S 00010135 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY l7 otic) / Q1
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL Q
BUILDING PROJECT IDENTIFICATION J
But LDINp ADDRESS: SANITARY N0. APPLICATION'SUBMITTAL DAl
76
QWNER'. NAME'. PHONE: CO R R NA E: IC
/!n q ` N/C CONTROL M
�A RCI 111'E/CTIEN'7Gl[lNEER: LIC NO V ADURF,SS: il. UC ❑
c9 I G ce q Ae (fin COr�tZS
CON'I'ACI'; PHONE: BUIfA1NC PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUM MECH
❑ El ' ❑
LICENSED CONTRACTOR'S DECLARATION Q'jy ELECTRIC PERMIT FEE
C a'Z
1 hereby alfim Ural 1 am licensed under previsions of Cbapmr 9(rummencing JOB DESCRIPTION
with Section 7")of Doemon of the BusinessanJ sCoditmam cna is
0'00 In -PERMIT ISSUANCE RESIDENTIAL:
FW_ full fora and effect. s ❑$FOWL El KITCHEN REMODEL
QUU Liccnse C4 Lie
FQ 4 APPLIANCES-RESIDENTIAL C1 ADDITION 11 PLUMBING RE-PIPE
CTs'e UF,
(it Dam S DE
F,Dm ARCHITECLARATION PANELS [I MULTI-UNIT [I STRUCTURAL
ZOrNZ IunJersland my plans shall be used as public records h10D1E1CAT10N
OZ�-M UP1021gIAMPS ❑INTERIOR El CHIMNEY REPAIR
1a1 hianeW l'ndc sional 261-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION VER1(kMIAMPS ❑BATH REMODEL/REPAIR El DEMOLITION
C Q 1 hereby affirm that I am exempt from the Contractors License Law fm the
yxj 3.U following reason.(Section 1631.5.Business and Professions Cade:Any city or county SI IS ELECTRICAL []OTHER
h which requires a permit m cram odid.alter,imPrmve,demolish,or repair any structure
Fu0 prior to iv,issuance,at-requiressheupplieam basuch pdrannurfileasignial statement SPEC\ CIRCUIT/MISC.
f p- That he in licensed pursuant to the provisions of the Contractors License"is(Chapter 9
(commencing with Section IOW)of Division 3 of the Business and Professions Crde)ter TEMP OR POLE INST. COMMERCIAI:
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any Golanof ElPONEW BLDG/ADDITION ElDEMOLITION
W noI Station10315 by any ii,licam far.permitmbjnpts IM1e appludill ma evil pxnalry of -POWER DEV(
Yl—rn []TENANT C]FOOD SERVICE.
SCnut mon than five hundred dollms 18501st. IMPROVEMENT
(] Lm'uwner n(the proprny,tar nq ennplayces wilM1 wugev.+their vole unnpcnxulinn, SWIMMING POOL :Cl'RIC
wJl Jn IM1e work,vnJ the urve W rc ip nnI intended or offered for said(Sec.11144,Biomass [-]OTHER
¢a] m and Professions Code.'the Contractor's Liccnse law does not apply to an owner of OUTLETS-SWI'TCI{ES TX'IGRES
d'3 property who builds or improves thereon,vnA outdoes.such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL F;LFCT FT.
sale.If.however,the building orimprovenuad isnold within maymmofcomPlcOen,the SQ.IT.FLOOR AREA $/SQ.FT.
ousucoluildmemll have the buMen of proving that he did not build nr improve Ter pot-
,so of sled.
❑1,m srxncr of IM property,am<edu+ivdy cmntraning wish licenced commnors to TOTAL:
omwasheesonot
(Sec.lata.Business.ad Professions Code:)The thereon,
and
nu Lawddesr suchapply man ith a carame ny who
sedpds orlmprothethereon.and QTY. PLUMBING PERMIT
wM10 contracts for such projma with a armmcmrrivl licensed pursuant m the Commnor's
License Law. PERMIT ISSUANCE
El I am exempt under Sec. .B&P C for Thi,reason
Owner
ALTER-DRAIN ft VI:N'I'-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO EC'K DEVICE /-�/�
1 hereby affirm under penalty of perjury one of the fallowing declarations: 5(/t_J.
