B 0200 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL R
_ BUILDING PROJECT IDENTIFICATION 'XO 2
.0 0
2
BUILDING ADDRESS: - - SAN[TARY NO. AP(/P/LI'CATION SUHMITTAL GATE
Its V
OW ER' NAME: PHON .f/� C NTRACfOR'S NAME O ^��
N ' N/C CONTROL M
IIT'40 ARCHITECT/F.NGINF. ADDRESS: Oa ❑.
CONTACT: ^7� p f PHONE: B 1NG PE INFO
6 t Tb�✓I a+1 r �8 381-7-IQ G ❑ Consultant Fees Paid by Applicant(Initial) ALD ELE PLUM MECH
W Aloe D9A,1-4*$/ ❑
LICENSED CON'TRACTOR'S DECLARATION - QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOB'DBSCRIPTION
C0Z with Section 7")of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
FOO in full force and eBect ERMIT ISSUANCE
94 3 7 El SPENT, ❑KITCHEN REMODEL
GVzU License Class V Lick pppLIANCLS-RESIDENTIAL. [I ADDITION ❑PLUMBING RE-PIPE
N 6 Wm Date Contractor Q&
RCHITECPS DECLARATION El MULTI-UNIT ❑STRUCTURAL ,
1..7 to PANELS- MODIFICATION
Z pv�'ZZ .' I understand my plans shell he used are
s Public cords
0Z�1q UP TO 2M AMPS El INTERIOR El CHIMNEY REPAIR
art I" Licensed Professional 20140f10AMPS IMPROVEMENT SWIMMING POOLS
W�W�-
g� affirm
OWNER-BUILDER DECLARATION OVER I"AMPS - ❑BATH REMODEWREPAIR El DEMOLITION
a I hereby arm that 1 am exempt from the Contractor's License Law far the
C)d U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
I++LL W y which requires a Permit to consumer,aheq improve,demolish,or repair any structure,
F-,yOQ prior to it,issmince,also requires the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC. ��/
�y" that he is licensed pursuant to the provisions of the Contactors License Law(Chapter 9 (_�_��/jr
�l2 (commencing with Sec0on 7")of Division 3 of the Bitaressanl professions Code)ar TEMP.METER OR POLE INST. - COMMERCIAL:
4 es aa thea he is exempt therefrom and the basis for the alleged exemption.Any violation of []NEW BLDG/ADDITI El DEMOLITION
.tar W 'calm.]031 5 by any applicant for a permit subjects the applicant to a civil penalty of YOWER DEVICES
Yy' not more than five hundred dollars Won), El TENANT FOOD SERVICE
' Q ❑Ctrs owner of the properly,or my employeeswith wages ax their sole compensation,' SWIMMING POOL EL C IMPROVEMENT
will do the work,and lbe structure is not intended oroffered fbrs.le(See.7044,Business ❑OTHER
W and Profesinns Code:The Convector's License Law does not apply to as owner of OUTLETS=SWITCHE. -FI _
properly,who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENT ELECTR IT -
salalf,however,the building or improvement is sold withinere yearnfcomplearn,the SQ.FT.FLOOR AREA $/SQ.Cr.
er-builder will have the burden of proving that he did nm build or improve for par-
poseafsale.).
1,as owner of the property,am exclusively cramming with licensed contractors m TOTA
14
construct the project(Sec.7044,Business and Professions Codep The Contractors Li-
cense Law has not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PE IT FEE
who contracts for such projects with.contmemr(s)licensed pursran to the Contactors
License Lew. PERMIT ISSUANCE
I am exempt under Sec. .R&P C for this reason
Owner Data
ALTER-DRAIN&VENT-WATER(EA) pLCAT WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE 6
one
est will tai under penally to of Cm em ofthe following
or W kne.Cr
Ihave andwlll for
rection 37M of the.Laor Code,
nvark forthe Performance
Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES ECONST ION
cellon,ns video for mi Section 3]00 of the Labor Cade,for the performance of the - t
wort which this permit is issued. FIXTURES-PER TRAP I
have and will maintain Worker'sonceof the
Compensation work
for which
h required by Section
3700 of the Lubar Cale,for the performance oRhe work faprtpwhich this permit i/s issued. GAS-EA.SYSTEM-1 INC.4OUTLETS k OCC GROUP
My Workers rush�sM[s(.St an Y No-aryNWrre l�yp_.Z GAS-EA.SYSTEM-OVER 4(EA). in
J ^M
CERTIFICATE OF EXEMPTION FROM WORKERS'
rets\ GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
ti�don need nmt bo completed ifthepermlUs[or ooehuodred dnllarx(SLOB) GRfiASE TRAP
orless7 N E
I reality that in the performance ofthe%ark forwhich this permit is issued,i shall SF,WER-SANITARY-STORM EA.200 FT.
mucanployanyperson in any manner so as to ecomgsltMcad 10ltp Workers'Cnmpen- /� ENERGY FEE
O ,� satianLaw.ofCali[�ia}tte _ O SSCC77 1SStt WATER HEATER WNENVELECTR CITY Ur '
O Applicant 'Y�ACS— iti^ GRADING PCi:
:Zs Vj NOTICE TO APPLI ANT:IL alter mak g this Cermficnte of Exemption,you WATER SYSTEM/TREATING SOILS FEE
became sobject o the Worker's Confirmation provisions df the Labor Code,yam..all
Wforthwith comply wish such provisior0 or this permit shall be deemedrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT PAID
��� Thereby affirm that there isaconstruction lending agency for the performance of Receiptk '
FNe work for which this permit is Issued(Sec.3097,Civ.C.)
(L Lendera Name TOTAL'.
O LUkI Lenders Address 'TOTAL:
L>r I centry that l have read this application and slate that the,bove information is BUILDING HE
N7 cancer.)agree to comply with all city and county ordinances and suite laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U G building constructions and hereby authorize representatives of Nis city to enter open the
ahwdwincntioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep henmless the City of Cupertino against ELECTRIC FE
liabilities,judgments,costs and expenses which may in any way accme against said CityequegaALTER OR ADD TO MECH. F
in contaminates,of the nging of this permit. ALTER A�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGU 65. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00II CPMZX CONSTRUCTION TAX
Sigoamre of ConmasI., EXHAUST HOOD QVMUCT) HOUSING MITIGATION FEE -
HAZARDOUS MATERIALS DISCLOSURE
Willtheuppllcam,mf re bmldin pant saoreor handle hnzadous mmerial HEATING UNIT 100,"E
as defined by the Cut a.Municin ode Chapter 9.12,and the Health and Safety '
Code,Section 25532(0)7 HEATING UNIT(OVER AW BTU)
❑YesON accm PAID
VENTILATION I'A INGLE RESID) me c ,pt k
Will the applicant or future building occupant use equipment or devices which At
emit hazardous nit conduction ms as it ed by the Bay Area Air Quality Management BOILER-CO (3HP OR 100B IF BTU) TOTA
District? - / BOILER OMP(OVER IW,000 BTU)
Ely- BN
I have read the hisadous materials requirements under Chapter 6.95 of the Cali- AIR ONDITIONER ISSUANCE DATE
//�
fomia Health&Safety Cade,Sections 25505,25533 uud 25534.I understand that if the NEW RESIDENTIAL MECIL SQ.PT .y-
buildingdoesnotcurrentlyhaveamountNatitis y responsibility to notify the circular
of the origin, h stbemetp' eofa Cerifwte of Occupmcy.
Owneroruuahori W n Data TOTAL: ISSUED BY: O
OFFICE