B 0623 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 6062,3 PERMIT NO. n n
BUIEDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL. SOOO1
]BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: .-/-f�^� ✓r ��� � ��Q'� SANITARY NO. A/PP/L�IJCATION SUBMiTFAL DAI
OWN- 'S NAME: oV L
PHONE: CO ACTOR'S NAME: LIC N/O', v ^Z
k 2 6-' a (. ya'd N6 N/C CONTROL«
IW\RCHITECT/E ,INFER: LIC NO: ADDDDRESS. Alit ❑
J
CONTACT 1) t,. ,� ( PHONE: BUI LDING PERMIT INFO
311 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MGCH
❑ ❑ ❑
LICENSE)CONI FACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby olfirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WonC=z with Senion]00)nl Divdsinn3ofthe Rosiness and ltafessiom Coda vnd my license ds RESIDENTIAL;
Ili O O PERMIT ISSUANCE
FWW F in lull I'nme and caret /iO A5/ ❑SFDWL ❑KITCHEN REMODEL
a_U Lscnsc Clas — Lic.p `-L y ,10 APPLIANCES-RESIDE.NT'IAL El ADDITION ❑PLUMBING RE-PIPE
N¢i Dam comm . T
g.Om ARCHIT'ECT'S DECLARATION —� PANE" ❑MULTI-UNIT ❑STRUCTURAL.
m Z I understand my plans shall be used as public records MODIFICATION
OZ—CI UP*r02WAMPS [I INTERIOR ajo CHIMNEY REPAIR
on
Fu: Licensed Pndessimal 201-1"AMPS IMPROVEMENT [3 SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(KK)AMPS ❑BATH REMODEL(REPAIR ❑DEMOLITION
IX IY G 1 hereby affirm that I am exempt from the Conlmemr'.s License Law for the
4 0 6 U fallowin Section]031.5.Business and Profmuions Code:An I a ❑(TfHlik
X 3 g rtnson,1, y ci y or county SIGNS ELECTRICAL.
W a he which requires a permit to conswet,a[mr,improve,demolish,or repair any so-uemm
oc Prior vRa issuance,al no requires the applicant fnrsuchpenniuo free aeigned Namorcal SPECIAL CIRCUIT/MISC.
F } that he is licensed pursuantto the provisions of the Contractors License law(Chapter9
WIYMC (commencing with Section Division 3 of the Business and Professions Cartel or TEMP METER OR POLE I ' Of COMMERCIAL:
'A.a e C that he is istau a therefmor and the basis fnr the alleged nxentpaian.Any violation al' ❑NEW BLDG/ADDITION -1 DEMOLITION
19
Section 7031.5 by ua,.p,licanlfor.permixtibjects the applicant mt civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
not mac than five hundred dollars(550).
Fes} SWIMMING 100 ELECTRIC IMPROVEMENT
x6 Q Lux owner of the property,nr my employees with wu8es as their vole mmprnsminn,
W E.O will Bothe walk,and the swctum is not intended oroffemd for xale(Sec.]M4.Puniness El OTHER
1041 ce and Pudessair,Corr:The Contmemr's License Law does not apply man owner of OU'r1mS-S TCHES-FIXTURCS
prolrny who hands or improves action,and who dors such work hiinselfor through
his own employees.provided that such improvements are not intended nor offered for NEW R ENTIAL ELFCIB SOFT
sale.If.however,the building or improvemenl'c ovid within one year of ianunction the S(�.IT FI c)O$,BBIiL... .ET.
owns 1buiWcr will have ace burden of proving that he did not build or Improve for pur-
�
post of sale.l L/�''`�
1,as net of act pmpcny,am exclusively contmeling with licensed convadors m 1 OTAL I D
mgmd the proms,(Sec.]IWt,Business and Professions Codc:)The Comdcmr's Li-
c Law does ma apply to an owner ofproperty who baildsorimproot, rem,and Y. PLUMBING PERMIT FEE I JUN 2 3 199
who enlracd fatsuch...japeswithaeonarauunls)licensed pursuant mahe Commatoe,
License Law. PERMIT ISSUANCE J
of arta exempt under Sec. B&P C for this reason OO]
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE fLy .
