S 2801 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLIIMiiING-MECHANICAL C O O
ItUILDINO o
PROJECT IDENTIFICATION J
BUILDING ADDRESS: O I O e SANITARY NO. FAPPLICATIONSUDMITTAI.DATE
OWNERS NAME: 1 IIfJN4' J C( l CJ'QR'SN i ^ IJ�N(' �N1
(•I Y/^/ 333yyy 1Lii /I rn�71`/ii!F�—J J NIC CONTROL#
ARCHI'IECI'IENGINf:ER: TIC NO: -776CC[ES�/Ny(•(,t '( ^ �� ❑
CONTACT: PHONE BUILDING PERMITUSED
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
g G)1Z ❑. ❑ ltl-
DECLARAfION QTY ELECT'RIC PERMIT FEE
wih S1 herchy affirm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z tection 7")of Division 3 attire Businessand Professions Csdc,and an,license is RR IDF$_FNTIAL_
00 feBe Class
epee PERMITISSUANCE
m• in p�eJ/X J� ❑ADITI ❑KITCHEN
FQUU License Claes (lam, KKyy Lic.# _?f) AI'PLIANCFS-R[SIUENT'IAL OADDITION ❑PLUMBING RE-PIPE
N Q L Date—Com.11.1
ARCHITECT'S DECLARAI'10 ❑MUUH.UNIT ❑STRUCTURAL
Z O Z I unJatxumd my plans nhull be anent ns public recordsPANELS MODIFICATION
oz—0
7,—Q UP'TO200 AMPS [I INTERIOR [I CHIMNEY REPAIR
F-4E-al Elwood Prnl'ex"amvl C 201-100AMPS IMPROVEMENT E]SWIMMING POOLS
9 Y ; OWNER BUILDER DECLARATION OVER I001AMP5 [1 BATH REMODEL REPAIR 0 DEMOLI TION
Q 1 hereby u1Fna that 1 am exempt from the Cn dhacmr's Llannsn Law far the
sX 3 y F following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
F^O m which requires a Ir_rnat m construct, t1mr,Improve,demolish,or repair any smsmre
primo,itsissuance,also requires thevpplicant for such platinum file a signed statement SPECIAL CIRCUITIMISC.
r�t� that he
(commencing
oda Srction7 the provision of the eBusinss and
Proelaw(Chopter9 COMMERCIAL:
A. O the,he is Osawilh Sections ad ofDivision ssf3 tit he Business andon.An,
lmom I TEMP.MITER ON NILE INST.
A.y o y that he is exempt zany applicant
ran anJ the cis for the alleged exemption.Any vlNminn of ❑TEN BLDG/ADDITION ❑DEMOLITION
i� {+• Section 717131.5 by any icvnars($5 emiit suhjems the applicant tovcivil lrenalry of I'OWIiN DEVICES _ ❑TENANT ❑FOODSERVICE
y} not momwne fveh po,c y.or yirop. IMPROVEMENT
Q ❑ I,ns owner of the prnryny,or my enmluyces with wages as their sole compensation, SWIMMING POOL ELECT RIC
FO will do the work,and the stmcture is not intended oroffcred for sale(Sri.76 ,Business ❑OTHER
a3ro and Professions Code:The Contractor's License law does non apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves themnn and who does such work himself or through
his awr unpinyecs,pooti,lcd that such impmvaments arc not intended or offered for NEW RESIDENTIAL ELECT R SEEr
Bale.IL however,the building or improvement is sold within one year of completion.the FT.FLOOR AREA
1 �wns,h older will Mac the burden of proving that he did nal build or improve for pur-
9sc of sole), 11
I,as owner of the property, at exclusively common.,with licensed contrnmors m *1'OTAI: (/ Z
construct the project(See,7044,Business and Professions Csdea The Contractors Lb [!/�
cause law does not apply to an owner of property wha builds or improves thereon.and QTY. PLUMBING PERMIT FEF.