]l havcand will maintain.Certitictne of Consent to self-insure for Worker's Compere DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTIOI
Bion,as provided for by Section 3700 of the Ltxn Cale.for the Performance of the \
work for which this permit is issued. FIXTURES-PER TRAP
Q11 have and will maintain Worker's Compensation Insurance,as required by Section
3101 of the Labor Cod,.for the performance ofthe work for whichthis permit' issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP /JAPN
My Carrier: T+ t*
Carrier:
imm,,and Policy
� GAS-EA.SYSTEM-OVER4(EA) L a/C_'
777%(UJCEERfIFFIIC11AI EEXX017 EXEMPTION FROM WORKERS' J
COMPENSM ION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(lhi+saaion need not W roo,l®W if the pe...if is fur one hundred dollars($100) BUILDING DIVISION FEES
m le"') GREASE TRA(' PLANC KP[E
I certify lhm in thcperliamnncc nl Wewurkfnr which this Pcrmil i..+'issual.l slmll SEWER-SANI'fARV-STORM EA.2W FT.
nm employ troy pawn in any manner su vs,,hecomc.subjem n the Wnrkerd Comlxn- ENERGY FF,
Z nation laws of Californ.Date
Z - WATER HEATER WNLNT/ELECfR
Z Q Applicant GRADING FEE
NNOTICE
TO APPLICANT:If.atom making this Certificate of Exemption,you should WATER SYSTF.M/fREATING
become subject to she Workers Compensation pmv\stens of the labor Calc,you must SOILS FEE
� forthwith comply wish such provision or this permit shall be deemed revoked WATER SERVICE
c.
U Z CONSTRUCTION continuation
AGENCY NEW RESIDENTIAL PLAIB. SQ,FT. PAID
U Q I hor which thi that there i+s ed(See 30 len ding agency for the lrrdnrmance of Dam Receiptp
ry f' the work for which this permit is issued(Sec,3091,Civ.C)
C) U Lrndrrs Name TOTAL:
Lcndar's Addrasa 'TOTAL:
FG 1 anify the,1 how rad this upplicatinn and state thin the above infornmtlon is BUILDING FEB
Tit "meat.I."w'. reply with all city and coumy ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U Z building construction.and hcmhv umhorec repreFE
ccntativesofthis city former upon the SEISMIC E
above-memioncd property for inspcnion purposes. PERMIT ISSUANCE
agree Io save,indemnify and kap bareness the City of Cupcnino against ELECTRIC FEE
Iiahiliucs,judgmeno.costs and expenses which may in anv way accrue against said Cay ALTERORADDTOMECH.
in constipate..addle graming of this pearl PLUMBING FEE
APPLICANT U D RSLANDS AND WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT ITO 10660 CFM)
SOURCE REG .�+ IONS. MECHANICAL FEE
0/_1e� QD AIR HANDLING UNIT(OVER 16,M)CFM) CONSTRUCTION TAX
Sipnuturc of Ap ,or Date EXHAUST GOOD(W/DUCT)
a IA' DOUS xdXpH dIALS DISCLOSURE HOUSING MITIGATION EFF:
Wdl Ihearpplicam eT found building oscupanl store or handle humrdaus mmeriul HEATING UNI I'G 0101.0(d BTU)
as daft nc I by the Cupertino Municipal Cale.Chapter 9_1 2,sad the Health and Saba,
Calc,Section 25532(.)1 HEATING UNIT(OVER 100.00)BI U)
El Yes VENTILATION FAN(SINGLE RE5ID) PAID
Data Reeci"#
Will rhe apP onto em future building by the B tau ea Air a or devices which BOILER-COMP LOW OR I W.600 BTU)
iI ha aNnus air contaminants as defined try IM1<Bay Area Air Qualify Mawganens TOTAL
+Ira 11
❑Yes 1)b No BOILER-COMP(OVER 100.000 BTU) O e
I have read the hazardous nemedaBrequiremenu under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Ream. ram Svfefy Gide.Semmes 25511.5,2.5533 and 25534.1 understand shut if the NEW RESIDENTIAL MI CH. SQ.FT.
bulldinednr n entfy have a moans that It is my resprombility to unity the occupant
of the nc urwhieM1 must M+nun prionaissuunce nfa CeriOaleuf Oump: 'y,
Owner nr doth rd ge Dom TOTAL: ISSED BY:L/.
�reg
OFFICE