' Ilumby affirm under penal,of pe jmyane of the fnllnwiny declarations;
I have and will mandarin a Cenifcam of Consent mself-insure for Workers Comped DRAINS-FLOOR.ROOF AREA,COND.
sation,ax provided fnr by Section 3700 time laMr Code,for the performance of the STORIES TYPF;CO(((RST'RUCf
work fin which this moo is issued. FIXTURES-PER TRAP
(�s I have and will maintain Worker's Compensation Insurance.as required by Section v
l]aNl of the Lahr Crxla fUnMperfimnance tl IM1e work for whichthis perrrul iv is sae J. GAS-EA.SYSTEM-IINCAOIT.. S OCC,GROUP CYN20
MyWork�rsy Gr�pcnsaion ns Cartier and Pn-?,——�/• �l
My Wo: .91issF� n PalicY Nn; GAS-EA.SYSTEM OVER i 1 f//
CERI'11ICAT17 OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE �``N k ,,II GREASVINDUSTRL WAST M'BRCEPIUR
(Thi%section need not be completed if the permit is(mane hundred doljrlTi/11 BUILDING DIVISION FEES
te Icu.l GREASE TRAP PIANCHECK FEE
leertilythat othe performance ofthe work forwhichthx,scrmitisissucl.I shall SEWER-SANITAR -STORM IA.20FT.
not employ any person in any mortician as to become subject acthe Workers Campen- ENERGY FEE
zZ sation Lawx of California.Dote WATI7R HEAI'B /VENT/IJ,ECIR
O Applicant t GRADING FEE
rN-r
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS EMRRIATING
become abject or the Worker's Compunsauon provt ism of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions mid.,permixiedl bedeemcd revoked. WATT RVICE
Q
.ati. z CONSere is.'IONLENDINGAGENCY N+ RE5IUENTIAL VLMB. SQ,FT PAID
Thor whicfinn lhathcre isac.d(See 30 lending agency for the performance of Oat r p
W O the work for which this permit is Tested(Sec.JO],Civ.CJ
Lenders None TOTAL:
V Lender's Address TOTAL:
Fy 1 ramify that I have read this m+plimuna and mate that the above infnnnation is BUILDING I ITE
W ommil.Ial aro comply with all city and county ordinances and same lawsreladngm QTY, MECHANICAL PERMIT FEE
V z buildingeomwnion,and hereby authome repmsemmives of miuiry yr enol upon the SEISMIC PER O
atiom continued pro, for inspection purposes.
(We)agree to save,indemnify and keep hmmlcas the City of Cupertino againm PERMI'!ISSUANCE ELECTRIC PEE
liabilities.judgments.costs and expenses which may in any way accrue against said City tsALTERORADDTOMECH.
cqutae of the grarau,of this permil. PLUMBING d3E
APPLICANTLINGERS ANDS AND WIL COMPLY wirHALLNON-POINT AIR HANDLING UNIT(TO I0.d00 CFM)
A1ECHANICAL F,E
SOURCE REGULfffN S.
AIR HANDLING UNIT(OVER IO.INt M) CONSTRUCTION TAX
Si'arnmemmp iem ICommctor am EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE.
I IAPARUOUS MATERIALS DIS OSURF.
Will the applicum or(mud building occupant mon handle hvardous material HEATING UNIT(TO 10, TU)
as defined by the Cupertino Municipal Csxlc.Chapter 9,1 ,and the Hcalth and Safety
Code.Section 25532(a)I HEATING UNIT(OVP I(NIdll BTU)DY, bNn PAID
VENTILATION F (SINGLE RBSIDI Will the applicant or future building worepant um tyuipment or devices which Dam Receipt a
mit hallus air contaminants as defined by the Bay Area Air Quality Management BOILER-C P(3HI'OR 101000 BTU)
Di.ont,I TOFAL:
❑Ycs 10NoHOILU 4COMP(OV ER 10,00 BTU)
l have read the huwnlous mmcrialsmi,mm�ntnm under Chu mrl05 of the Cali- AIR ONDI'I IONIUt
4 p ISSUANCE DATE
forno Health&Skil Code,Section%25505,25533 and 25534.1 understand that if the W RESIDENTIAL NIECE. SQ.ET.
building docs not currently have ancient.that it is my resro,ibility to notify rhe occupant ''''C^� J.— Q
of 11,mat ..... which mast be a,m Prinrm iourrmofa Cenirram aro=cyryn /�
Owner nr�to alined 011% 1
en1 Dale TOTAL: ISSUED BY �—
OFFICE