S 0702 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Run,DING-ELECT RICA], PB \11T NO,
BUILDING.DIVISION APPLICATION/PFRNIIT PLUSIBING MECHANICAL � 0702
BUILDING ADDRESS
Gf r � ' BUILDING
DING PbROIFCT IDENTIFICATION
SANI'I'ANY NO. APPLI
CATION SUHM
TTAIOATI
OGMPHONE. CONTHAIOS NAMELIC OHS NAi1
Z44-7 NIC CON'Ro1.if
ARCHITE(7HE GINEE1L LIC NOADDRESSPi
❑
G f�
CONTACT PQHONE:'t( BUILDING PERNIITINFO
✓-9✓- / 7/� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEGA
❑ ❑ ❑
LICENSED CON HAC'IORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am E«need ander pervi.inn.of Cn.per 9 Uonammcing JOB DESCRIPTION
,0Z IhS«tion'700i Division3ofthe Businenand Pmfcs.ino'Cde.andnty licenscis RESIDENTIAL
FW- wtfullformunJ< L PERMIT ISSUANCE
WU~ License Clea 9 r L. �� ❑SFDWI. ❑KITCHIiN RfiMODliI,
<-U APPLIANCES-RESIDENTIAL ❑ADD]T]ON ❑PLUMBING RE-PIPE
6,<,t Dmc �--Cantrvnor
Om ARCHITECTS D[CLA AI'IO PANELS ❑MUI TI-UNIT [I STRUCTURAL
z O1,7,-, I understand toy plan•shall he used as public records MODIFICATION
oz-- UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licenwd Profmsloml 201-1001 AMPS IMPROVEMENT (]SWIMMING POOLS
CY C
OWNER BUILDER DECLARATION OV17R IOW AMPS ❑HAI H REMODEL/REPAIR [-1 DEMOLITION
Y Q 1 hereby union that 1 am exempt from the Contractor's License Law for the J
C,pmV El OTHER fa4.�e- -{ru/.rl.<.,
X 3 a fallowing reason.(Section 0031.5.Business and Ymfesions Cede Any city or county SIGNS ELECTRICAL
W la,h which requites a permit as mmeract,alcor,improve,demolish.or repair any structure
L C< prior tors issuance also requires the applicamfor such Permit to file a signed statement SPECIAL CLRCUIT/MISC.
7t2 that he is licemd parxaant to the m-mom ofthe Conloaclors Liecrac Lew(Clattery
l+'='00 (commencingwith Section 01)00,fDivision 3 oftc nBuonewand Profcvalns Gddor (PMP.METER OR POLE INS', 'R I
a a e W that he is exempt therel n..and the basis fm the alleged--spoon Any violation of ❑NEW HLDO/ADDITION ❑DEMOLITION
m W Section"/031.5 by any applicant hr a permit subjects the applicant to u civil pemhy of 141WIiH DEVICES ICES
F 7,} a momthin rive hundred dollors(35W). �iIN';Nu(�Lra/� p� .,QyIiQD S1iRVICIi
Q ❑ L as owner of the prnpeny.or my employees with wager as their sole compensation, SWI MMI NO POOL ELCCTH IC Mal
'{s/ILYpD
will do the work.and the structure is not intended m olTecd for sale(Sm.1(WCl
,Business OTIifiR
W_m and Parfeaon
i %Crdrvct
e:*Me Comor,Licen « mn
m Law dn not apply an vai ,of DO'H-LTS-SWITCHES-FIXTUREiS d the [ll• r .,
a 3- perfectly who builds or improve,thereon,and who)Jens such work himself or hmugh 111
his own employee,,providesuch impmvcmaa,um not intended or offered for NEW RESIDENTIAL ELECT "Q FT. �-�
tole lfhowaeethchnildingorimpmvcmentissold within one year or completion.the SQ.PI'.I1.00R AREA 5/SQ.II'.
