00010069 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O I UQ
CITY OF CUPERTINO' BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
.'BUILDING PROJECI`IDENTIFICATION
•,."'7 J,i s� •
BUILDING ADDRESS SANITARY NO. APPLICATIONS RMITTAL DATE
6C>02 7Dic Auza L /-
OW RS NAME
PHONE - �ooo
I4AZIp
CONTRACTORS NAME
RI . 88
NIC CONTROL#I� AM�GK WWAI � .
.HITECf/ENGINEER: LICNO. ADDRESS LiArnsS cKAo �3( z'1 Z4 S. 5rocrcrvkJ9`6 Logl 61
CONTACT: '� f�tpp PHONE: C•7_f +�jij�rj }-•BUILDING PERMIT INFO "l;'
�'� �fel••�/O 2 d GS Z-v J�I ❑ Consultant Fees Paid by Applicant(Initial) BLDG BLECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION "-} - -- s"'-t) S -•si 1 § yi'
❑ ❑ ❑
QTY . I ELF.CTRIUPERMIT. I t r FEB °r•
Ihereby affirm that 1am licensedunderp ofChapterhvxmr9(commsais ' 'ill- - ., td I . ts - . "s -t Fiftp JOB DESCRIPTION
OCy with Section 90efofDivision i of the Business and Profess ons Cale,ane my licenses
SCO PERMIT ISSUANCE, RESIDENTIAL:
F infullforce inti eHecl /�
�U U License Cue Lia# �� a ❑SFDWL ❑PKIT LUMBING
REMODEL
F�W Uate 1�1� U� Contractor APPLIANCES-RESIDEIJTIAL El ADDITION ❑PLUMBING RE-PIPE.
F
N ARCHITECT [_1El'S DECLARATION PANELS MULTI-UNIT STRUCTURAL
N.`l.
� z0 Z Iundentand my plans shallhaverts public records MODIFICATION
OZ-O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fs.'�bI m Licensed Pmfessiunal 201-1000AMPS IMPROVEMENT
❑xR q OWNER-BUILDBR DECLARATION ❑SWIMMING POOLS
W Q 1 hereby afforded 1 am exempt fns.the Continuum's License Law for rhe OVER IU00 AMPS ❑BATH REMODEL REPAIR ❑DEMOLITION
O y U following reason.(Section 9031.5,Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑OTHER
whmb requires a{ eanit In coons the,aIle[,improve,demolish,or repair any.Wclure"'-,�1 y0y edentula Lsuance,ulna requireethe applicemfor such perminn file aligned stntemem SPECIAL CIRCUIT/MISC.
eel —1 jffe�
p.r that he it licmaedpursunum theprovisions umbo Cortisone,License Law(Chapter 9
00 (emannoeing with Section V000)af Division 3 of he Business and Profession,Code)., I EMP METER OR POLE INST. COMMERCIAL:
pacat� that he Is exempt therefrom and the basis for the alleged exemption.Any viclmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant fora permit sublaDdie applicant loo civil penalty of POWER DEVICES
not more than five hundred dollars($500),
❑TENANT ❑FOODSERVICE
�a0 ❑ 1,as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
a, will do the work,and the slrvemre is not intended or offered for sale(Sec.]0,14,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. properly who builds or improves theram,and who does such work himself or through
his own employees,provided Ihal euch improvement,arc not intended or offered for NEW RESIDENTIAL HLECTR SO Fr.
sale,If.however,the building or improvement is sold within one year of completion,the SQ.Fr.FLOOR AREA 8/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
paee of sale.)
0 1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
onstruct the p Jeer(Sri.9044 fdainew,and Professions Codi The Contractor It-
carte
. .
carte Lax does not apply to fp pony h b'Id or improves menton and QTyil, t PI,gMgRGtP RMITr t 1 .1 #`j P.EB rityyl
who contracts for such p jct.vwith acontretr(s)licensed pursuant to the Contractors .I
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,H&P C for reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Dale VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of rhe following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-whFLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
.,tion,as provided for by Section 3900 of du Labor Cade,for the performance of the
work for ich th,scrod is issued. FIXTURES-PER TRAP
❑ I have sad will maimaln Worker's Compumarear Insurance,i s requited by Section
3700 of the Labor Code,for the performance orthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GROUP / yprj
My Workers Campwsetlon Insurance turnaround Policy number are:
Carrier: Polley Na.: CAS-EA.SYSTEM-OVER 4(EA) O
CERTIFICATE OF COMPENSATION
INS FROM WORKERS'
COMPENSATION INSURANCE CRGSEIINDUSTRI.WASTE INTERCEPTOR
(This section need not becomplead Hine permit is foroune hundred dollars Dffff ,'$ Bun.oiNGpIti+151tiN�EBS'.. A#
or loss) GREASE TRAP PLANCHECK PSE
1 certify Rod in theparmormnce of the work for which this permit is issued,],hall
not employ any person in any manner so as to become subject to the Worker,2Compen- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
O sZ cation Law,of Cabfomia.Data WATER HEATER W/VENT/F.LECPR
O Applicant GRADING FEE
72 NOTICE TO APPLICANT If,after tnnking this Certmemo of Exemption,you should WATER SYSTP.MR'REATING
became subject to the Worker,Compensation provisions of the Labor Code,you must SOILS FEE �•�.•s"`� �..
((WYQ forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
I � z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I PUSH. SQ.Ff. PAID I hereby affirm thai is aamstriation lendln,,eency lar thepedbrremeeof Dlea� Rair\ l
Uwork which this permit is issued(See.3119),Civ,CJ
Lende
Q Leede N AL:
W Londe Add TOTAL
' ' representatives
.. +
likm
_ t
LL I cert fy that I h d th pp1 cal on and state that theabove automotive" AE6 r.
st
B DIN
G
f/ correct 1B t comply with all city d county t d state l relatingt
Z huildmgconstruction, dhereby amhtp t t sof thiscity to tuponnto ECIANC
AL
IF SEI CFE
E
PERMIT ISSUANCE C(✓) g t .ered fy ilkeep harmle. theFE
Cnyolcu
E
iebiliiesjudgmern cost and expenses which may in any waycememity
in consequence of the gmuang of this permit ALTER ORADD TOMECHPLUMB FEE—
�i�•
APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,000 CFM)
SOU sREGULXRONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
Sigaamre of ApplizahlAbmituarlo, Dam EXHAUST HOOD(W)DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occepant store or handle hamorkas material HEATI NO UNIT ORD 100,000 BTU)
as definal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)4 - HEATING UNIT(OVER 100,000 BTI!)
❑Yes ON.
VENTILATION PAN(SINGL[RE51D) PAID
Will thea Ream or future brilli n t use a ui l or devices which Data Receipt#
mil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
mumu[ BOILER-COME(OVER 100,000 BTI)) TOTAL:
❑Yea E]No
iheve rend the hazardous materials mquon onsc under Chapter 6.95 of rhe Cali- AIR CONDITIONER ISSUANCE DATE
forme Health&Safety Cade,Sections 25505,25533 and 25534.I undemwnd in.,if the NEW RESIDENTIAL MECH. SQ.EL
building does not currently have a tenant, it is my responsibility to notify the occupant
of the requirements which most be met fine to ismauea of a Cenifiene of Occupancy.
Owner.,authorized agent Dam TOTAL: ( �`l
ISSUED BY:
OFFICE