM building mrimpnwcmem isxnld within nne cut of con,pletinn,file SQ,IT.FLOOR AREA EI,Q.Fr.
wilder will have file burden of proving that Int did not build or improve for put. / �,a
mom sale,. 4A 2 "�
as msmer of the property,am exclusively contracting with licensed contractors m ' TO'T'AL: ` ! T
construct the projsat(Sec.9144.Business and Professions Cod,)'fhe Cmmrnctn ,Li. ,l /^y
canto Law does not improves
apply to an owner of property who builds or thercon,and QTY, PLUMBING PERMIT FEE 4/a /0 fl
wnocoaLaw.for such pmjcctswith acnntracmgs)licemcd pursuammNe Convacnor's e45O
License exe PEHMII'ISSUANCE. (/A
❑lam acmpronJcr Srs � ,p&PCfonhit neat....
ALTER-GRAIN&VENT-WATER(EA)
Dote VALUATION
S O MSCC`
ENS 10 D2 , tATLON BACK FLOW PROTECT.DEVICE O O
hereby affirm under methal isl perjury ane of the following declarations: lJ V V
L have and will mommin a Cenificme of Consent to self-insure for Worker's Courtin DRAINS-FLOOR,ROOF.AREA,COND. STORIES TVI'F,CONSTRUCTION
cation,as provided lot by Section 37fN,of the Labor C ic,for the perfarmmm n1 the
work for which this permit is issued. FI%TURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance,at required by Section
37M offilo Labor Code,for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Comensa1mr luxuriate cerieranJ Polis OCC.GROUP AI'N
p ynumber arc: �I I,
Carver. Policy No.: GAS-IiA.$Y$T,?MOV13R 4(EA)
CfiRTIFICATE OF HXEMPTION FROM WORKERS' v` /
COMPENSATION INSURANCE OREASIIINDIIS'I'RL WASTE INTERCEPTOR
('This section need not be completed if the Narcan is formic hundrW dollars(SIM) BUILDING MV ISION FEES
carless.) GREASETRAP PL. '11ICK FEE // 7
Loy anythein no efformanymannce erof thework become subject
bjech ttophe s is Workers
onifer- SFWER-SANITARY-S'TGItM EA.2011,T. _
not employ any person in any manner so as m became subject to the Worked Conifer- F. ITH / S e D sY's
Z scans Laws of C.1ifomiii. d 111,
O VP WATER HEATER W/VENTIF.LELTR ,µ LNG FF.F.
O A licam I
N
NOTICE TO APPLICANT:LL Daher tmking this Certificate mf Esensim,you should WATER SYSMIvirrREAFING
a ; become subject to the Workers Compensation provisions of the Labor Code,you must BS FEL
W) forthwith comply with such provisions or this permit Aall he deemed revoked. WATER SERVICE
Q
5z CONSTRUCTION LENDING AGENCY NEW RI?SIDF.NTIAL PCMB. SQ.PI'. ,'All
Ll O L hereby affirm that is a construction lending agency for the perfmrmunce of Dam Rcccipt#
the work fur which this permit is issued(Sec.3097,CIv.CJ
C U Lender's Name TOf O
W Lenders Address TOTAL
1 certify that I have rend this application and state film the above information it BUILDING FEE I
raid correct. agree m comply win an city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT PP.P.
301
V Z building cnnxwction,and hereby amhoriu reprcsematives of this city Incineration the SIfEiMC Plili �Q
abate-mentioned property for inspection purposes. PERM("f ISSUANCE ry /
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC /\
Iiabilinvac judgments,costs and expenses which may in any way acerae against said City ^+....-�
in consax,mrseMne granting ofbis perNt. ALTER OR ADD TOM C11. �.�•��„ PLUM
APPLICANT UNDER, NDS AND W COMPLY WITH ALL NON POINT' gilt HANDLING IINI (fO�I II,WtI CFM)�a\ I� p-� MIFCHA 'ALFfai
SOURCE REGO NS.
AIR HANDLING UNI IDVBH INI B,gCFM) I I r CO TRUCTION TA%
ig u ppl am/Cnntm r Date EXHAIISTHOOD( C17 IIWSI CMITICATION FF.B
rt 13
HA US MATERIA,S ,,CLOSURE s
Will rte applicant .Tulare Willingomu ntstorecamiallehazardommntiamil HEATLNGUNIT(T sl ).WOBTU)
us defined by tic Cupertino Municipal Ctode,Chapter 9.12,and the Health tad Safety n
Code.Section 25532(0)1 HEATING UNI'('(O'ER1100.oW ITT U)
❑Yes CIN. VIJ ILATION FAN(SINGLE RPAID -.
Date Raeipta
will the applicant nr fmurc huileied b the 8t use eyui it Qu or devices which BOILER-COMP LHP OR 1110.008 HTU
emit hazvdous air contaminants as definM by the Bay Arca Air Quality Management ( 1
District? TOTAL:
[:1 ye, F7 No BOILER-COMP(OVER 100,000 BTU)
43
I have and the hazardous materials qTuircments under Chapter 6.95 of the Cut. AIR CONDITIONER _ ISSUANCE DNIe
fear.Health&Su ay Code,Seeions 25505,25533, J 25534.1 mautswnd riot Hthe NEW RESIDEN'1'[A],MI!CII I SQ.IT.
building does not cavemly e a tenant,that it is responsibility it)notify the occupant 2�. _ ^v c) Co
of rtyuiamcy mabcn t drn tot a Com,mete of Occupancy.
-levrt2ird agent z Data TOTAL:i IISSUED BY:
OFFICE _ IcaipQ