row e,haildcr will have the burden of proving mat ha ds not(vim or improve fia par-
, pa°cafsalc.l. P M
• 1
-1L,as owner of he property,am axeloo,wely nmirnning wan Bwneed contractors to TOTAL'' y
con,wet the project(Seo](43,Business and Profn,sion%Gds)The Contractor's Li- DC
cnw Law toes not apply to an owner of property who build%or imPmaves thereon.and QTy. PLUMBING PERMIT FE /�
who contracts for such pmjecu with aeonaaror(s)licamd poru
uano the Contractor'% CV �[•A
Lic° reason
Law. PERMIT ISSUANCE, /s17 inn
I am exempt under Sec. .B A P C far this ALTER-DRAIN&VE'N'T-WA [U) C17'fPR[
) !"[�r 1[uATfUN
Owntr Dae
WOIIKEWS COMPENSATION DECLARATION HACK FLOW PROTCCT.DEVICE
1 hereby allirnt under Penalty of perjury one ol'tbo following declarations R-
F7Have and will meanuiraCertlficateofConsent owlf-inure for Worker's Com,ser- DRAINS-FLOOR,ROOF.AREA.COND. STORIES 'TYPE CONSTRUC'il(lN
Ption,as pruvidcd for by Section 3700 of the Labor Code,for the Nifirroan«of the
far which this permit is nota d, FIXTURES-PER TRAP
have and will maintain Workers Co e,an-tion Imumnce,e,required by Section
of the Libor Calc,for the perforranneof the work fur which his permit is iswed. GAS-EA,SYSTEJ.1-I INC.q OUTLETS OCC.GROUP APN
My Wodcrx CnmP< tion lnwm ce carticr anA Policy numlur art
III Carticc f O��• n /.n:/ Policy Nn.: � �- n -
GAS-EA.SYSTEM OVER 311 \I
COMPENSATION INSURANCE GRiAS%INUUSTRI.
WASTE IN'L'EHCIiVTOH
-BUILDING DI V IMf1N i'IiES
('Reis section need not lncompleed iftMpernttt I%hrore hundred dull..'ISIIM)) GNI:ASPTRAP
nr
R-)(This
Il
?8
Icerifyrhat intbe Ninsome,cofbe week fanwhich thin Permittsiaaed.[,hall SEWER-SANITARY-STORM CA.2W FT.
not employ any panni in any manner so as to became subject to the Workers'Com,an. ENERGY PEI;
Z ,Z -tion Iowa of California.Date WATER HEATER WNENr?LECTR
Q Applicant 1 GRADING ill
!n NOTICE TO APPLICANT:If,after making this Cerifirnm of Eaempaon,you should W'AI FR SYSTEM/TRIiA'TINC, Soil's FEE
ahecm soWake,',onhbal ,,the Woer's Compeow0on provisions of the Lubar Code,you roust
W t'orhwih comply with such previsions art this xeronr shall he droned revoked. WAI HR SERVICE
a0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLK111. SQ,FT. PAID
7 C) I hereby ohm m
rthat there is a coraction lending agency ria pe
the rfarmunce of Date Receipt
U O the weak for which this permit is issued(Sec 319].Civ.CJ
C) E-' Lenders Name
TOTAL
V lender's Adams% TOTAL:
r a I ecrify that 1 have mad tris application and ewta that the alsoc information is BUILDING Il?F
h correct.1 agree to comply with all city rmd County adinaaces and state laws relating Ire (yl Y. MECHANICAL,PERMIT PEE
U Z huilding mnvlmctian,unIII hereby authori'rercpr'cwnmtivmaf his city to enter upon the SEISM If,FEE
.hove-mentioned property for into mpurpows' 1',RMI'I'ISSUANCC
(We)agree tnaa-,indummfy and keep hannles,the Cil,of Cupertino against ELECTRIC I E13
liabilities.judgmenls.cosla andexpenses which may in any way accrue against said City ALA ER OR ADD TO MECH.
in consequence of he granting or his Permit. PLUMBING FEE
APPLICANT UND17RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(L(0171 CFM)
MECI{ANIGI.PF.E
SOURCE REGULATIONS.
AIN HANDLING UNIT(OVER 10,000 CF.N) CONSTRUCTION TAX
Signature of ApplicunUConwctor Unto EXHAUST HOOD(W/DUCT) HOUSING MI'I GATLON T17,
IIA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingaauptnt stom or handle hound mumfi.l HEATING UNIT(TO 100.06)B'I'UI
as defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety _
Code.Section 25532(.)1 HEATING UNIT(OVER 100,010 HTU)
C]Yes nN. VENTILATION FAN(SINGLE RESID) PAID Due Receipt Jo
W II the applicant or rum a building«che Fl use equipment or Mann ement
"`it M1vuMmus air nmmminrmta as dcfinal by lM Bay Arca Air Quality Management BOILER-COA1P LHP OR I(XI,IMMI BTU)
Zoll I TOI'Al�
❑Yec Fl No
BOILER-COMPfOVB:N 100 UII(11{l'UI
I have mad the luiardom%material, oder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCF DKTE
requirements ane p
Ramis Huhn 6e Safety tly ha have
25505,2553)and 25533.1 to)notify the
that if the NEW RESIDENTIAL MECH.
building a«a not currently have a-nam.tnaaf N my mamn,inairy as notify me«eapnm
of the umems which mast rte met Prim to iweam<of a Ca ificate of Occaptncy.
(l n ramhneireJ ub'cnl Y� -1 m TOTAL: ISSUI3D BY:
OFFICE