who contracts for such projects with v contractors)licensed pursuant at the Commemea
License law. PERMIT ISSUANCE
am exempt kinder Sec. .11&PC forthis reason
Owner Dom ALTER-DRAIN&VENT'-WATER IEA) VALUATION
0 WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby nffmn under penult,of perjury one of the following denlmmion
❑l have and will maintain a Cerificacof Conant to self-insure for Workers Compen- DRAINS-FLOOR,ROOK.AREA,GOND. 5 ] S TYPECONSTRUCTION
nation,as provided for by Section 3]01 of the[.shot Code,for the performance of the
91,for which this perou is issued. FIXTURES-PER TRAP
1 hove and will maintmo Workers Compero out Imurance,It,required by Scetiom
371X1 nfthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS (>C UP APN
My WarCnr9pensat�i {J��Jd rrieranJ Pollcyn nb /�y�g/�X GAS-EA.SYSTEM-OVER 4(EA)
Cartie� •{,�jacc_Pnlicy Nn.�� X/�
C[NTIFIC OMPE SATION1I INSURANCE
WORKERS' GRFAMUINDUSTRL WASTE INTERCEPT COMPENSATIONINSURANCE RBY ILDING DIVISION plias
p'bi,wetionnrebnmb completedif Rep iiiiisloronehundre dnllan($1(X) GR1EASETRAP
kir leas) PLANCHECK PEE
I certify that in Ne performance ofthe work for which this penton is issued,I shell SEWER-SAN]pARY-STORM HA.200 FT.
nm employ any person in any manner m ns to become supiect to the Worlacm Cumpen- ENERGY PEE
O z ,anon laws of C.ffomia.Date WATER HEATER WNEN'I'/ELECTR GRADING FEE
O Applicant
rj1 NOTICE TO APPLICANT:IL after making this Certificate at Exemption,you should WATER SYS]EMODUR PING SOILS FEE
[-t '••t became object m flue Worker's Compensation pro,kion of the Labor Gnle,you moa
forthwith comply with such provisions or this Permit.shall he deemed revoked WATER SERVICE
Q
UO CONSTRUCTIONLENDlNGAGENCY NEW RESIDENTIALPLMB. SQ,FT. PAID
I hereby affirm that theree isisacecomwction lending agency for the loerfnrmmnee of Tat Receipt#
[L p•t the work for which this permit Is issued(Sec.309'7,Civ.C.)
O U Lenders Name
TOTAL,r LU Leader,Adilms, TOTAL:
1 certify that I have real this epplicmion and sate Dat the eMwe inlomtation is Fli
�s t,II correct.1 agree to comply with all city and county onlirawas and state laws relating in QTY. MECHANICAL PERMIT
U z building concoction,and hereby authorize representatives of city to enter upon the P
above-mentioned property for inspection purposes. PCNMI'C ISSl1ANCE(We).gree m save,indemnify and keep harless the City of Cuertino against FEElivbiliam,taigmties cr cos and expenses which may In any way accrue against avid City ALTER OR ADD'1'O MEiCILin consequence of the granting of this permit. SEEAPPLICAN'IONPERS'I AN US A NO WILL COM PIR WITH ALL NON-POINT AIR HANDLING ON[T(TO 10,0X0 CFM) ICAU 'ESOURCIi RF.GGLATIONS ' 1-k4aAIR HANDLING UNIT(OVER ItI,(KKI CFM) UCI'ION TAXSignaS�ppu n r actor Datc EXHAUSTHOOD(W/DUCT) MITIGATION FEEHAZARDOUS MATERIA DISCLOSURE
Will the applicant or future building occupant store or handle lineations material HEATING UNIT(TO 11X1,000 BTU)as defined by the Cupertino Municipal Cede,Chapter 9.12,end the Health and Safety
Coda,Section 25532pd? HIiATINGUNIT IOVEIt IW,Op BTU)
❑Yes [3RR VI?NTILATIDNFAN(SINGLERI?SID) Dom Reccipt#
. Will the applicant or Mme building occupant use equipment or dr,wc,which BOILER (3HP OR HOME BTU)
emir h irminus air cmmamim tints as retired by the Bay A.Air Quality Mvnagemenl 'TOTAL:19
Dlatdet? BOIL17R-COMP(OVEN 100.0 Xl BI U) /�
❑Yes 9;44, V
I baso read the hmatious materials rcquiremem,under Chapter 6.95 of the Cali- AIN CONDITIONER 41 ISSUANCE DATE
Gonia Ilcvllh&Safety Code.Sections 25505.25533 and 25534.1 understand that if the NEW R17S HotNI IAL MECIL SQ.KC.
hooddlmgdo<,v not currently h.seat mnvnI that it is my resPmsibility to notify the orcupont
of the iri[nls wInchm s inti poi to issuance ofa Ccnifica if(%ap c
Do., i vuthonac agent / Date T ISSUEDBY:
OFFICE